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Carpal Tunnel Syndrome

Referrals for USS guided steroid injections to RCHT Clinical Imaging have restarted.  Please note there is limited capacity so referrals should be reserved for patients with significant disabling and persistent symptoms.  Please click here for full details



Covid-19 Update: Corticosteroid Injections During The Coronavirus Pandemic  

Please ensure and document that a discussion has happened that the patient is aware corticosteroid injections pose a possible and quantifiably unknown increased risk of, and complications from, Covid and the possible risk of reduced Covid vaccine efficacy prior to performing.  Secondary care referrals for steroid injection, including image guided injections, require the patient to be counselled and risk assessed prior to referral and this documented in the referral.  Please see guidance available here for detailed information. 

 


Classical Presentation

Nerve Conduction Studies

Conservative Measures

Referral For Surgery

 

Classical Presentation

Sensory symptoms, usually in the hand, but may be more extensive eg. Forearm or whole arm which are:

- Present at night / interrupt sleep

- Worse with use

- Relieved by dangling / movement

Motor symptoms: weakness and/or wasting of the thenar muscles

 

Blood tests are only considered if history and/or examination suggest a systemic cause such as Diabetes, Hypothyroidism, Rheumatoid arthritis

 

Nerve Conduction Studies are not usually necessary unless:

- Diagnostic uncertainty

CTS questionnaire < 5/9

- Recurrence of symptoms after surgery

 

Referral should be submitted through the RMS

 

Conservative Measures

1. Night splints are suitable for:

- Short history of symptoms with a definable cause that is likely to remit

- Predominantly night symptoms

- Patient not fit or willing for surgery

 

Splints can be accessed from:

Readily available online for patients to buy themselves

RCHT Appliance Department – specify small/medium/large/X large/Left/right

Local physiotherapy department

 

2.Steroid injection in-house or inter-practice referral

Useful for symptom relief and confirming diagnosis

Trial of 1 injection prior to referral for surgery

Subsequent injection may be appropriate if patient does not want surgery or wishes to postpone surgery

 

http://policies.kernowccg.nhs.uk/DocumentsLibrary/KernowCCG/IndividualFundingRequests/Policies/MusculoskeletalCorticosteroidInjectionPolicy.pdf

 

Referral criteria

Red Flags      

 

Urgent referral to Hand Clinic (via fracture clinic)

Fracture

Onset of numbness/paraesthesiae after injury

Urgent outpatient referral

Nerve tumour, tumour, symptoms associated with a lump in the carpal tunnel region

 

Yellow Flags 

 

Urgent outpatient referral (to other specialities)

An underlying neurological disorder other than compression is suspected

Peripheral limb ischaemia (thoracic outlet syndrome or Raynaud’s disease)

Cervical nerve root entrapment

Active inflammatory joint disease

 

 

Refer at first presentation if there is:

-A fixed neurological deficit (e.g. permanent numbness/thenar muscle wasting) OR

-Sudden progression of symptoms

 

Otherwise refer when:

 

- Primary care management has failed OR

- Significant functional impairment* AND

- Symptoms are > 6 months duration

 

*Significant functional impairment is defined as a loss or absence of an individual’s capacity to meet personal, social or occupational demands. Please provide examples of the impairment the individual is experiencing.

 

 

Recurrence Following Carpal Tunnel Decompression

Recurrence rates are between 0.3 to 12%.1

 

Refer if:

  • Symptoms deteriorate after surgery (urgent referral)
  • Recurrent or persistent symptoms after decompression (>3/12 post surgery)
  • Complex regional pain syndrome not resolving after two weeks (refer hand therapy)

 

 

Providers

RCHT clinics:  Royal Cornwall Hospital

           Camborne Redruth Hospital

                       West Cornwall Hospital

           Bodmin Hospital

 

The majority of carpal tunnel surgery is done at St Michaels Hospital, Hayle.

Surgery is also done at: Probus Surgery  (Over 18yrs) & Duchy Hospital (Over 18 and BMI < 40)

 

References:

1.   Carpal Tunnel Syndrome Commissioning Guide.  British Society For Surgery Of The Hand, Royal College of Surgeons, British Orthopaedic Association, January 2016

2.   Carpal Tunnel Syndrome, Clinical Knowledge Summaries, National Institute of Clinical Excellence 2008

3.   Carpal Tunnel Syndrome.  British Society for Surgery of the Hand 2016

             4.   KCCG commissioning policy 2019

 

 

Date reviewed                     8/2/2022

Next review due                  8/2/2023

Sifter name                          Dr Rebecca Hopkins

 

Contributors:

Mr Anwan Al-Shawi (Orthopaedics), Dr Brendan McLean (Neurology), Dr Rebecca Hopkins (GP), Dr Sheona Burns (GP)

 

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