Management of Carpal Tunnel Syndrome (2024)

Strong evidence suggests that CTS-6 can be used to diagnose carpal tunnel syndrome, in lieu of routine use of Ultrasonography, or NCV/EMG.

There were ten high and five moderate quality studies supporting the use of either the CTS-6, NCV/EMG, and ultrasonography for the diagnosis of carpal tunnel syndrome (High-Quality: Wong 2004, Draghici 2020, Martikkala 2021, Falsetti 2022, Fu 2015, Moran 2009, Fowler 2014, Graham 2008, Wang 2020, Chen 2021) (Moderate-Quality: Mehrpour 2016, Mallouhi 2006, Naranjo 2007, Abdel Ghaffar 2012, Kanagasabai 2022). Although there was heterogeneity in the patient populations and comparisons for different studies there was strong and consistent evidence supporting these tools in diagnosing carpal tunnel syndrome. For example, Fowler 2014 studied ultrasonography versus NCV/EMG using CTS-6 as a reference standard (a tool that encompasses signs and symptoms used by clinicians to diagnose carpal tunnel syndrome) and found a positive predictive value of ultrasound and NCV/EMG of 94% and 89% respectively, and a negative predictive value of 82% and 80% respectively. In Fu 2015, the authors used clinical diagnosis of carpal tunnel along with NCV/EMG to test the use of ultrasonography and found a sensitivity and specificity of 91% and 93% respectively. In Graham 2008, NCV/EMG confirmation of carpal tunnel syndrome was used as the reference standard to test the correlation of the pre-test probability of having carpal tunnel syndrome using the CTS-6. The correlation of having carpal tunnel syndrome by using the CTS-6 compared to NCV/EMG diagnosis was as high as 0.9. There was no strong evidence demonstrating clinical superiority between diagnostic tools in this review, therefore we do not propose superiority of one test over the other, however, we highlight the use of CTS-6 as a diagnostic tool and/or screening tool, and the utilization of ultrasound or NCV/EMG as diagnostic tests when the positive predictive value when using the CTS-6 is low.

Benefits/Harms of Implementation
There is no specific research focused on the benefits/harms of the various modalities used to diagnose carpal tunnel syndrome that were found in this review. Roe (2022) found that from a shared decision-making perspective, patients want decision making for the testing for carpal tunnel diagnosis (ultrasound or NCV/EMG) to be equally collaborative. Harms of utilization of NCV/EMG include the unpleasant and invasive experience of the test, in addition to delays in treatment and costs. Similar harms related to delays and costs may be present for the utilization of ultrasound.

Outcome Importance
There was no evidence from this review that provided guidance for how the diagnostic tool used affected clinical outcomes.

Cost Effectiveness/Resource Utilization
While not the purpose of this systematic review, the guideline informs how future studies assess the cost effectiveness of testing for carpal tunnel syndrome.

Future Research
Future investigation can focus on differences in cost and patient outcomes based on diagnostic tools used.

Moderate evidence suggests that MRI and Upper Limb Neurodynamic Testing should not be used to diagnose carpal tunnel syndrome.

The evidence shows that MRI and Upper Limb Neurodynamic testing should not be used for carpal tunnel syndrome. For the use of MRI, only one moderate quality study (Jarvik 2002) was reviewed which reported there was low specificity with moderate sensitivity using this tool to diagnosis carpal tunnel of any severity. Their findings suggest MRI was a poor tool in the diagnostic algorithm for Carpal Tunnel syndrome. Similarly, the use of Neurodynamic testing is as a tool for the diagnosis of Carpal Tunnel Syndrome was evaluated in a randomized controlled trial (Beddaa 2022) with high quality evidence demonstrating poor specificity (47%) and moderate sensitivity (76%) compared to the reference standard of Electrodiagnostic testing. Overall, the recommendation above is based on moderate evidence with limited to moderate strength that MRI and Upper Limb Neurodynamic Testing should not be used in the standard work up for the diagnosis of carpal tunnel syndrome.

Benefits/Harms of Implementation
Based on available evidence with low Specificity and moderate Sensitivity for both MRI and Neurodynamic testing, outcomes show that neither test provides benefit in the diagnosis of carpal tunnel syndrome compared to other more appropriate tools (CTS-6, Ultrasound, electrodiganostics). These tests have associated costs to patients and health systems and appear to provide no improved accuracy in the diagnosis of this condition.

Outcome Importance
Given the availability of alternative methods of diagnosis, and the importance of appropriate diagnostic clarity for patients, the use of these tools for diagnosis is not recommended.

Cost Effectiveness/Resource Utilization
Considering the associated costs of MRI and Neurodynamic testing they provide poor cost effectiveness in the standard work up for a patient presenting with Carpal Tunnel syndrome. This is important given the relative cost and availability differences between these tools and clinical exam testing (CTS-6) and the low-cost availability of alternatives.

Acceptability
Overall, the acceptability of this recommendation is expected to be high as obtaining MRI and Neurodynamic testing is not common practice. In addition, the associated costs and the potential for poor diagnostic clarity given the limited specificity of these tests make the value attached to use poor.

Feasibility
Because of the alternative diagnostic options for carpal tunnel syndrome, including exam alone (CTS-6), it is feasible to not utilize MRI or neurodynamic testing in the evaluation of a patient for carpal tunnel syndrome.

