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Neurol Sci 

DOI 10.1007/s10072-009-0213-9 

REVIEW ARTICLE 

Diagnosis, treatment and follow-up of the carpal tunnel syndrome: 

a review 

Calogero Alfonso • Stefano Jann • Roberto Massa • 

Aldo Torreggiani 

Received: 5 August 2009 / Accepted: 24 December 2009 

Ó Springer-Verlag 2010 

Abstract The carpal tunnel syndrome is a compressive 

neuropathy with high incidence rates, and its correct 

diagnosis, treatment and follow-up may lead to significant 

benefits in healthcare, social and economic terms. In this 

review, based on systematic review databases and guidelines, 

we summarise the appropriate indications for the 

diagnosis, treatment and follow-up, accompanied, whenever 

possible, by the levels of evidence and strength of 

recommendations. 

Keywords Carpal tunnel syndrome Guidelines 

Surgical therapy Non-surgical therapy 

Katz hand diagram 

C. Alfonso 

U.O. Ortopedia e Traumatologia, Azienda Ospedaliera di 

Bologna Policlinico S. Orsola-Malpighi, Via Albertoni, 

15, 40141 Bologna, Italy 

e-mail: rinoalfonso@yahoo.it 

S. Jann 

U.O. Neurologia, A.O. Ospedale Maggiore Niguarda, 

Piazza Ospedale Maggiore 3, 20162 Milan, Italy 

e-mail: Stefano.Jann@OspedaleNiguarda.it 

R. Massa 

Dipartimento di Neuroscienze Università di Roma 

‘‘Tor Vergata’’, Via Montpellier 1, 00133 Rome, Italy 

e-mail: massa@uniroma2.it 

A. Torreggiani (&) 

Via Ciovasso, 4, 20121 Milan, Italy 

e-mail: torex@tin.it 

Introduction 

The present article, first in a series of two, is meant to 

suggest a synthesis of the current knowledge that could 

lead to the definition of diagnostic and therapeutic procedures 

aimed at improving the quality of care for 

patients affected by the most-frequent compressive 

neuropathies: carpal tunnel syndrome and lumbar sciatic 

pain. 

For the preparation of this paper, we consulted several 

sources capable of providing a reliable and authoritative 

synthesis of the current knowledge of specific aspects of 

each disease: the Cochrane Library (database created by 

the Cochrane Collaboration including, among other 

things, systematic literature reviews) [1], clinical evidence 

(a summary of evidences, organised by disease, 

that reports information on incidence and prevalence, 

therapeutic and diagnostic, clinical and instrumental 

aspects, as well as prognostic features) [2], and 

guidelines. 

Reference to the guidelines on the selected topics is 

always indicated by the authors with the corresponding 

strength of recommendations and level of evidence [3]. 

The LOE acronym represents the classification according 

to the ‘‘Levels of Evidence’’, identified by Roman 

numerals. By LOE, we refer to the probability that a given 

number of evidence be derived from studies planned and 

conducted in such a way as to produce valuable information, 

free from systematic errors. 

The SOR acronym designates the ‘‘Strength of Recommendations’’. 

These are indicated by letters from A to E. 

By SOR, we refer to the probability that the clinical 

application of a recommendation determine an improvement 

in the health condition of the population to whom the 

recommendations are directed Tables 1, 2. 

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Table 1 Levels of evidence [3] 

I Evidence obtained from several randomised controlled clinical 

trials and/or from systematic reviews of randomised studies 

II Evidence obtained from a single randomised trial with adequate 

design 

III Evidence obtained from cohort studies with concurrent or 

historical controls or from their meta-analysis 

IV Evidence obtained from retrospective case–control studies or 

from their meta-analysis 

V Evidence obtained from case studies (case series) without control 

group 

VI Evidence based on the opinion of authoritative experts or expert 

committees as indicated in guidelines or consensus conferences, 

or based on opinions of the members of the working group 

Table 2 Strength of Recommendations [3] 

A Performance of a given procedure or diagnostic test is highly 

recommended. Indicates a particular recommendation supported 

by scientific evidence of a good level, although not necessarily 

of levels I or II 

B Questions arise on the fact that a given procedure/intervention 

should always be recommended, and its performance must 

always be carefully taken into consideration 

C Considerable uncertainty exists in favour or against the 

recommendation to perform a procedure or intervention 

D Performance of the procedure is not recommended 

E It is strongly recommended not to perform the procedure 

Compressive and entrapment neuropathies 

Compressive neuropathies are mononeuropathies or radiculopathies 

caused by mechanical distortion produced by a 

compressive force. In particular, we define entrapment 

neuropathy a chronic focal compressive neuropathy caused 

by a pressure increase inside specific unstretchable anatomical 

structures (channels) [4]. 

