Carpal Tunnel

Scope

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

Please note referral criteria are applicable in this referral.

Assessment

Signs and Symptoms

  • Paraesthesia / numbness, often painful, in median nerve distribution (thumb, index, middle +/- ring finger)
  • Initially intermittent, may become constant
  • Often worse at night

Differential Diagnoses

  • Cubital tunnel syndrome (ulna nerve compression at the elbow; paraesthesia / numbness in little / ring finger, hand weakness)
  • Cervical radiculopathy (neck pain, radiating into the arm in dermatomal distribution, e.g. C6 = thumb, C7 = middle finger)
  • Thoracic outlet syndrome
  • Peripheral neuropathy (e.g. diabetic; glove and stocking distribution)

Investigations

Nerve conduction studies are only indicated in the following circumstances:

  • The diagnosis is unclear – see differential diagnosis
  • Recurrent disease suspected (previous carpal tunnel surgery)

Management

For severe CTS (when the hand no longer feels normal between episodes of pins and needles; thenar wasting; weakness) there is a risk of irreversible nerve damage and therefore no place for conservative management. Refer for surgical decompression.

For all other patients, trial of conservative management with:

  • One month trial of night splints (patients can buy wrist splints online or from pharmacies) if there are nocturnal symptoms
  • Single cortisone injection into carpal canal (see corticosteroids)

If persistent symptoms after 3 months of conservative management, refer for surgical decompression.

Surgical decompression involves a 15 minute operation under local anaesthetic

Referral

Referral Criteria

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.

Click on the link for the complete NEW 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 request form

Refer to Orthopaedics e-Referrals Service Selection

  • Speciality: Orthopaedics
  • Clinic type: Hand and Wrist
  • Service: DRSS- Western – Orthopaedics-Hand and Wrist-NEW Devon CCG-99p

Referral Forms

DRSS Referral Proforma

Supporting Information

Patient Information

MyHealth patient information - Carpal Tunnel

NEW Devon Individual Funding Request - Patient information leaflet

Evidence

BOA – Commisioning guide: Treatment of painful tingling fingers

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: March 2017

 

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