Future Research
Additional high-quality studies should compare MRI and Neurodynamic testing against other standards of diagnosis outside of CTS-6, ultrasound, or electrodiagnostic testing if there were a hypothesis on a diagnostic advantage (e.g., improved specificity/sensitivity compared to alternate tests).

Strong evidence suggests corticosteroid injection does not provide long-term improvement of carpal tunnel syndrome.

While many high-quality studies addressed efficacy of corticosteroid steroid injections (CSI), either as a primary intervention or comparison group, fewer included long term follow up. Three high quality studies with follow up ranging from 6 months to 5 years demonstrated no benefits (Hofer 2021, Salman 2018, Atroshi 2013). A study comparing CSI to nighttime immobilization found no significant differences at 1-2 years (Burton 2022) and an additional study comparing CSI to prolotherapy also showed no difference at 1 year (Aghaei 2021). Taken together, there is strong evidence that, while there may be short-term improvement in symptoms with CSI, there is no long-term benefit.

Benefits/Harms of Implementation
CSI may provide short term improvement in symptoms. A therapeutic injection may cause localized pain and swelling, rare allergic reactions, and a small possibility of nerve damage.

Outcome Importance
CSI are very common and popular interventions with high utilization in clinical practice, thus this recommendation informs standard treatment for many surgeons.

Cost Effectiveness/Resource Utilization
CSI are, individually, inexpensive interventions relative to many other treatments. Limited data address cost-effectiveness.

Acceptability
We expect this recommendation to be generally accepted, however, CSI for short term relief of symptoms may continue.

Feasibility
Minimizing use of CSI for any long-term benefit is readily available and feasible.

Future Research
Future investigation can focus on assessing the short-term benefits to patients, in relation to the cost, to evaluate the cost-effectiveness and value of CSI, given the lack of long-term effectiveness.

Strong evidence suggests PRP Injection does not provide long-term benefits in non-operative treatment of carpal tunnel syndrome (leukocyte rich or leukocyte poor PRP).

A randomized controlled trial with 12-month follow-up of PRP vs saline control showed similar improvement in symptom severity scale and functional status at all time points without clinically meaningful differences, though cross-sectional area and electrodiagnostic parameters showed some beneficial effect from PRP (Chen, 2021). While other high-level studies failed to follow patients long-term, short-term effects of PRP have shown mixed results. Raeissadat (2018) conducted a randomized controlled trial that compared the effects of wrist splitting alone versus wrist splinting combined with a single local PRP injection. They found that over the 10-week treatment period in comparison to control, a single PRP injection did not significantly enhance the effects of conservative treatment in terms of pain, symptom severity, functional status, and electrophysiological parameters. In contrast, Malhias (2018) performed an RCT which found PRP lead to increased success rates defined by a 25% difference in Q-DASH scores in comparison to placebo at 12 weeks.

Benefits/Harms of Implementation
PRP is an endogenously sourced blood product. Harvesting requires venipuncture and risks of injection are low. Benefits are unclear.

Cost Effectiveness/Resource Utilization
PRP is relatively expensive due to the cost of purification and separation equipment necessary to isolate and extract the platelet-rich fraction from whole blood. With no clear benefit to patient outcomes, its utilization may be wasteful.

Acceptability
PRP is performed by many practitioners despite limited evidence of effectiveness. It is not considered a standard treatment for carpal tunnel syndrome.

Feasibility
Implementation of this recommendation is feasible as it recommends against the use of PRP for the treatment of carpal tunnel syndrome.

Future Research
There are few placebo-controlled trials of PRP with long-term follow up. More high-level research with longer follow up is critical to evaluating any significant differences between PRP and placebo.

Strong evidence suggests that there is no difference in patient reported outcomes between a mini-open carpal tunnel release and an endoscopic carpal tunnel release.

There are multiple high and moderate quality studies that were identified to evaluate the difference in outcomes between a mini-open carpal tunnel release and an endoscopic carpal tunnel release. These studies consistently demonstrated no difference in long-term outcomes (e.g., patient reported outcome measures, range of motion, grip strength) between the two techniques (Oh 2017, Kang 2013, Larsen 2013, Aslani 2012, Wang 2022, Capa-Grasa 2014). We used mini-open carpal tunnel release as a term to describe a small incision in the palm that does not cross the wrist crease, which is smaller in size than more traditional open approaches.

Benefits/Harms of Implementation
There is no consistently demonstrated benefit of utilizing a mini-open carpal tunnel release or an endoscopic carpal tunnel release. Endoscopic carpal tunnel release may afford a shorter return to work however this may depend upon post operative protocols, patient occupation, and other factors. Endoscopic carpal tunnel release can be associated with greater costs, which may affect patient preference for this option. Although not included in this review, complication rates for endoscopic carpal tunnel release may be higher than previously described and should be considered (Carrol 2023).

Cost Effectiveness/Resource Utilization
Cost data regarding endoscopic and mini open carpal tunnel release vary and are based upon several factors including surgical location (e.g., office, operating room) and stakeholder perspective (e.g., societal, payer) (Barnes 2021, Zhang 2016). Prior studies evaluating the cost effectiveness of these approaches have favored mini-open carpal tunnel release when completed in the office setting, however, advances in endoscopic release in the office may need to be considered. Recent literature on higher complication rates with endoscopic release may affect future CAEs on this topic.