When the nerve fibres are subjected to a mechanical 

force, demyelination of the paranodal region initially 

develops in the compression site, which then spreads to 

the entire internodal segment. In this first phase, a block 

of nervous transmission occurs, caused by focal demyelination 

with intact axons (neuroapraxia). If the compression 

persists, blood flow to the endoneural capillary 

system may be interrupted, leading to alterations in the 

blood-nerve barrier, development of endoneural oedema, 

and onset of a vicious circle made of venous congestion, 

ischaemia and local metabolic alterations. This series of 

events, if protracted in time, may lead to axonal 

degeneration, macrophage attraction and activation, 

release of inflammatory cytokines, nitric oxide, and 

development of ‘‘chemical neuritis’’ [4]. In compressive 

123 

neuropathies, pain is caused by an abnormal diffusion of 

the Na ? channels into the damaged nociceptive fibres, 

with hyperexcitability and ectopic discharge induction. 

An important role in the genesis of compressive neuropathic 

pain is played by inflammatory mediators, in 

particular TNFa [4]. 

Compressive radiculo-neuropathies are frequent disorders 

(represent a series of diffuse diseases) with similar 

(invariable) pathogenesis, and they correspond to a high 

percentage of general practitioners’ and specialists’ outpatient 

activities, and of pharmaceutical, hospitalisation 

and rehabilitative expenses. Carpal tunnel syndromes and 

lumbar disc herniations are the most-relevant clinical 

manifestations. 

The carpal tunnel syndrome 

The carpal tunnel syndrome (CTS) is a neuropathy caused 

by entrapment of the median nerve at the level of the carpal 

channel, delimitated by the carpal bones and by the 

transverse carpal ligament. 

Epidemiology 

Neurol Sci 

CTS is the most-frequent entrapment neuropathy, with 

prevalence rates of up to 9.2% in women and 6% in men 

[5] and incidence rates of up to 276:100,000/year [6]. 

Considering the data of the 2001 Second Dutch Survey 

of General Practice, concerning a population of almost 

400 thousand subjects, a 6.5% yearly incidence of upper 

limb disorders was estimated, higher in women (7.6%) 

than in men (5.6%), with a 15% prevalence (12% in men 

and 17% in women) [7]. In all Western countries, an 

increase is reported in the number of work-related 

musculoskeletal disorders (WMSDs) caused by strain and 

repeated movements (biomechanical overload). In Europe, 

in 1998, over 60% of upper limb musculoskeletal 

disorders recognised as work-related were CTS cases [8, 

9]. Data reported by INAIL (the Italian National Institute 

for Insurance against Industrial Accidents) concerning 

WMSDs in the period 1996–2000 show a marked 

increase both in the reported cases, and in the recognised 

ones: from the 931 reported and 10 accepted cases in 

1996, they reached 1960 reported and 1,061 accepted 

cases in 2000. The most-frequent disorders reported in 

2000 were CTS (57%), wrist, hand and shoulder tendinitis 

(19%), epicondylitis (10%), and disc arthrosis and 

herniation (7%) [10]. In 2000, of the WMSDs accepted 

by INAIL, 39% derived from the engineering sector, 

11% from the textile and clothing industry, 9.5% from 

the food sector, 4.6% from the ceramic industry, 4% 

from the building industry, 2.4% from wood processing,

Neurol Sci 

2.2% from the footwear sector, and 2% from the transport 

sector [11]. 

The number of WMSDs reported to INAIL has become 

the highest, after the cases of hypoacusia, of the ‘‘nonlisted’’ 

professional diseases. In 2004, reports of CTS alone 

were 941 [11]. Naturally, these data reflect the increasing 

level of sensitivity to this problem, which is translated into 

a higher number of reports, rather than reflecting an actual 

increase. 

Clinical features and stages 

CTS may be classified on the basis of symptoms and signs 

into three stages: 

First stage: Patients have frequent awakenings during 

the night with a sensation of swollen, 

numb hand; furthermore, they report of 

severe pain that irradiates from the wrist 

to the shoulder, and an annoying tingling 

in their hand and fingers (brachialgia 

paraesthetica nocturna). Hand shaking 

brings relief. At morning, a sensation of 

hand stiffness usually persists. 

Second stage: Presence of symptoms also during the day, 

mostly when the patient remains in the 

same position for a long time, or performs 

repeated movements with hand and wrist. 

When motor deficit appears, the patient 

reports that objects often fall from his/her 

hands. 

Third stage: Final stage, hypo-/atrophy of the thenar 

eminence. In this phase, sensory 

symptoms may diminish [12]. 

Diagnosis 

The clinical pattern is well known, and two papers by the 

Quality Subcommittee of the American Academy of Neurology 

(AAN) defined the guidelines for clinical [10] and 

neurophysiologic diagnosis [11]. 

Two papers by the Quality Standards Subcommittee of 

the American Academy of Neurology [13] and American 

Association of Electrodiagnostic Medicine, American 

Academy of Neurology and American Academy of Physical 

Medicine and Rehabilitation defined the guidelines for 

clinical and neurophysiologic diagnosis of CTS [14]. 

