Carpal Tunnel Syndrome

Scope

When patients present with non-traumatic painful tingling of the fingers, the following should be considered:

  • carpal tunnel syndrome
  • cubital tunnel syndrome
  • cervical nerve root entrapment

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

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

Carpal tunnel syndrome is normally diagnosed in primary care and early management is non-surgical.

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

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

Please note referral criteria are applicable in this referral.

Referrals for Nerve Conduction Studies (NCS) are generally not required for classic Carpal Tunnel Syndrome (CTS), so requests for NCS diagnostics in these cases may be returned

For information required when making a CTS referral, please see the referral section. Referrals submitted without this information will be returned

Key NHS Devon CCG policy criteria summary:

Symptoms persisting for more than three months after conservative therapy with either local corticosteroid injection and/or nocturnal splinting

or

The patient is suffering from significant functional impairment, pain or sleep deprivation

or

There is neurological deficit resulting in constant altered sensation, muscle wasting, or weakness of thenar abduction.

Significant functional impairment is defined as a loss or absence of an individual's capacity to meet personal, social or occupational demands.

Assessment

Signs and Symptoms

Carpal tunnel syndrome and cubital tunnel syndrome are the most common causes of upper limb tingling.

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

Cubital tunnel syndrome occurs due to compression of the ulnar nerve at the elbow which causes changes in feeling of the little and ulnar half of the ring finger with weakness of small muscles of the hand but not the thumb.

History

  • Intermittent paraesthesia in the correct distribution
  • Nocturnal symptoms (or pain/paraesthesia exacerbated at night)

Examination

  • Subjective sensory impairment in the correct distribution in more severe cases.
  • Subjective weakness in the thumb/loss of co-ordination.

Differential Diagnoses

May include:

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

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

Red Flags

May include

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

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

Investigations

  • Nerve Conduction Studies (NCS) are not indicated
  • Blood tests are only needed if the history and examination suggests a specific secondary cause

Management

Patient Information

Patients with mild carpal tunnel syndrome can be treated with a trial of conservative management:

  • Splints at night (patients can buy wrist splints online or from pharmacies)
  • Single steroid and local anaesthetic injection if:
    • Painful reversible paraesthesia not helped by splints

Or when:

  • Diagnosis is uncertain
  • Surgery cannot be undertaken safely

Patients with a potential reversible cause (pregnancy, hypothyroidism) can be considered for conservative treatment.

Patients with mild carpal or cubital tunnel syndrome should be improved after 6 weeks of conservative management.

Referral

Referral Criteria

Referral Criteria for Nerve Conduction Studies (NCS)

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

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

Referral Criteria for Carpal Tunnel Syndrome (CTS)

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

Surgery for carpal tunnel syndrome is commissioned in the following circumstances:

Symptoms persisting for more than three months after conservative therapy with either local corticosteroid injection and/or nocturnal splinting

or

The patient is suffering from significant functional impairment, pain or sleep deprivation

or

There is neurological deficit resulting in constant altered sensation, muscle wasting, or weakness of thenar abduction.

Significant functional impairment is defined as a loss or absence of an individual's capacity to meet personal, social or occupational demands.

Referrals submitted without this information will be returned.

Refer for consideration of surgery

The assessment for carpal tunnel surgery and the actual procedure will be performed in a primary care service if available

  • moderate to severe or deteriorating symptoms
  • sudden and severe symptoms
  • daily symptoms, frequent night waking
  • persistent symptoms causing functional impairment not responding to up to 12 weeks of evidence based non-surgical treatments; this time to include any treatment received in primary care.

Refer to Secondary Care if requires a GA or previous hand surgery

Click on the link below for the complete

NHS Devon CCG surgery for carpal tunnel syndrome commissioning policy

Referral Instructions

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

Individual funding requests

Individual funding requests form

Refer to Orthopaedics e-Referrals Service Selection

  • Speciality: Orthopaedics
  • Clinic type: Hand and Wrist
  • Service: DRSS-South Devon & Torbay-Orthopaedics-Hand & Wrist-Devon CCG - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Supporting Information

Patient Information

MyHealth patient information - Carpal Tunnel

NHS Devon Individual Funding Request - Patient information leaflet

Evidence

BOA – Commissioning guide: Treatment of painful tingling fingers

Pathway Group

This guideline has been signed off NHS Devon CCG.

Publication date: February 2016

Updated: May 19

 

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