Acceptability
Mini-open and endoscopic release are both accepted surgical techniques for carpal tunnel release.

Feasibility
Both techniques are feasible, however each technique should be performed only by those who are trained in each technique.

Future Research
Future investigations can focus on the development of tools to help guide patients in understanding the benefits, risks, and costs associated with each technique to support a shared decision-making approach that aligns with patient preferences.

Strong evidence suggests local anesthesia alone can be used for carpal tunnel release.

There are three high quality and six low quality studies that suggest local anesthesia alone can be used for carpal tunnel release. Three randomized controlled trials evaluated local anesthesia as compared to intravenous regional anesthesia (Nabhan 2011, Okamura 2021, Sorensen 2013). One study demonstrated decreased tourniquet time and OR time in the local anesthesia cohort with no differences in patient reported outcomes (Nabhan 2011). Another study demonstrated lower intraoperative and postoperative pain and analgesic use in the local anesthesia cohort (Okamura 2021). Sorensen et al, demonstrated that patients in the local anesthesia cohort reported less postoperative pain and analgesic use. Lower quality studies have demonstrated adequate and/or improved pain control in the local anesthetic cohort (Kang 2019), low or no increased risks of complications (Rellan 2021, Wellington 2021), and similar patient reported outcomes as compared to other anesthetic modalities (Tulipan 2017, Tulipan 2018).

Benefits/Harms of Implementation
There are potential benefits and harms associated with local anesthetic and intravenous regional anesthesia that should be discussed with patients. For example, local anesthetic may allow for flexibility in procedure location (e.g., office-based surgery) and ability to drive oneself home, however it may be anxiety provoking for some patients. A shared decision-making approach on the use of local only for surgery may be beneficial.

Cost Effectiveness/Resource Utilization
Cost effectiveness and resource utilization were not primary outcomes of this review, and costs and resource utilization vary based upon context, however in general, carpal tunnel release with local anesthetic results in lower costs and resource utilization compared to other forms of anesthesia (e.g., monitored anesthesia care) (Carr 2019, Kamal 2019).

Acceptability
Based on descriptions in the literature, local anesthesia has been adopted by surgeons and patients in multiple countries as an acceptable approach for carpal tunnel release.

Feasibility
Local anesthesia is readily available and feasible as it does not require any additional medications or changes to the surgical approach.

Future Research
Future investigation can focus on the development of tools to help understand patient preference and guide patients in understanding the benefits, risks, and costs associated with available anesthetic techniques. The financial advantages of local only anesthesia may be further explored in future cost effectiveness analyses.

Moderate evidence suggests postoperative supervised therapy should not be routinely prescribed after carpal tunnel release.

This recommendation is based on one high-quality, two moderate-quality, and one low-quality study evaluating the use of physical therapy after carpal tunnel release (Provinciali 2000, Pomerance 2007, Schroeder 2022, Gil 2020). These studies consistently demonstrate that there are no functional or outcome benefits of using therapy after carpal tunnel release. There was one high-quality study that demonstrated short term benefits (of improved motor dexterity at one month and shorter return-to-work) (Provinciali 2000).

Benefits/Harms of Implementation
The benefit of the use of therapy after carpal tunnel release has not been demonstrated. Its use may result in unnecessary costs (direct, indirect, intangible). There may be scenarios or patients in whom post-operative therapy may be beneficial, however, studies are required to identify this potential patient population. While formal physical therapy is not substantiated across the majority of patients, it may benefit some patients on a case-by-case basis.

Future Research
Future research is needed to determine which patients may benefit from physical therapy after carpal tunnel release. Research evaluating the cost-effectiveness of physical therapy post-operatively, particularly in specific patient populations, may be beneficial to promote high-quality low-cost care.

Moderate evidence suggests immobilization through sling or orthosis (e.g., splint, brace) should not be used after carpal tunnel release.

This recommendation is based on one high-quality, five moderate-quality, and one low-quality study evaluating the use of postoperative splinting in comparison to no splinting. These studies demonstrate that there are no functional or outcome benefits of utilizing splinting after carpal tunnel release.
One high-quality article (Logli 2018) demonstrated no difference in patient reported or clinical outcomes at any follow up period to 12 months after mini-open CTS surgery in patients who utilized a non-removable orthotic (plaster, Webril cotton wrap) or patients who used a soft dressing (gauze wrap) when compared to a removable orthotic (V-Strap wrist brace).
One moderate-quality article (Cebesoy 2007) showed that patients who had been treated with a surgical intervention for CTS had a significantly better BCTQ-SSS score when treated with a post-op Bulky Bandage than patients who were treated with a splint.

One moderate-quality article (Ritting 2012) showed that patients treated with early mobilization after surgical intervention for CTS had better grip strength and tip pinch strength than patients treated with medicated gauze, cotton gauze, cast padding, and elastic roller bandage.

One moderate-quality article (Cook 1995) showed that patients who began range of motion exercises after CTS surgery post-op day one had significantly better outcomes in return to daily living, light duty work, and full duty work than patients who were splinted for two weeks following surgery. Grip strength, key-pinch strength, and VAS pain were also improved in the unrestricted movement group, however these effects only lasted until the one-month follow-up.

Two moderate-quality articles (Finsen 1999 and Huemer 2007) and one low-quality article (Kroeze 2020) showed no significant differences in observed outcomes between their restricted and unrestricted movement groups.