Case history must focus on symptom onset (in the early 

stage, mainly nocturnal paraesthesias), provocative factors 

(positions, repeated movements), working activity (instrument 

use, vibrating tools), pain localisation and irradiation 

(in the cutaneous median nerve region with ascending, 

sometimes up to the shoulder, or descending irradiation), 

manoeuvres which alleviate symptoms (hand shaking, 

position changes), presence of predisposing (prognostic 

no!) factors (diabetes, adiposity, chronic polyarthritis, 

myxoedema, acromegaly, pregnancy), sports activity 

(baseball, body-building) (Table 3). 

Physical examination 

The list of findings and manoeuvres used in the diagnosis 

of CTS is long; however, a recent literature review has 

focussed its attention on a symptom diagram, and on two 

signs that are most of help in predicting a positive 

electrodiagnosis of CTS (diagnostic test of reference) 

[15]. 

The Katz hand diagram [16] is a self-administered diagram 

that allows the patient to localise symptoms and to 

describe them as numbness, pain, tingling and 

hypoesthesia. 

The diagrams may be classified into three patterns. 

Classical pattern: Symptoms affect at least two 

of either first, second or third 

fingers. Symptoms involving 

the fourth and fifth fingers, 

wrist pain and radiation of 

pain proximal to the wrist are 

permitted. Involvement of 

palm or dorsum of the hand 

is not allowed; 

Probable/possible pattern: Same symptoms as in the 

classical pattern, except for 

the palmar symptoms, which 

are accepted if limited to the 

median side. Possible pattern: 

involvement of only one of 

Table 3 The likelihood of CTS increases with the number of 

symptoms and provocative or mitigating factors listed below [13] 

Symptoms 

Dull, aching discomfort in the hand, forearm, or upper arm 

Hand paraesthesias 

Weakness or clumsiness in the hand 

Dry skin, swelling or colour changes of the hand 

Occurrence of these symptoms in the median distribution 

Provocative factors 

Sleep 

Sustained arm or hand positions 

Repetitive actions of the hand and wrist 

Mitigating factors 

Change in hand posture 

Shaking of the hand 

123

the first, second or third 

finger; 

Unlikely pattern: No symptoms are present in 

first, second or third finger. 

A classical or probable diagram is indicative of CTS 

(sensitivity = 0.64; specificity = 0.73; LR = 2.4; 95% 

CI = 1.6–3.5) (LOE I) [15]. 

The finding of hypalgesia in the median nerve territory 

(sensitivity = 0.51; specificity = 0.85; LR = 3.4; 95% 

CI = 2.0-5.8) and weakness of the abductor pollicis brevis 

muscle (sensitivity = 0.66; specificity = 0.66; LR = 2.0; 

95% CI = 1.4–2.7) are indicative of CTS (LOE I) [15]. 

Some traditional manoeuvres such as the Tinel and 

Phalen signs, the finding of a reduced two-point discrimination 

or of atrophy of the thenar eminence, has scarce or 

no diagnostic value (LOE I, SOR D) [15]. It must be 

remembered that objective examination may be absolutely 

normal in patients with a typical case history of CTS [13] 

(Table 4). 

Differential diagnosis 

CTS must be differentiated from: 

• Cervical radiculopathy (especially C6–C7) 

• Brachial plexopathy (in particular of the upper trunk) 

• Proximal median neuropathy (especially at the pronator 

teres level) 

• Thoracic outlet syndrome 

• CNS disorders (multiple sclerosis, small cerebral 

infarction) 

Instrumental diagnosis and its evaluation 

Neurophysiological diagnosis 

Nerve conduction studies and electromyography may 

confirm, but not rule out, the diagnosis of CTS. The aims of 

Table 4 Key points 

Diagnosis 

Clinical classification 

First stage: brachialgia paraesthetica nocturna 

Second stage: daytime complaints 

Third stage: hypo-/atrophy of thenar eminence 

An accurate case history leads to a first diagnostic hypothesis 

A classical or probable Katz hand diagram is indicative of CTS 

(SOR A) 

Signs indicative of CTS (SOR A) 

Hypalgesia in the median nerve territory 

Weakness of the abductor pollicis brevis 

123 

Neurol Sci 

this evaluation are the following: (1) to confirm a focal 

damage to the median nerve inside the carpal tunnel; (2) to 

quantify the neurophysiological severity by using a scale; 

(3) to define the nerve pathophysiology: conduction block, 

demyelination and axonal degeneration. In a recent review, 

the American Association of Electrodiagnostic Medicine, 

the American Academy of Neurology and the American 

Academy of Physical Medicine and Rehabilitation defined 

the Practice Parameters for electrodiagnostic studies in 

CTS [14]. 

