Carpal Tunnel Syndrome - Referral Pathway

Publication: 14/08/2007  
Next review: 09/07/2023  
Referral Guideline/Pathway
CURRENT 
ID: 1163 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Referral Guideline/Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Referral Pathway for patients with Carpal Tunnel Syndrome

Assessment and Management in Primary Care

The management must be based on making a firm diagnosis of CTS. This primarily depends on taking a history as most patients do not have physical signs and provocative tests (Phalen's and Tinel's) are unreliable.

The history is the "gold standard" for diagnosis, there being no tests with 100% reliability. Many practitioners assume that EMG is the "gold standard" and that without it a firm diagnosis cannot be made. In fact, the incidence for both false positives and false negatives is approximately 30% in studies carried out in my department.

Once a firm diagnosis has been made, management depends on the severity of the symptoms and the presence of any underlying cause. Many patients with the milder forms will remit spontaneously, particularly those that occur during pregnancy. Those with the more severe forms will still benefit from conservative treatment while waiting for surgery.

It is proposed that patients be categorised by the GP, into three types (mild, moderate and severe) based on the severity of their symptoms and that the treatment given then depends on the grade of severity.

The recommended treatment, based on the category, can be summarised as follows (and see Appendix 2 and Appendix 3).

Assessment and Management in Primary Care

1. Mild CTS

Symptoms
The sensory symptoms occur:

  • No more than once during the day
  • Once or twice a week during the night
  • Lasting for up to 10 minutes
  • Pain is not present

Treatment
 

  • Explanation of condition
  • Lifestyle Advice
  • Consider steroid injection if symptoms do not improve within a few weeks

2. Moderate CTS

Symptoms
The sensory symptoms occur

  • Two or three times during the day 
  • Once most nights 
  • Last for more than 10 minutes
  • Pain may be present. 

Treatment

  • Explanation of condition
  • Lifestyle Advice
  • Nocturnal wrist splints if waking at night is troublesome
  • Steroid injection
  • Consider early or immediate referral for surgery

3. Severe CTS

Symptoms
The sensory symptoms occur

  • Frequently each day and can last for more than an hour at a time
  • Can be continuous
  • Sleep is disturbed with more than two wakings every night
  • Pain can be prominent
  • Wasting and weakness of the thenar muscles may be present, together with sensory loss in the median supplied digits.

Treatment

  • Explanation of condition
  • Lifestyle Advice
  • Nocturnal wrist splints if waking at night troublesome
  • Consider palliative steroid injection
  • Immediate referral for surgery

 

Symptomatically there are two additional presentations
a) Acute CTS - this is not common.
The sensory symptoms come on suddenly, typically on waking up the day after a period of excessive use of the hand. They can be severe for several days then slowly improve. Pain may be prominent.
The symptoms can be managed with rest and analgesics.
Urgent surgical referral may be necessary if the symptoms do not improve quickly
b) Persistent numbness in the median area of the hand, without pain or much tingling. This is usually seen in the elderly. Wasting and weakness of the thenar muscles is often present.
A surgical opinion should be sought.

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Appendix 1 - Evidence for the use of EMG in CTS

To my knowledge, their has been no study comparing the outcome of treatment in two groups of patients, one managed conventionally, using EMG and the other without EMG, basing the diagnosis on symptoms alone. There has one been study from the Warwickshire Hospital, UK which looked at the response to treatment in a group of 100 patients with the symptoms of CTS and normal EMG. Twenty nine had surgery and 90% of them had a good or excellent outcome (Kitsis et al. CTS despite negative neurophysiological studies. Acta Orthopaedica Belgica. 2002; 68:135-140). The authors concluded that the diagnosis of CTS is clinical and not neurophysiological.

