• American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guideline on the treatment of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008 Sep. 76 p. [116 references]

This is the current release of the guideline.

It is anticipated that this guideline will be revised in 2011.

Definitions of the levels of evidence (I-V) and grades of recommendation (A-C, I) are provided at the end of the "Major Recommendations" field.

Note from the American Academy of Orthopaedic Surgeons (AAOS): This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report (see "Guideline Availability" and "Availability of Companion Documents" fields) for this information. The guideline developers are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone.

Carpal Tunnel Syndrome (CTS) is among the most common disorders of the upper extremity. It is related to many factors but is thought to be caused by increased pressure on the median nerve in the carpal tunnel at the wrist.

Recommendation 1

A course of non-operative treatment is an option in patients diagnosed with carpal tunnel syndrome. Early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. (Grade C, Level V)

Recommendation 2

The authors suggest another non-operative treatment or surgery when the current treatment fails to resolve the symptoms within 2 weeks to 7 weeks. (Grade B, Level I and II)

Recommendation 3

The authors do not have sufficient evidence to provide specific treatment recommendations for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace. (Inconclusive, No evidence found)

Recommendation 4a

Local steroid injection or splinting is suggested when treating patients with carpal tunnel syndrome, before considering surgery. (Grade B, Level I and II)

Recommendation 4b

Oral steroids or ultrasound are options when treating patients with carpal tunnel syndrome. (Grade C, Level II)

Recommendation 4c

The authors recommend carpal tunnel release as treatment for carpal tunnel syndrome. (Grade A, Level I)

Recommendation 4d

Heat therapy is not among the options that should be used to treat patients with carpal tunnel syndrome. (Grade C, Level II)

Recommendation 4e

The following treatments carry no recommendation for or against their use: activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics, exercise, electric stimulation, fitness, Graston instrument, iontophoresis, laser, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants and NSAIDs), nutritional supplements, phonophoresis, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction, yoga. (Inconclusive, Level II and V)

Recommendation 5

The authors recommend surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum regardless of the specific surgical technique. (Grade A, Level I and II)

Recommendation 6

The authors suggest that surgeons do not routinely use the following procedures when performing carpal tunnel release:

• Skin nerve preservation (Grade B, Level I)
• Epineurotomy (Grade C, Level II)

The following procedures carry no recommendation for or against use: flexor retinaculum lengthening, internal neurolysis, tenosynovectomy, ulnar bursa preservation. (Inconclusive, Level II and V)

Recommendation 7

The physician has the option of prescribing pre-operative antibiotics for carpal tunnel surgery. (Grade C, Level III)

Recommendation 8

The authors suggest that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. (Grade B, Level II)

The authors make no recommendation for or against the use of postoperative rehabilitation. (Inconclusive, Level II)

Recommendation 9

The authors suggest physicians use one or more of the following instruments when assessing patients' responses to CTS treatment for research:

• Boston Carpal Tunnel Questionnaire (disease-specific)
• DASH – Disabilities of the arm, shoulder, and hand (region-specific; upper limb)
• MHQ – Michigan Hand Outcomes Questionnaire (region-specific; hand/wrist)
• PEM – Patient Evaluation Measure (region-specific; hand)
• SF-12 or SF-36 Short Form Health Survey (generic; physical health component for global health impact) (Grade B, Level I, II, and III)

Definitions:

Levels of Evidence for Primary Research Question¹

1. A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
2. A combination of results from two or more prior studies.
3. Studies provided consistent results.
4. Study was started before the first patient enrolled.
5. Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.
6. The study was started after the first patient enrolled.
7. Patients identified for the study based on their outcome, called "cases"; e.g., failed total hip arthroplasty, are compared to those who did not have outcome, called "controls"; e.g., successful total hip arthroplasty.
8. Patients treated one way with no comparison group of patients treated in another way.

Grading the Recommendations

A: Good evidence (Level I Studies with consistent findings) for or against recommending intervention.

B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.

C: Poor quality evidence (Level IV or V) for or against recommending intervention.

I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.

None provided

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

• American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guideline on the treatment of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008 Sep. 76 p. [116 references]

Not applicable: The guideline was not adapted from another source.

2008 Sep

American Academy of Orthopaedic Surgeons - Medical Specialty Society

American Academy of Orthopaedic Surgeons

Work Group Panel

Panel Members: Michael Warren Keith, MD (Chair) Orthopaedic Hand Surgeon; Victoria Masear, MD (Co-Chair) Orthopaedic Hand Surgeon; Kevin Chung, MD, University of Michigan Medical Center, Plastic and Reconstructive Surgery; Peter C Amadio, MD, Mayo Clinic, Orthopaedic Hand Surgeon; Michael Andary, MD, Michigan State University, Physical Medicine and Rehabilitation Neurology; Richard W. Barth, MD, AAOS Board of Councilors, Orthopaedic Hand Surgeon; Kent Maupin, MD, Orthopaedic Surgery; Brent Graham MD, University of Toronto, Orthopaedic Hand Surgeon/Microsurgery

Guidelines Oversight Chair: William C. Watters III, MD, Orthopaedic Spine Surgeon

American Academy of Orthopaedic Surgeons (AAOS) Staff: Charles M. Turkelson, PhD, AAOS Research Director; Robert H. Haralson III, MD, MBA, AAOS Medical Director, Orthopaedic Surgeon; Janet L. Wies, MPH, Clinical Practice Guideline Mgr

American Academy of Orthopaedic Surgeons (AAOS) Research Analysts: Kevin Boyer, Lead Analyst; Andrew Chang, MPH; Erica Smith, MPH

All panel members gave full disclosure of conflicts of interest prior to voting on the recommendations contained within these guidelines. These guidelines were funded exclusively by the American Academy of Orthopaedic Surgeons who received no funding from outside commercial sources to support the development of this document.

All members of the physician Work Group disclosed any conflicts of interest prior to the development of the recommendations for this guideline. Conflicts of interest are disclosed in writing with the American Academy of Orthopaedic Surgeons via a private on-line reporting database and also verbally at the recommendation approval meeting. No member of the carpal tunnel syndrome (CTS) Work Group disclosed a conflict of interest for this guideline.

This is the current release of the guideline.

It is anticipated that this guideline will be revised in 2011.

None available

This NGC summary was completed by ECRI Institute on December 26, 2008. The information was verified by the guideline developer on January 15, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact AAOS Department of Research and Scientific Affairs, 6300 North River Road, Rosemont, IL 60018; Phone: (847) 823-7186; Fax: (847) 823-8125.