Electroneurography Median sensory and motor conduction 

studies have a mean overall sensitivity of 85% and 

specificity of 95%. The standard examination involves a 

measurement of the median nerve sensory conduction 

velocity (SCV) across the wrist with a conduction distance 

of in a 13–14 cm (SORA). If this is altered, SCV is also 

measured on a similar distance on another adjacent nerve in 

the same hand (e.g., third finger-median vs. fifth fingerulnar) 

to rule out possible polyneuropathy. If SCV in the 

median nerve is normal, one of the following additional 

studies are recommended: (a) comparison of SCV or mixed 

nerve CV through the wrist, over a 7–8 cm distance, with 

ulnar SCV or mixed CV over the same distance, or: (b) 

comparison of median SCV with SCV of another nerve in 

the same finger (fourth median/ulnar finger or first median/ 

radial finger) or; (c) comparison of median SCV or mixed 

CV through the carpal tunnel with proximal (forearm) or 

distal (finger) median SCV or mixed CV (SOR A). The 

study of motor conduction velocity and of distal motor 

latency (DML) in the median and ulnar nerves in the same 

hand may provide additional data (SOR B) [14]. 

Needle electromyography May be useful to confirm 

axonal degeneration of the motor fibres innervating the 

abductor pollicis brevis and opponens pollicis muscles. The 

study of other upper limb muscles with C5-T1 innervation 

may be useful in the differential diagnosis with disorders 

more proximal to the median, or to rule out a radiculopathy 

(SOR C) [14]. 

Neurophysiological classification In order to standardise 

the diagnostic and therapeutic approach to any disease it is 

essential to: 

1. have a common interdisciplinary language, 

2. have a classification possibly based on objective 

findings, not on reported symptoms or on imprecise 

and non-specific clinical signs. 

The electrophysiological classification [17, 18], in 

agreement with the AAEM guidelines, follows the neurophysiological 

progression of CTS severity and includes the 

following classes: 

Negative CTS: Normal findings on all tests (including 

comparative and segmental studies);

Neurol Sci 

Minimal CTS: Abnormal findings only on comparative 

or segmental tests; 

Mild CTS: SCV slowed in the finger–wrist tract 

with normal DML; 

Moderate CTS: SCV slowed in the finger–wrist tract 

with increased DML; 

Severe CTS: Absence of sensory response in the 

finger–wrist tract with increased DML; 

Extreme CTS: Absence of thenar motor response 

This classification has the advantage/disadvantage of 

using adjectives commonly used; therefore, we suggest to 

specify that the quantification refers to neurophysiological 

data (Table 5). 

Diagnostic imaging 

In most CTS cases, the cause is not easily identified (idiopathic 

form). The causes of the secondary forms of this syndrome 

include space-occupying lesions (tumours, synovial 

tissue hypertrophy, bone formation, osteophytes), metabolic 

and physiologic conditions (pregnancy, hypothyroidism, 

rheumatoid arthritis), infections, neuropathies (associated to 

diabetes mellitus or alcoholism), and familial disorders. 

When the presence of space-occupying lesions is suspected, 

a wrist study performed by magnetic resonance or 

by other imaging techniques (CT, X-ray) are of basic 

importance for an aetiologic diagnosis. On other hand, 

diagnostic imaging is not currently used in clinical practice 

for the diagnosis of idiopathic CTS (SOR D). However, 

MRI provides an excellent visualisation of the median 

nerve and of its links with the other carpal tunnel structures 

and, in particular, it allows for the individuation of either 

nerve adhesion or compression. Last, a correlation between 

some MRI parameters and the level of electrophysiologic 

severity has recently been demonstrated [19, 20]. 

Treatment of the carpal tunnel syndrome 

The conservative or surgical treatment of CTS is indicated 

when symptoms are so painful as to interfere with daily 

activities (SOR A) [13]. 


Instrumental diagnosis 

EMG and nerve conduction studies may confirm, but not rule out, 

the diagnosis of CTS 

Standard exam: measurement of sensory conduction velocity of the 

median nerve in the third finger–wrist tract 

It is essential to have an objective classification to evaluate the 

electrophysiological severity of CTS 

Diagnostic imaging is not used in clinical practice in the diagnosis 

of idiopathic CTS 

The conservative treatment is suggested as a first option, 

unless progressive motor deficit, severe sensory deficit or 

serious electrophysiologic abnormalities occur [13]. The 

most-frequent conservative treatments include: 

1. Modification of daily activities 

2. Drugs (NSAIDs, oral or intracarpal steroid injections, 

diuretics) 

3. Ultrasonography 

4. Hand and wrist splinting 

Pharmacological treatment 

There is an extremely limited number of studies on the 

pharmacological treatment. First of all, it is important to 

treat all conditions associated with CTS. In particular, the 

treatment of rheumatoid arthritis or of other types of 

inflammatory arthritis may improve symptoms. Hypothyroidism 

and diabetes mellitus must also be treated, 

even though the effect of this treatment on CTS is still 

uncertain. 

