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
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
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)
VersionNo. 3.3