Definitions of the levels of evidence (I-V) and grades of recommendation (A-C, I) are provided at the end of the "Major Recommendations" field.
Note from the American Academy of Orthopaedic Surgeons (AAOS): This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report (see "Guideline Availability" and "Availability of Companion Documents" fields) for this information. The guideline developers are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone.
Carpal Tunnel Syndrome (CTS) is among the most common disorders of the upper extremity. It is related to many factors but is thought to be caused by increased pressure on the median nerve in the carpal tunnel at the wrist.
Recommendation 1
A course of non-operative treatment is an option in patients diagnosed with carpal tunnel syndrome. Early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. (Grade C, Level V)
Recommendation 2
The authors suggest another non-operative treatment or surgery when the current treatment fails to resolve the symptoms within 2 weeks to 7 weeks. (Grade B, Level I and II)
Recommendation 3
The authors do not have sufficient evidence to provide specific treatment recommendations for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace. (Inconclusive, No evidence found)
Recommendation 4a
Local steroid injection or splinting is suggested when treating patients with carpal tunnel syndrome, before considering surgery. (Grade B, Level I and II)
Recommendation 4b
Oral steroids or ultrasound are options when treating patients with carpal tunnel syndrome. (Grade C, Level II)
Recommendation 4c
The authors recommend carpal tunnel release as treatment for carpal tunnel syndrome. (Grade A, Level I)
Recommendation 4d
Heat therapy is not among the options that should be used to treat patients with carpal tunnel syndrome. (Grade C, Level II)
Recommendation 4e
The following treatments carry no recommendation for or against their use: activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics, exercise, electric stimulation, fitness, Graston instrument, iontophoresis, laser, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants and NSAIDs), nutritional supplements, phonophoresis, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction, yoga. (Inconclusive, Level II and V)
Recommendation 5
The authors recommend surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum regardless of the specific surgical technique. (Grade A, Level I and II)
Recommendation 6
The authors suggest that surgeons do not routinely use the following procedures when performing carpal tunnel release:
- Skin nerve preservation (Grade B, Level I)
- Epineurotomy (Grade C, Level II)
The following procedures carry no recommendation for or against use: flexor retinaculum lengthening, internal neurolysis, tenosynovectomy, ulnar bursa preservation. (Inconclusive, Level II and V)
Recommendation 7
The physician has the option of prescribing pre-operative antibiotics for carpal tunnel surgery. (Grade C, Level III)
Recommendation 8
The authors suggest that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. (Grade B, Level II)
The authors make no recommendation for or against the use of postoperative rehabilitation. (Inconclusive, Level II)
Recommendation 9
The authors suggest physicians use one or more of the following instruments when assessing patients' responses to CTS treatment for research:
- Boston Carpal Tunnel Questionnaire (disease-specific)
- DASH – Disabilities of the arm, shoulder, and hand (region-specific; upper limb)
- MHQ – Michigan Hand Outcomes Questionnaire (region-specific; hand/wrist)
- PEM – Patient Evaluation Measure (region-specific; hand)
- SF-12 or SF-36 Short Form Health Survey (generic; physical health component for global health impact) (Grade B, Level I, II, and III)
Definitions:
Levels of Evidence for Primary Research Question1
Types of Studies |
|
Therapeutic Studies
Investigating the results of treatment
|
Prognostic Studies
Investigating the effects of a patient characteristic on the outcome of disease
|
Diagnostic Studies
Investigating a diagnostic test
|
Economic and Decision Analyses
Developing an economic or decision model
|
Level I |
- High quality randomized trial (RCT) with statistically significant difference but narrow confidence intervals
- Systematic Review2 of Level I RCTs (and study results were homogenous3)
|
- High quality prospective study4 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients)
- Systematic review2 of Level I studies
|
- Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard)
- Systematic review2 of Level I studies
|
- Sensible costs and alternatives; values obtained from many studies; with multiway sensitivity analyses
- Systematic review2 of Level I studies
|
Level II |
- Lesser quality RCT (e.g. <80% follow-up, no blinding, or improper randomization)
- Prospective4 comparative study5
- Systematic review2 of Level II studies or Level I studies with inconsistent results
|
- Retrospective6 study
- Untreated controls from an RCT
- Lesser quality prospective study (e.g. patients enrolled at different points in their disease or <80% follow-up)
- Systematic review2 of Level II studies
|
- Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard)
- Systematic review2 of Level II studies
|
- Sensible costs and alternatives; values obtained from limited studies; with multiway sensitivity analyses
- Systematic review² of Level II studies
|
Level III |
- Case control study7
- Retrospective6 comparative study5
- Systematic review2 of Level III studies
|
|
- Study of non-consecutive patients; without consistently applied reference "gold" standard
- Systematic review2 of Level III studies
|
- Analyses based on limited alternatives and costs; and poor estimated
- Systematic review2 of Level III studies
|
Level IV |
Case Series8 |
Case Series |
- Case-control study
- Poor reference standard
|
Analysis with no sensitivity analyses |
Level V |
Expert Opinion |
Expert Opinion |
Expert Opinion |
Expert Opinion |
- A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
- A combination of results from two or more prior studies.
- Studies provided consistent results.
- Study was started before the first patient enrolled.
- Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.
- The study was started after the first patient enrolled.
- Patients identified for the study based on their outcome, called "cases"; e.g., failed total hip arthroplasty, are compared to those who did not have outcome, called "controls"; e.g., successful total hip arthroplasty.
- Patients treated one way with no comparison group of patients treated in another way.
Grading the Recommendations
A: Good evidence (Level I Studies with consistent findings) for or against recommending intervention.
B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.
C: Poor quality evidence (Level IV or V) for or against recommending intervention.
I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.