Benefits/Harms of Implementation
There are no harms associated with implantation of this recommendation.

Future Research
Future investigation should focus on determining benefits of early post operative mobilization, return to unrestricted activities of daily living and work activities.

Strong evidence suggests that NSAIDs and/or acetaminophen should be used after carpal tunnel release for postoperative pain management.

One high-quality article (Husby 2001) showed no significant differences in observed outcomes for patients who underwent surgery for CTS treated with acetaminophen vs. patients that were given matching placebo pills. Three high-quality articles (Husby 2001 and Ilyas, 2018/2019) showed no significant differences in observed outcomes for patients who underwent surgery for CTS treated with acetaminophen vs. those who were given non-steroidal anti-inflammatory drugs (NSAIDs) (Naproxen or ibuprofen). Ilyas (2018) also showed that the patients who took acetaminophen or ibuprofen after mini-open carpal tunnel repair had statistically significantly lower Worst Daily Pain (0-10 scale) than those who took Oxycodone – 2.5 and 3.4 respectively. Ilyas (2019) again showed that the patients who underwent CTS surgery who took acetaminophen or ibuprofen also had less VAS Worst Daily Pain than patients who took Oxycodone – 2.5, 2.5, and 2.9 respectively; these differences reached statistical significance. Adverse events were also significantly less common in patients taking NSAIDs or acetaminophen in comparison to Oxycodone. Ilyas 2018 reported 11% of the oxycodone group reported adverse events compared to 3% in the acetaminophen group; Ilyas 2019 adverse events were reported in 15% of the oxycodone group, 1.6% of the acetaminophen group, and 1.6% in the NSAID group.

Benefits/Harms of Implementation
The benefit of having two non-opioid medications for postoperative pain management is that pain can still be managed despite concomitant conditions, which may preclude a patient from taking either NSAID or acetaminophen. In addition, this helps avoid the many adverse effects of opioids (overdose and addiction).

Outcome Importance
NSAIDs and acetaminophen are options to help control postoperative pain.

Acceptability
Accepted treatment for pain in the postoperative state as there are over-the-counter medications.

Feasibility
Feasible as these are over-the-counter medications that are familiar to patients and clinicians.

In the absence of reliable evidence, it is the opinion of the workgroup that there is no association between high keyboard use and carpal tunnel syndrome.

No high- or moderate-quality studies were identified to address the question of the association of keyboard use and carpal tunnel syndrome. A single low-quality study that met inclusion criteria, (Eleftheriou et al. 2012), reported a statistically significant association between high keyboard use and carpal tunnel syndrome.

Benefits/Harms of Implementation
This recommendation is based upon a research question that was specifically focused on the association of high keyboard use and carpal tunnel syndrome. The potential harm in the CPG lies in the lack of recognition of keyboard use as a strong risk factor or causative variable for carpal tunnel syndrome which has implications for worker’s compensation cases and physicians called upon to evaluate causation.

Evidence suggests therapeutic ultrasound does not provide long-term improvement of carpal tunnel syndrome.

There is limited standardization of the studies assessing the effectiveness of therapeutic ultrasound on carpal tunnel symptoms; this recommendation has been downgraded for inconsistency and heterogeneity of both treatments and outcomes. Studies were inconsistent with the use of constant versus pulsed-wave treatments as well as dosages and supplementing treatment with an orthosis. Only one study provided long term follow up (Jothi, 2019) and showed no significant difference between therapeutic ultrasound and sham ultrasound therapy. Two additional papers also showed no significant difference between treatment and control groups, although the follow up was only one to two months (Catalbas 2018 and Yildiz 2011). Only one paper favored the use of ultrasound for treatment of CTS (Dincer, 2009) while Ebenbichler et al. Showed more mixed results in 1998. Many studies evaluated therapeutic ultrasound against various other treatments, including, exercise, phonophoresis, pulsed radiofrequency, heat and laser therapy, however, ultrasound was not clearly superior. There was limited standardization of the use of therapeutic ultrasound on carpal tunnel symptoms, such as the use of constant versus pulsed-wave treatments as well as dosages.

Benefits/Harms of Implementation
Therapeutic ultrasound does not show any significant difference from placebo. Although it does not have any direct biological adverse reactions, ultrasound adds to the time and cost of treatment without established benefit to patients. There are no harms expected from this recommendation based on the evidence.

Cost Effectiveness/Resource Utilization
Given the lack of effectiveness of therapeutic ultrasound, it is not cost effective to use it as a therapy for CTS.

Acceptability
Due to lack of supporting evidence, this guidance is anticipated to be accepted by surgeons, patients, and therapists.

Feasibility
Readily available and feasible to not use this modality.

Future Research
More long-term follow up studies are required to confirm the lack of effectiveness of therapeutic ultrasound in the treatment of CTS.

Evidence suggests that the following non-operative treatments do not demonstrate superiority over control or placebo: acupressure, insulin injection, heat therapy, magnet therapy, nutritional supplementation, oral diuretic, oral NSAID, oral anticonvulsant, phonophoresis.