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Appendix 2 - Outline of symptoms in CTS

In mild to moderate CTS, the symptoms are typically intermittent, last minutes at a time and occur between once a week and several times a day. During the day, they may be brought on by sustained gripping, such as using a phone or driving. They often occur when patients are sitting still and watching TV. They can wake the patient from sleep, when they are usually at their worst. They are relieved by shaking the hand.
The cardinal symptoms are numbness and/or tingling in the hand. If they do not have these symptoms then they do not have CTS. Many patients are referred for EMG because of hand or arm pain with no other symptoms. This is unnecessary. The symptoms classically affect the thumb, index and middle fingers but there are many variants. Thus, only one or two digits may be affected. 50% of patients have symptoms which affect the whole hand, including the ring and little fingers (Stevens JC et al. Symptoms of 100 patients with electromyographically verified CTS. Muscle Nerve 1999; 22:1448-1456). The symptoms during the day may be confined to the median territory but during the night affect the whole hand.
In the more severe forms of CTS, the numbness and tingling can last much longer than a few minutes. In the most severe type and also in the acute type, the symptoms are continuous but may vary in severity. In most patients the onset is usually insidious and the symptoms can get progressively worse or stabilise for long periods of months or years. Spontaneous remission is not uncommon. The patients may report transient exacerbation following a period of increased use of the hands or note improvement when on holiday.
More than half the patients have pain in the hand or arm, sometimes felt as high as the shoulder. These pains occur at the same time as the sensory symptoms in the hand. Persistent pain felt throughout the day, with only infrequent sensory symptoms in the hand, is unlikely to be due to CTS.

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Appendix 3 - Treatment - Lifestyle Advice

Simple advice on the cause of CTS and how to improve the symptoms should be given to all patients. When patients ask what the cause is, I say it is due to the way we are designed and give a brief description of the anatomy of the carpal tunnel. I stress that the damage is done when the hand is used for any heavy or prolonged task but the symptoms come on when they are at rest, either from sleep or when sitting still watching TV or holding something like a phone. As soon as they notice the symptoms they should move the hand or put the phone down. I suggest avoiding heavy jobs if possible and trying to give their hands a rest. If sleep is disturbed I explain that wearing a wrist splint at night can help but do not recommend wearing it during the day.

Provenance

Record: 1163
Objective:
Clinical condition:

Carpal Tunnel Syndrome

Target patient group: Patients with Carpal Tunnel Syndrome
Target professional group(s): Primary Care Doctors
Secondary Care Doctors
Adapted from:

Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Background

For many years, the Departments of Clinical Neurophysiology at the LGI and St. James's have taken referrals from GP's, the majority for nerve conduction studies and electromyography (EMG). A recent audit of 72 referrals has shown that 50 (69%) had carpal tunnel syndrome (CTS). In 90% of these, the clinical diagnosis was straightforward. In 30%, EMG was normal (false negatives) and in a study of 25 normal controls, 28% had abnormal EMG (false positives).

Thus patients were waiting for test that is not completely reliable, when most could easily be diagnosed clinically. The evidence for the benefit of EMG in the management of CTS is poor (see Appendix 1). For many years, both physicians and surgeons in Leeds have been treating CTS without EMG. In rheumatology, it is standard practice to give steroid injections into the carpal tunnel, without requesting EMG first. Some surgeons are concerned about the medico-legal implications of operating without EMG, believing that to do so could be held as negligent. The evidence for this belief is not clear.

The current CTS referral pathway has been very variable in the past. While many GP's referred for EMG first, others referred directly to hand surgeons, orthopaedic surgeons, rheumatologists or MSK, some of whom will then request EMG. Some GP's requested EMG and simultaneously referred to hospital, with the result that EMG's were sometimes carried out after the patient had surgical decompression.

I have been seeing more than 500 patients a year with CTS for over 20 years and in my experience, many could be managed in Primary Care, as the first line treatment is often not surgical. Patients can benefit considerably from simple explanation of the condition and advice on how to improve the symptoms.

In view of these considerations, a new standardised referral pathway was commissioned in 2007 by the PCT.CTS patients are now initially assessed by the GP and treatment of the less severe cases carried out by the GP. Support for GP's has been provided by training sessions in early 2007.

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