Correspondence
Diagnosis and
treatment of carpal
tunnel syndrome
While I believe that the Review by
Luca Padua and colleagues 1 can
be useful for many health-care
professionals, an excellent analysis
of the available evidence regarding
carpal tunnel syndrome 2 was not
included. Hand surgeons will
approach this disease in a slightly
different manner than Padua and
colleagues do. From a surgeon’s
perspective, each of the non-surgical
management strategies described by
the authors can be considered a low
risk, but also a low benefit approach,
with any improvement in symptoms
likely transient in nature, and possibly
related to placebo effect.
Non-surgical management should
be considered in mild cases, and if
symptoms can reverse spontaneously
(eg, during pregnancy). The risks
associated with surgical treatment
are low, especially if endoscopic
surgery is performed under local
anaesthesia. 1 Surgery is usually a
cure of the disease, as it is the only
treatment that addresses the root
cause of carpal tunnel syndrome—
namely that the volume of the carpal
tunnel is too small for its contents.
Surgery should be considered in
any patients with symptoms that
cause substantial sleep disruption or
interference with activities of daily
living, or if there are symptoms or
signs of advanced disease, such as
constant numbness, thenar weakness
or atrophy, or denervation observed
on EMG testing. But surgery can
also be considered in mild cases—
why should anyone suffer if a cure
is available? Instead of a universal
hierarchy of treatment (eg, all
patients should undergo at least
1 month of splinting, or all patients
should have a steroid injection
before considering surgery), better
to choose the best treatment for each
individual patient.
www.thelancet.com/neurology Vol 16 April 2017 263
The authors believe “that a
comprehensive diagnostic work-
up is needed.” However, roughly
half of hand surgeons surveyed
think that no electrophysiological
or other diagnostic testing is
necessary in patients with a typical
history of carpal tunnel syndrome.3
Electrophysiological testing can be
useful (eg, in atypical presentations,
when looking for other potential
nerve compression sites, or for
medicolegal reasons), but routine
use of diagnostic testing and trials of
non-surgical management, such as
steroid injection, increase costs, delay
definitive treatment, and offer no
improvement in outcome.4
I agree with the authors on the
importance of history-taking in
diagnosis. Patients are often referred
to surgeons like me after a diagnosis of
carpal tunnel syndrome, but without
the typical features in their clinical
history. Convincing a patient that
the diagnosis was wrong, or that they
need a different work-up or treatment
can lead to frustration. In the words of
Sir William Osler, one of the founding
fathers of modern medicine,5 “Listen
to your patient; he is telling you the
diagnosis.”
I declare no competing interests.
J Grant Thomson
grant.thomson@yale.edu
Section of Plastic Surgery, Yale School of Medicine,
New Haven, CT 06520, USA
1 Padua L, Coraci D, Erra C, et al. Carpal tunnel
syndrome: clinical features, diagnosis, and
management. Lancet Neurol 2016;
15: 1273–84.
2 American Academy of Orthopaedic Surgeons.
Management of Carpal Tunnel Syndrome
Evidence-Based Clinical Practice Guideline.
Feb 29, 2016. www.aaos.org/ctsguideline
(accessed Oct 10, 2016).
3 Lane LB, Starecki M, Olson A, Kohn N.
Carpal tunnel syndrome diagnosis and
treatment: a survey of members of the
American Society For Surgery of the Hand.
J Hand Surg Am 2014; 39: 2181–87.
4 Sears ED, Swiatek PR, Hou H, Chung KC.
Utilization of preoperative electrodiagnostic
studies for carpal tunnel syndrome: an analysis
of national practice patterns. J Hand Surg Am
2016; 41: 665–72.
5 Roberts CS. H L Mencken and the four doctors:
Osler, Halsted, Welch, and Kelly.
Proc (Bayl Univ Med Cent) 2010; 23: 377–88.
Authors’ response
We thank J Grant Thomson for
highlighting the differing clinical
perspectives in patient care.
Our Review 1 aimed to provide a
comprehensive overview of the
scientific literature that met our criteria
for inclusion, which were described
in our article. The conclusions of our
narrative Review can therefore conflict
with some opinions.
Thomson’s views seem to be based
upon opinion and common practices
of hand surgeons, as opposed to
objective evidence. Additionally, the
information presented is somewhat
contradictory. While Thomson
notes that steroid injections do not
improve outcomes and advocates
surgery as a first-line treatment
for carpal tunnel syndrome, the
guidelines of the American Academy
of Orthopaedic Surgeons 2 provide
the following recommendation:
“Strong evidence supports that the
use of steroid (methylprednisolone)
injection should improve patient
reported outcomes.”
Concerning diagnostic testing, we
agree with Thomson that unnecessary
testing can increase cost of care. The
same is true for expensive, unnecessary
treatments including surgery. There
is no consensus on the best approach
to diagnosing carpal tunnel syndrome
and approaches vary by medical
speciality and training. Inherent bias
exists within each of us.
To quote American psychologist
Abraham Maslow, “I suppose it is
tempting, if the only tool you have
is a hammer, to treat everything as if
it were a nail.”3 It cautions each of us
to consider all potential solutions to
clinical dilemmas, even if the solution
requires using a different tool.
We declare no competing interests.
*Luca Padua, Daniele Coraci,
Carmen Erra, Costanza Pazzaglia,
Ilaria Paolasso, Claudia Loreti,
Pietro Caliandro, Lisa D Hobson-Webb
luca.padua@unicatt.it