The overall strength was downgraded for this option given the heterogeneity in treatment modalities, study quality, control cohort utilized, and follow-up time periods. Single studies evaluating acupressure, insulin injection, heat therapy, immobilization, oral diuretic, and oral NSAID for the treatment of CTS showed no significant difference at short term follow up (Asgari, 2020, Kamel 2019, Mansiz Kaplan 2019, Kocak Ulucakoy 2020, Chang 2020). Two studies showed moderate evidence that there was no significant difference between patient treatment with magnet therapy and controls (Colbert 2010 and Baute 2018). Patients treated with nutritional supplementation did not show improvement over controls in two studies (Paolucci 2018 and Faig-Marti 2017), however, showed improvement in a single study with very short term follow up (Marvulli 2021). There is strong evidence that oral anticonvulsants are not effective in the treatment of CTS with three out of four articles showing no significant difference between treatment and placebo groups (Hui 2011, Eftekharsadat 2015, Mehmetoglu 2018, Hesami 2018). Lastly, there is strong evidence against the use of phonophoresis to treat CTS (Boohong 2020 and Haghighat 2021).

Benefits/Harms of Implementation
The above treatments do not show a consistent significant difference from control groups and add to the time and monetary expense for patients suffering from CTS and to the health system (low value care). Moreover, adverse reactions from oral diuretics, NSAIDs and anticonvulsants are well recognized and are discouraged for non-operative treatment of CTS through this guideline.

Outcome Importance
As the above treatments do not show a difference in symptom improvement for CTS, they should not be recommended.

Cost Effectiveness/Resource Utilization
Given the lack of effectiveness of the above treatments are not considered cost effective to treat CTS.

Future Research
No long-term follow up studies are available to confirm the lack of effectiveness of these therapies, however, are likely not necessary, given the lack of short-term benefits.

Evidence suggests the following non-operative treatments do not improve long-term patient reported outcomes for carpal tunnel syndrome: oral corticosteroid, hyaluronic acid injection, hydro dissection, kinesiotaping, laser therapy, peloid therapy, perineural injection therapy, topical treatment, shockwave therapy, exercise, ozone injection, massage therapy, manual therapy, pulsed radiofrequency.

The overall strength was downgraded for this option given the heterogeneity in treatment modalities, study quality, control cohort utilized, and follow-up time periods. One study evaluating oral corticosteroid (Chang 1998). Two studies evaluating hyaluronic acid injection demonstrate limited evidence in favor of hyaluronic acid injection at 6 months as compared to a normal saline injection (Wu 2022) and no difference between a hyaluronic acid and normal saline injection at 1-, 3-, and 6-mo follow up time points (Su 2021).

There are three studies that evaluated the utilization of hydro dissection for the treatment of carpal tunnel syndrome. Elawamy et al.2020 demonstrated improved pain and function 6 months after hydro dissection with Hyalase and 10 mL saline solution injection as compared to hydro dissection with 10mL of saline solution only. We et al.2018 demonstrated that hydro dissection resulted in improved function and symptom severity compared to subcutaneous injection at 6mo. He et al.2022 demonstrated that hydro dissection with 5% dextrose as an add on to a corticosteroid injection resulted in improved patient reported outcome scores at 3 mo.

Five studies evaluated kinesiotaping, two favoring kinesiotaping and three demonstrating no difference as compared to various treatment modalities including an orthosis, placebo kinesiotaping, nerve and tendon gliding exercises (Geler 2016, De Sire 2021, Aminian 2022, Mansiz 2019, Yildririm 2018).

Seven studies evaluated the utilization of laser therapy, four of which were either mixed or favored laser therapy whereas three demonstrated no difference in outcomes when comparing laser therapy to orthosis and/or placebo (Barbosa 2016, Chang 2008, Dincer 2009, Evic 2007, Fusakul 2014, Guner 2018, Yagci 2019). Metin et al.2017 evaluated peloid treatment with nighttime orthosis as compared to nighttime orthosis alone and demonstrated improvements in functionality at one month.

The overall strength was downgraded for this option given the heterogeneity in treatment modalities, study quality, control cohort utilized, and follow-up time periods. One study evaluating oral corticosteroid (Chang 1998). Two studies evaluating hyaluronic acid injection demonstrate limited evidence in favor of hyaluronic acid injection at 6 months as compared to a normal saline injection (Wu 2022) and no difference between a hyaluronic acid and normal saline injection at 1-, 3-, and 6-mo follow up time points (Su 2021).

There are three studies that evaluated the utilization of hydro dissection for the treatment of carpal tunnel syndrome. Elawamy et al.2020 demonstrated improved pain and function 6 months after hydro dissection with Hyalase and 10 mL saline solution injection as compared to hydro dissection with 10mL of saline solution only. We et al.2018 demonstrated that hydro dissection resulted in improved function and symptom severity compared to subcutaneous injection at 6mo. He et al.2022 demonstrated that hydro dissection with 5% dextrose as an add on to a corticosteroid injection resulted in improved patient reported outcome scores at 3 mo.

Five studies evaluated kinesiotaping, two favoring kinesiotaping and three demonstrating no difference as compared to various treatment modalities including an orthosis, placebo kinesiotaping, nerve and tendon gliding exercises (Geler 2016, De Sire 2021, Aminian 2022, Mansiz 2019, Yildririn 2018).

