Carpal Tunnel Syndrome

Scope

Carpal Tunnel Syndrome (CTS) occurs when the median nerve is compressed at the wrist in the carpal tunnel.

This is the commonest form of nerve entrapment. The prevalence of Carpal Tunnel Syndrome in the UK is 7–16%.

Carpal Tunnel Syndrome is normally diagnosed in primary care and early management is non-surgical.

However, referral for early surgical management is appropriate if the patient presents with signs of neurological deficit resulting in constant altered sensation, muscle wasting, or weakness of thenar abduction.

Nerve Conduction Studies (NCS) are NOT needed to make a diagnosis

Please note referral criteria are applicable in this referral.

For Nerve Conduction Studies (NCS) referrals may be returned if considered classic Carpal Tunnel Syndrome. To see information required please see Referral Section, referrals submitted without this information will be returned.

Key Devon CCG policy criteria summary:

Surgical treatment of carpal tunnel will be routinely commissioned only if one of the following criteria is met:

a) The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a manageable level with either one local corticosteroid injection and/or nocturnal splinting for 12 weeks;

or

b) There is either:

i. a permanent (ever-present) reduction in sensation in the median nerve distribution;

or

ii. muscle wasting or weakness of thenar abduction (moving the thumb away from the hand).

Assessment

Signs and Symptoms

Carpal Tunnel Syndrome occurs due to compression of the median nerve at the wrist which causes changes in feeling of the thumb, index, middle and radial half of the ring finger.

History

  • Paraesthesia in the correct distribution (thumb, index, middle and radial half of the ring finger)
  • Nocturnal symptoms (pain/paraesthesia exacerbated at night)
  • Subjective weakness in the thumb/loss of co-ordination

Examination

  • Tinel's test (light percussion over the median nerve)
  • Phalen's test (maximal palmar flexion of the wrist for 60 seconds)
  • Objective thenar muscle wasting
  • Objective weakness of thenar abduction (moving the thumb away from the hand)

Differential Diagnoses

May include

  • Fracture
  • Onset of tingling/ numbness after injury
  • Tumour
  • Neurological diseases Inflammatory joint disease (including gout and RA)
  • Peripheral limb ischaemia (thoracic outlet syndrome or Raynaud's disease)
  • Cervical nerve root entrapment
  • Cubital tunnel syndrome (changes in feeling of the little and ulnar half of the ring finger with weakness of small muscles of the hand but not the thumb)

These issues should result in referral to appropriate service in secondary care

Red Flags

May include:

  • Fracture
  • Onset of tingling/ numbness after injury
  • Tumour
  • Neurological diseases
  • Inflammatory joint disease (including gout and RA)
  • Peripheral limb ischaemia (thoracic outlet syndrome or Raynaud's disease)
  • Cervical nerve root entrapment

These issues should result in referral to appropriate service in secondary care

Investigations

Nerve Conduction Studies (NCS) are not recommended for patients with classic symptoms of Carpal Tunnel Syndrome (CTS). Diagnosis can be made clinically and treated accordingly.

Nerve Conduction Studies NCS should only be used where there is diagnostic uncertainty as to the cause of the patient's symptoms. Referrals may be returned if considered classic Carpal Tunnel Syndrome

Blood tests are only needed if the history and examination suggests a specific secondary cause

Management

  • Mild cases with intermittent symptoms causing little or no interference with sleep or activities require no treatment. Patient information can be useful
  • Cases with intermittent symptoms which interfere with activities or sleep should first be treated with:

a) corticosteroid injection (medication injected into the wrist: good evidence for short (8-12 weeks) term effectiveness)

or

b) night splints (a support which prevents the wrist from moving during the night: not as effective as steroid injections). These can be purchased by the patient over-the-counter at most Pharmacies or on-line.

Please note that repeated steroid injections are not encouraged. Early referral for surgical management is appropriate if the patient presents with signs of neurological deficit resulting in constant altered sensation, muscle wasting, or weakness of thenar abduction.

This is to prevent irreversible nerve damage.

Referral

Referral Criteria

Referral Criteria for Nerve Conduction Studies (NCS)

Nerve Conduction Studies (NCS) are not recommended for patients with classic symptoms of Carpal Tunnel Syndrome (CTS). Diagnosis can be made clinically and treated accordingly.

Nerve Conduction Studies NCS should only be used where there is diagnostic uncertainty as to the cause of the patients symptoms. Referrals may be returned if considered classic Carpal Tunnel Syndrome

Referral Criteria for Carpal Tunnel Syndrome (CTS)

Red flags should result in referral to the appropriate service in secondary care

Surgical treatment of carpal tunnel will be routinely commissioned only if one of the following criteria is met:

1. The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a manageable level with either one local corticosteroid injection and/or nocturnal splinting for 12 weeks;

or

2. There is either:

a) a permanent (ever-present) reduction in sensation in the median nerve distribution;

or

b) muscle wasting or weakness of thenar abduction (moving the thumb away from the hand).

Referrals submitted without this information will be returned.

Click on the link below for the complete Devon CCG Surgery for carpal tunnel syndrome commissioning policy

Commissioning policy - surgery for carpal tunnel syndrome

Referral Instructions

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Individual funding requests

Individual funding request form

Refer to Orthopaedics e-Referral Service selection

Speciality: Orthopaedics

Clinic type: Hand and Wrist

Service: DRSS-Northern-Orthopaedics-Hand & Wrist- Devon CCG- 15N

Referral Letter

Supporting Information

Patient Information

MyHealth patient information - Carpal Tunnel

NHS Devon Individual Funding Request - Patient information leaflet

Evidence

BOA – Commisioning guide: Treatment of painful tingling fingers

Pathway Group

This guideline has been signed off NHS Devon CCG.

Publication date: December 2015

Updated: October 19

 

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