The conservative treatment is generally more effective if 

the neuroperipheral damage of peripheral nerve is mild 

(intermittent hypoesthesia and absence of sensory or motor 

deficit at neurological examination). 

The most-common conservative treatments for CTS are: 

steroids, both by systemic administration and by localinjection, 

non-steroidal anti-inflammatory drugs (NSAIDs), 

diuretics, pyridoxine, and splinting. 

Steroids The hypothesis is that they reduce interstitial 

fluid pressure inside the carpal channel. Studies have been 

conducted to assess the effect of oral prednisone administration, 

of the local administration of depot steroids, a 

comparison study between the two ways of administration, 

and one comparison study between intramuscular and 

local-injection. 

What emerges from these studies and is also underlined 

by Cochrane reviews [22, 23] is that: 

• Oral treatment with 25 mg prednisone/day for 10 

consecutive days determines an improvement in symptoms 

for at least 8 weeks (LOE II). 

• The local administration of steroids is effective at least 

in the short-term (2–4 weeks) (LOE I). Local administration 

is more effective than the intramuscular (LOE 

II). 

• Local administration seems to be more effective than 

the oral, at least in the short-term (LOE II). 

Diuretics and NSAIDs In spite of their constant use, 

these drugs have shown no effective results on controlled 

studies (LOE I) [24]. In fact, CTS is not an inflammatory 

condition, and the pain it produces is not 

neuropathic. 

123

Pyridoxine (vit. B6) Its administration has not proved to 

be effective in controlled studies, in spite of the promising 

initial data (LOE I) [26]. 

L-Acetyl-carnitine (LAC) Has been shown to have 

analgesic effects in a series of 109 patients affected by CTS 

(LOE V). As indicated in the case of lumbar sciatic pain, 

the possibility that LAC have both a symptomatic and a 

neuroprotective effect on pain, makes this treatment 

promising [25] (Table 6). 

Non-pharmacological treatment 

The current evidence shows a significant short-term 

improvement after wrist splinting and immobilisation. 

Controversy also exists on the effectiveness of ultrasound 

therapy. Other conservative treatments do not seem to 

produce any improvements. Further studies are needed to 

compare treatments and evaluate the duration of their 

effectiveness over time. 

Ultrasound treatment 

In the literature, two randomised controlled studies are 

reported. In the first study, the application of ultrasounds 

(1.0 W/cm 2 , 15 min/session, 5 sessions/week for 5 weeks) 

led to a significant improvement in pain, paraesthesias, and 

hypoesthesia after 2 weeks, 7 weeks, and 8 months as 

compared to placebo (0 W/cm 2 ) (LOE II) [27]. 

The second study (of lower quality) compared the 

effects of low-intensity (0.8 W/cm 2 ) with high-intensity 

(1.5 W/cm 2 ) ultrasounds and placebo; no significant difference 

was evidenced in the severity of symptoms and in 

the frequency of awakening at night in the three groups 

after 20 days of treatment [28]. 

Hand and wrist splinting 

Splinting has been used for over 40 years in the treatment 

of CTS; however, randomised studies conducted on its 

effectiveness are very few. One randomised controlled 

study has proved that night-time wear of an innovative soft 

hand brace for 4 weeks was associated to a significant 


Pharmacological treatment 

Conservative treatment is effective in the mild-moderate forms 

Conservative treatment is suggested as a first option unless 

progressive motor deficit, severe sensory deficit or serious 

electrophysologic anomalies occur (SOR B) 

Steroids are effective, mostly when administered locally 

L-Acetyl-carnitine combines a potentially neuroprotective effect 

with effective pain control (LOE V) 

123 

improvement in symptoms and functions as measured with 

the Boston Carpal Tunnel Symptom Questionnaire [29], 

compared to the non-treated group (BCTS SYMPT: 1.21 

vs. 0.16, P \ 0.001; BCTS FUNCT:0.41 vs. 0.01, 

P \ 0.001) (LOE II) [30]. The degree of symptom and 

function improvement was comparable to that reported in a 

prospective study of patients after 3 months from surgical 

intervention [28]. 

Another study compared the effectiveness of splints 

immobilising the wrist at 20° extension with neutral 

angle splints [31]. The results showed that after 2 weeks, 

the neutral angle provided superior symptom relief as 

compared to extension. However, a re-analysis of the 

same data that simplified the outcome categories as 

‘‘improvement’’ and ‘‘no improvement’’ indicated that 

there was no difference between the two types of splint 

[31]. 

A third study did not evidence any significant difference 

between the full-time or night-only wear of a neutral angle 

splint used for 6 weeks [33]. 

Last, a small randomised study did not evidence any 

significant difference between the association between 

nerve and tendon gliding exercises (aimed at restoring the 

maximum excursion of the median nerve and of the carpal 

tunnel tendons) and the use of wrist splints as compared to 

splinting alone in terms of symptoms or function 

improvement after 8 weeks from the end of treatment [34]. 