Seven studies evaluated the utilization of laser therapy, four of which were either mixed or favored laser therapy whereas three demonstrated no difference in outcomes when comparing laser therapy to orthosis and/or placebo (Barbosa 2016, Chang 2008, Dincer 2009, Evic 2007, Fusakul 2014, Guner 2018, Yagci 2019). Metin et al.2017 evaluated peloid treatment with nighttime orthosis as compared to nighttime orthosis alone and demonstrated improvements in functionality at one month.

Wu et al.2017, when comparing perineural injection therapy with 5% dextrose to perineural injection therapy with normal saline, demonstrated clinical improvement in the former group at 6 months post injection. Five studies evaluated the use of topical treatments (e.g., lavender oil, chamomile oil) that demonstrated varied results as compared to placebo (Eftekharsadat 2018, Flondell 2017, Hashempur 2015, Karimi 2021, Hashempur 2017.

Ten studies evaluate short term (up to 6-month) effects of shockwave therapy, eight of which demonstrate benefits and two of which demonstrate no difference in outcomes as compared to sham treatment, (Habibzadeh 2022, Kocak 2020, Gesslbauer 2021, Chang 2020, Wu 2016, Vahdatpour 2016, Saglam 2022, Haghighat 2021, Raissi 2017, Karatas 2019). Six studies evaluated exercise therapy or neuromobilization for the treatment of carpal tunnel syndrome. There was great variation in the intervention protocols (Shem 2020, Zidkova 2019, Abdolrazaghi 2021, Hesami 2018, Salehi 2019). Shem 2020 showed symptom improvements after 6 weeks of self-myofascial stretching. Zidkova 2019 showed 9-week improved symptom scores after exercise with neuromobilization techniques. Abdorlrazaghi 2021 found that a 6-week gliding exercise with splinting protocol did not provide improvement in comparison to splinting alone. Hesami 2018 and Salehi similarly showed nerve and gliding tendon exercises provide benefit in comparison to splinting alone after 6-week protocols.

Bahrami (2019) evaluated ozone injection with splinting as compared to splinting alone and demonstrated clinical improvement in the intervention arm. Elbalawy 2020 compared sensory rehabilitation with physical therapy as compared to physical therapy alone for carpal tunnel syndrome and demonstrated no difference in cohorts.

Four studies evaluate various manual therapies for the treatment of carpal tunnel syndrome. Despite various therapy modalities and time periods of follow up, each study favors manual therapy as compared to the control cohort. Jimenez Del Barrio 2018 investigated diacutaneous fibrolysis; Wolny investigated neurodynamic techniques administered twice per week for ten weeks in both 2018 and 2019. Dinarvand 2017 compared hamate and scaphoid mobilization with splinting with splinting alone and found that while both groups improved significantly at ten-week follow-up, the degree of improvement was larger in the mobilization group. Chen 2015 compared ultrasound-guided pulsed radiofrequency treatment with night splinting as compared to night splinting alone and demonstrated improved pain and functional outcome scores in the intervention cohort. Weintraub et al. evaluated the use of static and pulsed electromagnetic fields for the treatment of carpal tunnel and noted improvements in pain as compared to sham treatment.

Benefits/Harms of Implementation
The above interventions do not demonstrate a consistently significant difference as compared to control cohorts. Each treatment is associated with its own time and monetary expense, as well as risk profile.

Cost Effectiveness/Resource Utilization
Given the lack of effectiveness of the above treatments, they are not considered cost effective for the treatment of carpal tunnel syndrome.

Acceptability
Due to lack of supporting evidence, this guideline is anticipated to be accepted by surgeons, patients, and therapists.

Future Research
Future research may include studies that compare non operative treatment options to carpal tunnel release and/or with a more consistently defined intervention and/or control cohort.

Evidence suggests no significant difference in patient reported outcomes between non operative treatment techniques for carpal tunnel syndrome.

Numerous articles compared various therapies for carpal tunnel against other therapies. Not only were the treatments and their comparisons very heterogeneous, but no long-term follow also up was described either – as such, this recommendation has been downgraded. The majority of the studies did not demonstrate any significant difference between the treatment arms. When comparing corticosteroid injection versus shockwave therapy, the results were equivocal with one study out of four favoring ESWT, another favoring CSI, and two showing no significant difference between the treatment groups. When comparing ESWT with various treatments, three studies showed a slight benefit in ESWT.

Benefits/Harms of Implementation
The above non operative treatments do not show a consistent significant difference from other treatments and add to the time and monetary expense for patients suffering from CTS.

Outcome Importance
As there is limited data with mixed quality of evidence, any particular non-operative treatment cannot be recommended over another non-operative treatment.

Cost Effectiveness/Resource Utilization
None of the non-operative treatments have shown long-term success in the treatment of CTS and therefore, are not considered cost-effective options.

Acceptability
Due to lack of supporting evidence, this guideline is anticipated to be accepted by surgeons, patients, and therapists.

Feasibility
Readily available and feasible to not use these modalities.

Future Research
No long-term follow up studies are available to confirm the lack of effectiveness of these therapies, however, are likely not necessary, given the lack of short-term benefits.

Limited evidence suggests carpal tunnel release may be safely conducted in the office setting.

No high- or moderate-quality studies were identified to address the question related to the association of site of carpal tunnel release on outcomes. Five low-quality studies were identified, most of which were single-surgeon, single-institution and/or retrospective or database studies evaluating carpal tunnel release conducted in the office setting as compared to the operating room setting (Halvorson 2020, Miller 2022, Moscato 2021, Randall 2021, Stephens 2021). These studies consistently demonstrated that carpal tunnel release in the office setting results in no increased risk of complications with higher ratings of patient experience and satisfaction when compared to surgical release in the operating room.

