Referral Pathway for patients with Carpal Tunnel Syndrome

• Assessment and Management in Primary Care
• Appendix 1 - Evidence for the use of EMG in CTS
• Appendix 2 - Outline of symptoms in CTS
• Appendix 3 - Treatment - Lifestyle Advice

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).

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.

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.

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.

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.