MLS laser therapy 

Multiwave locked system (MLS) laser therapy [35–38] is 

the synchronised delivery of continuous and pulsed laser 

emissions with different infrared wavelengths. Thanks to 

these features, it has an anti-oedema effect, as it stimulates 

blood and lymphatic circulation and induces fast reabsorption 

of fluid build-ups. The components MLS laser 

have been demonstrated to accelerate and improve the 

quality of nerve regeneration in rats after lateral neurorraphy 

of the ulnar and median nerves. In vivo studies 

demonstrated a complete remyelination at the level of the 

median nerve, with recovery of nerve conduction and of 

the contraction capacity of the innervated muscle, which 

regains its capacity of correctly receiving the nervous 

stimulation (Table 7). 

Surgical treatment 

Neurol Sci 

Several studies have been published on the indications and 

effects of CTS treatments, including one guideline document 

[13]. 

Surgical indication is limited to patients in whom the 

conservative treatment has not been effective in relieving 

pain or with progressive motor deficit, severe sensory

Neurol Sci 


Non-pharmacological treatment 

The use of ultrasounds is controversial (SOR C) 

Questions remain on whether neutral angle wrist splinting is better 

than extension splinting 

A soft hand brace have a short-term effectiveness on symptoms and 

functionality (SOR A) 

Full-time splint wear does not lead to greater improvement as 

compared to night-only wear 

deficit or severe anomalies on electrodiagnostic examination 

(SOR B) [13]. 

No randomised controlled studies have ever been 

reported in the literature comparing surgical versus no 

treatment. In a recent review of 209 studies on the treatment 

of CTS published between 2000 and 2006, which 

regarded 32,936 interventions, 75% of patients reported of 

complete symptom resolution or of mild residual symptoms 

after intervention, 17% reported mild improvement or 

no change, and 8% reported worsening [21]. 

There are three randomised controlled studies that 

compare surgical versus conservative treatment [40–42], 

two of which were included in a systematic Cochrane 

review [43]. In the studies included in the review [40, 42], 

the non-surgical group had been treated by hand–wrist– 

forearm splinting for 4 or 6 weeks. In the more-numerous, 

better-quality study, 71% of surgically treated patients 

experienced significant improvement after 3 months as 

compared to a 1.38 improvement (95% CI: 1.08–1.75) in 

favour of surgery [40]. This improvement still persisted 

after 6 and 18 months. In any case, it must be underlined 

that in this study, after 18 months 41% of patients in the 

splinting group had undergone surgical treatment. The 

reviewers concluded that, although short-term (1 month) 

statistical data were only mildly significant, surgical 

treatment is more effective than conservative therapies in 

preserving mid- to long-term improvement [43]. In the 

study by Ly-pen et al. [41], the non-surgical group 

underwent steroid treatment by local infiltration. Surgical 

treatment was significantly less effective in improving 

symptoms after 3 months (percentage of subjects with 

improvement equal to or higher than 20%; nocturne paraesthesia: 

94% with corticosteroids vs. 75% after surgery; 

daytime pain: 89 vs. 69%; compromised function: 88 vs. 

68%). However, after 6 and 12 month there were no significant 

differences between the two groups. 

There are two surgical procedures: 

1. ‘‘Open carpal tunnel release’’ (OCTR) after curvilinear 

skin incision in the palm, which may be associated, in 

case of thickening of the external nerve sheath, to 

epineurotomy and, if cicatricial tissue is present within 

the nerve, to internal neurolysis to decompress the 

single nerve fascicles. 

2. ‘‘Endoscopic carpal tunnel release’’ (ECTR), characterised 

by sectioning of the ligament from inside the 

carpal tunnel, leaving the structures and skin plane 

above the tunnel intact. 

Two systematic reviews [44, 45] and two randomised 

studies [46, 47] are available, which compare the two 

procedures. The conclusion is that, at the moment, there is 

no evidence to support the superiority of ECTR over 

OCTR in providing short- and long-term symptom 

improvement and in leading to recovery of normal activities 

(LOE I, SOR A). At present, the decision on the 

technique to be used seems to be basically linked to the 

patient’s and surgeon’s preference. 

Contraindications to surgical intervention 

There are no specific contraindications to OCTR. The 

patient’s clinical condition must be stable before the 

intervention. Pregnant women should postpone the intervention 

because symptoms often disappear after delivery. 