When examining surgical site infection (SSI) rates, Halvorson et al. (2020) discerned no significant disparity between clinic-based procedure rooms (PR) and traditional operating rooms (OR). In terms of patient experience and satisfaction, Miller (2022) highlighted the advantages of office-based procedures utilizing wide awake local anesthesia (WALANT). Patients in the office reported heightened enjoyment, reduced anxiety, and an overall more positive experience compared to those in the OR. Exploring patient satisfaction in relation to anesthesia and surgical settings, Moscato's study (2021) illuminated the superiority of office-based CTR surgeries with WALANT over hospital-based procedures with regional anesthesia and sedation. This was underscored by consistent correlations between WALANT anesthesia and enhanced patient satisfaction across settings. Regarding medical complications, Randall (2021) revealed comparable safety profiles for office-based procedure rooms (PR) and OR settings. Notably, no substantial differences were found in major medical, surgical site, or iatrogenic complications between office and OR environments, underscoring the safety of CTR procedures regardless of the chosen setting.

Lastly, Stephens' study (2021) evaluated long-term outcomes after open CTR procedures. The transition from OR to PR in 2014 did not yield discernible discrepancies in patient demographics or postoperative outcomes measured using the Boston Carpal Tunnel Questionnaire (BCTQ), highlighting the enduring clinical effectiveness of CTR procedures across various procedural environments.

Benefits/Harms of Implementation
The benefits of surgical release in the office as compared to the operating room include potential time and cost savings for patients and hospital systems. There are also potential improvements in the patient experience with office based carpal tunnel release. Notably, patients eligible for office-based procedures should be appropriately chosen and willing to undergo surgical release awake with limited anesthesia.

Future Research
Future research should include randomized controlled trials of office vs OR based carpal tunnel release and cost effectiveness analyses of moving cases from the OR to the office.

In the absence of reliable evidence, it is the opinion of the workgroup that limited draping is an option for carpal tunnel release.

There are no randomized trials of draping options or field sterility relevant to this question. Multiple case series of WALANT surgeries, including carpal tunnel release, have shown low infection rates using field sterility. Given the well-documented cost savings of in-office carpal tunnel release using field sterility and the low reported infection rates for carpal tunnel release in general, it is our opinion that field sterility should be considered adequate for performance of carpal tunnel release surgery.

Benefits/Harms of Implementation
Given the low risk of infection in CTR overall, the harms are minimal. Benefits apply largely to efficiency and cost of in-office or surgical suite CTR surgery where full operative draping may not be feasible.

Cost Effectiveness/Resource Utilization
Field sterility or minimal draping is less expensive than full operative draping and contributes to the cost-effectiveness of CTR.

Acceptability
Well accepted approach in the literature in multiple health system settings.

Feasibility
No feasibility issues are expected as this approach minimizes the use of potentially unnecessary draping.

Future Research
Randomized controlled trials of field sterility in hand surgery are lacking and would strengthen the evidence against their use.

Limited evidence suggests anticoagulation medication may be safely continued for carpal tunnel release.

Two low quality studies provide limited evidence suggesting that anticoagulation medication may be safely continued for carpal tunnel release. Kaltenborn (2019) utilized propensity score matching to evaluate the association of bleeding complications with acetylsalicylic acid use in patients undergoing carpal tunnel release and demonstrated no difference in bleeding outcomes between the acetylsalicylic acid cohort and the control cohort. Brunetti (2013) similarly demonstrated no difference in complications between cohorts undergoing carpal tunnel release taking acetylsalicylic acid and those not taking acetylsalicylic acid. Although not included in the guideline given the lack of results specific to carpal tunnel syndrome, a single-center, prospective cohort trial (Bogunovic 2015) evaluated the impact of uninterrupted Warfarin use on hand and wrist surgery. When case matched to those not prescribed Warfarin, those prescribed Warfarin (with an INR<3.5) demonstrated an infrequent risk of bleeding complications requiring reoperation.

Benefits/Harms of Implementation
The benefits and harms of continuing anticoagulation vary based upon the indication for the specific anticoagulation. From a surgical perspective, the harm in continuing anticoagulation may include complications related to bleeding, however this has not been definitively demonstrated in the literature.

Cost Effectiveness/Resource Utilization
Continuation of anticoagulation medication may prevent unnecessary visits to a patient’s cardiologist and/or medical team to inquire and/or obtain counseling related to pausing or bridging medications.

Acceptability
Use of anticoagulants is accepted practice but may vary based upon type of anticoagulation, patient factors, and surgeon preference.

Feasibility
No issues related to feasibility beyond the anticipated discussion on risks of bleeding/hematoma when continuing on anticoagulation medication.

Future Research
Future research should be conducted to explore various types of anticoagulation and to increase the quality of evidence.

Limited evidence suggests perioperative prophylactic antibiotics are not indicated for the prevention of surgical site infection following carpal tunnel release.

