In May 2024, the AAOS Board of Directors approved the updated Clinical Practice Guideline (CPG) for the Management of Carpal Tunnel Syndrome (CTS) to address the diagnosis and treatment of adult patients aged >18 years presenting with complaints that may be attributed to CTS.

The latest iteration of the CPG includes six strong and three moderate-strength recommendations. The CPG workgroup chose to categorize the recommendations by workup, treatment, and postoperative care of CTS. Recommendations address minimizing the risk of incorrect diagnosis and reducing unnecessary care in all phases of the surgical episode of care, such as preoperative testing, intraoperative antibiotic use, and postoperative immobilization.

Although the 2016 edition of the CPG primarily covered several recommendations for the short-term effects of CTS treatment, this update is streamlined to focus on the long-term benefits of various treatments. Co-chairs of the guideline development group, Lauren Shapiro, MD, of the Department of Orthopaedic Surgery at the University of California, San Francisco, and Robin Kamal, MD, FAAOS, of the Department of Orthopaedic Surgery at Stanford University Medical Center, spoke with AAOS Now to explain the rationale behind this strategic shift, underscoring important insights and considerations primary care physicians, neurologists, occupational medicine physicians, physical medicine and rehabilitation physicians, orthopaedic surgeons, and other healthcare professionals treating patients with possible CTS can glean from the new guidelines.

“In tune with the dynamic shifts in healthcare, our guidelines were mindful to reflect high-quality care, cost-effectiveness, and patient-centered care, strongly emphasizing shared decision making,” Dr. Shapiro said. “Guided by these principles, the workgroup’s objective was to use the best available evidence to prioritize treatments that demonstrate longevity and durable results.”

“An underlying theme of this CPG is to avoid the unnecessary and support interventions that improve patient health,” Dr. Kamal added. “Tests and treatments are all associated with some risk. However, for certain patients, physicians can avoid some debatable preoperative treatments (e.g., corticosteroid injections), preoperative tests, and postoperative therapies, based on the evidence cited in this guideline.”

Carpal tunnel diagnosis
The CPG opens with a strong recommendation regarding the diagnosis of CTS and underscores the efficacy of the CTS-6 evaluation tool. Robust evidence suggests that CTS-6 can be used as a diagnostic tool in lieu of routine use of ultrasonography or a nerve conduction velocity test (NCV) and electromyography (EMG). This recommendation is backed by evidence from 10 high-quality studies and five moderate-quality studies.

Dr. Kamal emphasized, “While nerve conduction testing has historically been considered a gold standard by some physicians, the literature supports CTS-6 as an effective, cost-efficient, less invasive, and less painful alternative to nerve conduction testing. This recommendation underscores the use of CTS-6 as a diagnostic and/or screening tool, advocating for using ultrasound or NCV/EMG only when the positive predictive value of the CTS-6 test is low. Shared decision making is encouraged when considering these modalities, as patients need to understand the cost and risks associated with the diagnostic tools.”

Considerations for surgery and postoperative care
The guideline contains one updated recommendation advising against the use of corticosteroid injection, alongside a new strong recommendation against platelet-rich plasma injections, citing evidence that shows these options lack long-term benefits in the nonoperative treatment of CTS.

“The notion of definitively treating CTS through nonoperative management is not substantiated by the evidence in the updated CPG,” Dr. Kamal underscored. “Although certain procedures may offer short-term relief, surgery stands as the evidence-supported method for long-term, disease-modifying treatment of CTS.”

When it comes to surgical options to treat CTS, the workgroup identified strong evidence to suggest that there is no difference in patient-reported outcomes between a mini-open carpal tunnel release and an endoscopic carpal tunnel release. Although it is not included in this review, the workgroup did highlight a recent study (Carrol 2023) that showed that complication rates for endoscopic carpal tunnel release may be higher than previously described and should be considered by physicians.

Dr. Shapiro added, “This is another opportunity for shared decision making. While each surgical technique has pros and cons in the short term, the studies consistently demonstrated no difference in long-term outcomes (e.g., patient-reported outcome measures, range of motion, grip strength) between the two techniques. Endoscopic release may afford an earlier return to work. Still, its clinical relevance has not been borne out of the literature, and this decision may be made on a patient-specific basis.”

The cost of orthopaedic treatments remains an important consideration for patients and speaks to the importance of providing value-based care for patients. Although cost-effectiveness and resource utilization were not primary outcomes of this review, as these factors vary based upon context, the CPG updated one recommendation and added two options designed to assist physicians and patients in navigating between carpal tunnel surgery performed in an office setting under local anesthesia versus those conducted in an OR. Options are formulated with either low-quality evidence, no evidence, or conflicting evidence.

Specifically, the CPG updated a recommendation from 2016 to provide strong evidence that carpal tunnel release with local anesthetic results in lower costs and resource utilization compared with other forms of anesthesia (e.g., monitored anesthesia care). Likewise, limited evidence suggests carpal tunnel release may be safely conducted in the office setting, as studies consistently demonstrated that carpal tunnel release in the office setting results in no increased risk of complications, with higher ratings of patient experience and satisfaction when compared with surgical release in the OR. Lastly, in the absence of reliable evidence, it is the opinion of the workgroup that limited draping is an option for carpal tunnel release.

Postoperative care recommendations in the updated CPG advise against routinely prescribing postoperative supervised therapy, using postoperative immobilization, and using NSAIDs and acetaminophen. Limited evidence suggests that perioperative prophylactic antibiotics are not indicated for the prevention of surgical site infection following carpal tunnel release.

“While there will always be controversial topics to address, we rooted ourselves in the evidence, recognized where the future of healthcare is headed, and identified where the current gaps exist for future research initiatives,” Dr. Shapiro said.

Dr. Kamal pinpointed that future research will focus on health services. “The safety profile and patient profile for local anesthesia, avoidance of some unnecessary testing, and cost/risk analysis will continue to be prime areas for future investigation,” he said.

The full CPG and accompanying documentation are available through AAOS’ OrthoGuidelines website and free mobile app.

Jennifer Lefkowitz is a freelance writer for AAOS Now.