In contrast, ECTR is contraindicated [48]: 

1. In case of rheumatoid arthritis (the intervention may 

worsen the inflammatory process) 

2. In CTS secondary to recent trauma with symptoms 

suggesting the involvement of the median nerve, 

limited wrist extension and previous wrist intervention 

3. In case of recurrent tenosynovitis or other palmar 

inflammations (these patients may benefit from neurolysis, 

which is only performed during OCTR) 

4. In case of Dupuytren syndrome or in case of previous 

hand interventions 

5. In patients undergoing anticoagulant treatment, 

because with ECTR only compressive haemostasis 

may be achieved 

6. When there is a marked involvement of the thenar 

motor branch, which makes ‘‘open’’ exploration 

necessary 

7. When the patient prefers to undergo general anaesthesia, 

which does not allow for the patient to report 

symptoms indicative of possible nerve lesions during 

the procedure 

8. In case of evident malformations or in the presence of 

a mass. 

Complications associated with the interventional technique 

The frequency of complications varies from study to study, 

independently of the technique. Two literature reviews 

conclude that transient nerve disorders (neuroapraxia, 

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Surgical treatment 

Surgical indication is limited to patients in whom the conservative 

treatment has not been effective in relieving pain or with 

progressive motor deficit (SOR B) 

Surgical treatment is more effective than conservative therapies in 

preserving mid- to long-term improvement (SOR A) 

After surgery, 75% of patients have complete symptom resolution, 

8% worsen 

At present, there is no evidence to support the superiority of ECTR 

over OCTR (SOR A) 

There are no specific contraindications to OCTR 

There are several contraindications to ECTR 

Postoperative use of rigid splints is probably useless or detrimental 

(SOR D) 

numbness and paraesthesia) are more frequent after ECTR, 

while OCTR is more often the cause of complications 

involving the wound (infection, hypertrophy and scar pain) 

[44, 45]. 

Postoperative treatment 

Keeping the hand lifted after the intervention and gradually 

resuming hand functions are recommended (LOE VI) [13]. 

The use of rigid braces that immobilise the wrist for 2– 

3 weeks after the intervention is usually suggested [13], 

although two randomised studies did not evidence any 

significant difference in grip strength or in the number of 

patients who were considered as healed after 2–4 weeks 

[49, 50]. Another randomised study concludes that, compared 

to no treatment, the use of a splint for 2 weeks after 

the intervention significantly delayed the return to work 

[51] (Table 8). 

Outcome evaluation and follow-up 

For both conditions, both lumbosacral radiculopathy and 

carpal tunnel syndrome, it is fundamental to individuate the 

main outcome measures [52]. 

For lumbosacral radiculopathy, patient-centred outcome 

measures may be used: 

• Clinical improvement according to the patient, general 

practitioner, or both 

• Pain decrease 

• Improved quality of life 

• Return to work 

• Objective improvement at neurological examination 

(reflexes, strength, sensitivity) 

• Possible surgical intervention 

As concerns the carpal tunnel syndrome, the Global 

Symptom Score (GSS) is often used. It consists in the 

123 


Follow-up 

For CTS outcome evaluation, the Generic Summary Score (GSS) is 

used 

numerical quantification from 0 (no symptom) to 10 (worst 

possible symptom) of 5 symptoms: pain, paraesthesia, 

hypoesthesia, hyposthenia, awakening at night. The sum of 

the scores for each symptom determines the GSS [53]. 

In Italy, the Boston Carpal Tunnel Questionnaire 

(BCTQ) is an increasingly used outcome measure in CTS 

as it is patient-oriented, highly reproducible, and validated 

in Italian language. In addition to symptoms (BCTQ 

SYMP, 11-parameter scale), BCTQ also evaluates function 

(BCTQ FUNCT, 8-parameter scale). Each parameter has a 

5-point scale; higher scores indicate more-severe symptoms 

and lower function [29]. Obviously, among the outcome 

measures for CTS there may also be an improvement 

in neurophysiologic parameters. 

As regards the first point, there are scales for the evaluation 

of the best overall clinical improvement, indicated 

as either Clinical or Patient Global Impression of Change 

(CGI-C and PGI-C). 

The pain visual analogue scale (VAS) is a widely used 

tool for pain evaluation. The VAS scale is represented by a 

100-mm line with anchor points of ‘no pain’ on the left 

extremity and ‘worst pain imaginable’ on the right 

extremity. Along with this, there are other numerical 

scales, the most-frequently used of which is the 11-point 

Lickert numerical scale. These scales assess pain intensity, 

whereas its quality may be assessed with the Short Form 

McGill Pain Questionnaire (SF-MPQ) [55]. Quality of life 

assessment is performed with a scale called SF-36 QOL 

[56]. 

As concerns follow-up, it has to be underlined that if 

there is no emergency condition (progressively worsening 

neurological deficit, risk of metastases or abscesses), conservative 

treatment may be followed for 4–6 weeks and 

possibly resumed cyclically (Table 9). 