Four low quality studies demonstrate limited evidence suggesting that perioperative prophylactic antibiotics are not indicated for the prevention of surgical site infection following carpal tunnel release. Multiple retrospective reviews have demonstrated that the use of prophylactic antibiotics for carpal tunnel release does not decrease the rate of infection, even in patients with diabetes (Harness 2010, Mehta 2022, Tosti 2012, Vasconcelos 2017). A claims database study evaluating the effectiveness of perioperative antibiotics for common soft tissue hand procedures that controlled for several patient demographic factors through propensity score matching demonstrated no difference in infection rates between cohorts with and without perioperative prophylactic antibiotics (Li, 2018). Notably, this study, despite including over 60,000 patients undergoing carpal tunnel release (>50% of included patients) was not included in the evidence as the infection rate was not detailed by condition.

Benefits/Harms of Implementation
The benefit of perioperative prophylactic antibiotics is the prevention of surgical site infection; however, this has not been demonstrated in the literature. The harm of perioperative prophylactic antibiotics includes risks related to the side effects of antibiotics (allergic reactions, development of drug-resistant organisms, and Clostridium difficile infection) without the proven benefit of reducing infections.

Cost Effectiveness/Resource Utilization
There are costs associated and resources utilized in the delivery of perioperative antibiotics and the treatment of downstream adverse effects.

Acceptability
It is accepted practice to limit the overuse of antibiotics although not strictly practiced by all surgeons due to other guidelines for major surgery that support the routine administration of preoperative antibiotics (e.g., total joint arthroplasty).

Feasibility
There are no feasibility issues with the implementation of this recommendation as it suggests limited unnecessary care.

Future Research
Future research should address the strength of recommendation through more condition-specific analyses for the use of preoperative antibiotics.

In the absence of sufficient evidence specific to carpal tunnel, it is the opinion of the workgroup that routine pre-operative testing (e.g., labs, CXR, EKG) is not indicated.

There are no studies evaluating the utilization of pre-operative testing (e.g., labs, CXR, EKG) for carpal tunnel patients only. One study evaluated the use of pre-operative testing for patients with common hand conditions (including carpal tunnel) and demonstrated increased generation of downstream tests, procedures, and costs. Studies outside of hand surgery consistently demonstrate that pre-operative testing for healthy patients undergoing minor procedures leads to delays in care, unnecessary downstream testing and care, and added costs.

Benefits/Harms of Implementation
The potential benefits of this recommendation include decreasing the utilization of unnecessary testing that has the potential to lead to increased costs, delays in care, and downstream care cascades. The potential harm is missing a critical test result that may impact care or the patient’s health. In healthy patients, this risk and thus potential harm is low. As such, the working group recommends that peri-operative testing not be performed routinely on healthy patients before carpal tunnel release and may be utilized on a case-by-case basis for non-healthy patients when it may impact their anesthetic type or peri-operative care.

In the absence of reliable evidence, it is the opinion of the workgroup that, when multiple risk factors for amyloidosis are present, pathological analysis of tenosynovium may be performed.

Amyloidosis has various clinical manifestations that can include cardiac dysfunction. Carpal tunnel is often one of the earliest clinical manifestations of amyloidosis (Nakagawa 2016). A recent cross-sectional study of patients with carpal tunnel syndrome undergoing carpal tunnel release showed that 10.2% exhibited amyloid deposits on tenosynovial biopsy, leading 4% to disease-modifying treatment. Although the diagnosis of amyloidosis is rare, given the lack of high-quality evidence to guide the decision to perform pathological analysis of tenosynovium, it is the opinion of the workgroup that this decision should be guided by patient preference and risk factors (Sood 2021).

Benefits/Harms of Implementation
The benefits of tenosynovial analysis include the possible detection and possible treatment of amyloidosis. The harms include the downstream care cascade that may result from a positive biopsy (e.g., lab testing, echocardiograms) that may be negative.

Cost Effectiveness/Resource Utilization
There are costs associated and resources utilized in the pathological analysis of tenosynovium. There are also downstream care cascades that may result from a positive sampling.

Acceptability
Accepted practice but may vary based upon risk factors and patient preference.

Feasibility
No feasibility issues beyond limitations in access to appropriate labs.

Future Research
Future research should involve the cost effectiveness of pathological analysis of tenosynovium based upon various risk profiles and the impact of downstream care cascades that may result from a positive sample.

In the absence of reliable evidence, it is the opinion of the workgroup that Tramadol may be considered over other opioids for postoperative pain management.

Miller et al. (2017) conducted a prospective cohort study to compare the effectiveness of opioids (i.e., hydrocodone, codeine, oxycodone) and tramadol. The results showed that patients that took opioids postoperatively had more medication-related side-effects and pill-consumption than those who took Tramadol. A multivariate regression analysis demonstrated that a tramadol prescription was an independent predictor of decreased total pill consumption. Moreover, patients with opioid prescriptions consumed only 28% of the filled prescription, compared to 36% consumption for tramadol. As this is the only article that met inclusion criteria and was low-quality due to its observational study design, the workgroup has provided the opinion consensus statement above.

Benefits/Harms of Implementation
The use of Tramadol over opioids for postoperative pain management has benefits as it avoids the many adverse effects of opioids (overdose and addiction).

Outcome Importance
Tramadol remains an option to help control postoperative pain.

Acceptability
Accepted treatment for pain in the postoperative state.

Future Research
There are no high-quality studies comparing the use of tramadol versus opioids in the control of postoperative pain after carpal tunnel release.