Natural history 

Neurol Sci 

An observational study conducted on patients with idiopathic 

CTS reports symptom resolution within 6 months 

without treatment in 34% of hands. Remission rates were 

higher in younger subjects, in women, and in pregnant 

women [57]. In another study, according to the parameter 

examined, 27–34% of hands showed spontaneous 

improvement after 10–15 months. The most-severe 

patients had the greatest improvement. Favourable prognostic 

indicators included the short symptom duration and

Neurol Sci 


Natural history 

CTS may improve or resolve spontaneously 

young age. Negative predictive factors included bilateral 

symptoms and positive Phalen signs [58] (Table 10). 

Appendix 

Considerable contribution to the preparation of this document 

was obtained from an extensive number of Physicians 

specialised in Neurology, Orthopaedics, Physiatrics, Pain 

Therapy, and General Medicine, who supported us by 

bringing in corrections, integrations, suggestions and, in 

any case, in full agreement: 

Sebastiano Adamo, Massimo Alunni, Gaetano Amorico, 

Antonio Augusti, Mario Avalle, Giuseppa Barbera, Eugenio 

Barbieri, Massimo Baroncini, Angelo Bartesaghi, 

Angela Bassani, Maurizio Bejor, Giuseppe Bernardi, 

Antonio Bernardo, Claudio Boninsegna, Davide Bonomo, 

Silvano Botteselle, Enrico Califano, Valeria Campanella, 

Antonio Campisi, Riccardo Canero, Michele Capuano, 

Antonio Carbonari, Fabio Carbone, Piero Cataldo, Antonino 

Catanese, Antonio Cazzato, Riccardo Cecchetti, 

Francesco Chilelli, Alessandro Ciarimboli, Mario Ciarimboli, 

Giovanni Cilia, Roberto Conigliaro, Roberto Corezzola, 

Renzo Cosso, Ettore Costabile, Domenico Cremonesi, 

Marcello Cusitore, Michele D’Arienzo, Antonio D’Aura, 

Vincenzo D’Orsi, Angelo D’Annibale, Maurizio Daccò, 

Massimo Darbisi, Roberto De Masi, Paolo De Stefanis, 

Vito De Tullio, Maria Teresa Desiato, Giuseppina Di 

Stefano, Michele Dotta, Salvatore Emmola, Maurizio 

Falso, Andrea Fedeli, Giovanni Ficola, Alfio Mauro Finocchiaro, 

Giulio Fiorenza, Sabino Fiume, Michele Formoso, 

Elio Fortuna, Andrea Foti, Silvia Galeri, Raffaele 

Gambardella, Renato Gatto, Elisena Geraci, Sergio Gigliotti, 

Letizia Giulia Mauro, Luigi Grompone, Vittorio 

Guglielmo Grosso, Fabio Guerriero, Stefano Guidotti, 

Raimondo Ibba, Francesco Indiano, Giovanni Italiano, Rita 

l’Episcopo, Alessandro La Medica, Matteo Laringe, Rosita 

Laurenti, Vincenzo Lo Scalzo, Mario Longo, Davide 

Lucchi, Maria Lucia, Emanuele Lupetti, Vincenzo Roberto 

Macrì, Marco Maltinti, Alessandro Mannoni, Roberto 

Mantia, Fabrizio Mantia, Domenico Mantova, Marina 

Carlotta Marazzi, Nicola Margiotta, Claudio Mariani, 

Maria Letizia Marini, Angelo Claudio Marrone, Gianni 

Martelli, Daniele Martini, Alfredo Mattaliano, Massimo 

Maurencig, Giulio Mazzini, Rossella Medda, Alfonso 

Megna, Oriano Mercante, Antonio Mileto, Carmelo Militello, 

Gaetano Militenda, Donatella Moci, Mario Mosconi, 

Silvia Oldani, Maurizio Olivieri, Michele Olivieri, 

Giuseppe Partexano, Elisa Pasqualetto, Alberto Pellegrinetti, 

Massimo Pettinà, Pietro Pinelli, Giovanni Pozzuoli, 

Fausto Prete, Luca Puccetti, Antonino Pugliesi, Giovanni 

Antioco Putzu, Raffaele Quaranta, Daniele Raimondi, 

Giancarlo Rando, Fabrizio Rasi, Pietro Rettagliata, Leonardo 

Rivelli, Vincenzo Rollo, Pierpaolo Romani, Sergio 

Ronco, Vincenzo Rossi, Alberto Sampietro, Antonino 

Sanfilippo, Provvidenza Sansone, Giovanni Savoca, Giuseppe 

Scaglione, Antonio Scala, Francesco Sellitto, Agostino 

Spinelli, Fausto Stante, Walter Starace, Salvatore 

Torre, Raffaele Torre, Lucia Toscani, Arturo Tricarico, 

Enrico Trucco, Tobia Ulisse, Angelo Vetro, Cesarino Vezzosi, 

Massimo Vigilante, Renato Villaminar, Gennaro 

Vitiello, Luciano Wolensky, Leonardo Wolensky, Giancarlo 

Za, Antonio Zampogna, Angelo Zuppardo. 

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