Referral Criteria: Carpal Tunnel Syndrome Feb 2019 1 5.2. Carpal Tunnel Syndrome Background Carpal tunnel syndrome present with non-traumatic tingling of the fingers due to compression of the median nerve at the wrist. Carpal tunnel syndrome is a common condition with a prevalence of between 7-16% in the UK. It is the commonest form of nerve entrapment. The differential diagnosis includes cubital tunnel syndrome (ulnar nerve entrapment at the elbow causing tingling in the lateral fingers), cervical nerve root irritation and adverse neural tension (loss of extensibility of the nerves arm with movement). Typical symptoms of carpal tunnel syndrome include: Intermittent tingling, numbness or altered sensation and burning or pain in the distribution of the median nerve (the thumb, index finger, middle finger, and radial half of the ring finger). Symptoms are often worse at night and can disrupt sleep. Symptoms may affect one or both hands. Pain in the hand may radiate up the arm into the wrist or as far as the shoulder. The person may complain of loss of grip strength, clumsiness and reduced manual dexterity for example when doing up buttons. Some people may present atypically, for example, they may have sensory changes in all digits. Severe disease may cause unremitting sensory symptoms, weakness or thenar muscle wasting. Investigations Blood tests are only needed if the history and examination suggest an (undiagnosed) secondary cause or association such as inflammatory arthritis, hypothyroidism, acromegaly or diabetes. Imaging may be required if suspected trauma, fracture or ganglion. Electrophysiological testing should only be carried out in specialist settings of care, and reserved for situations where there is diagnostic doubt, complex cases, or if symptoms recur after initial surgery. If referral is not indicated, manage carpal tunnel syndrome in primary care by Optimising treatment of any underlying condition, such as osteoarthritis, rheumatoid arthritis or hypothyroidism. Advise the person that lifestyle modifications (such as avoidance of repetitive movements or breaks from tasks that precipitate symptoms) may help. Wrist splinting in a neutral position - this can help with night time symptoms in particular. Splints can be purchased by the person from a pharmacy. Corticosteroid injection - this can be carried out in primary care if appropriate expertise is available.
Referral Criteria: Carpal Tunnel Syndrome Feb 2019 2 Referral to General Practitioner (Referral from triage, community or hospital services specifically for primary care medical review) Assessment and management of multi-morbidity e.g. diabetes, hypothyroidism, osteoarthritis, and psychiatric co-morbidity. If high suspicion of possible inflammatory arthritis, do not delay referral to a rheumatologist by waiting for investigations. Medication reviews and non-urgent prescriptions. Advice regarding achieving and maintaining optimal weight, nutrition, physical activity and healthy lifestyle, including smoking cessation advice. Discussion about fitness for work and sickness certification. Management following discharge from community or secondary care where no further intervention planned. Patients referred back from community services with known or suspected serious underlying pathology where non-urgent (for re-evaluation and possible referral to secondary care). Patients seen in community or secondary care settings who need emergency or urgent assessment e.g. suspicion of inflammatory joint disease, peripheral vascular disease or fracture.
Referral Criteria: Carpal Tunnel Syndrome Feb 2019 3 Referral to Community Physiotherapy or First Contact Physiotherapy in Primary Care Requires provision of splint if unable to purchase. (Patients can purchase wrist splints from pharmacy or online). Requires advice on splint fitting and usage (in non-routine circumstances). Requires advice on activity modification if causing symptoms. Requires stretching and strengthening and joint mobilisation. If post-operative hand therapy commissioned: Post-operative hand therapy Patients who need urgent rheumatology assessment e.g. suspicion of inflammatory joint disease. Patients who need emergency orthopaedic assessment e.g. suspected fracture. Patients with muscle weakness or wasting (refer to interface service).
Referral Criteria: Carpal Tunnel Syndrome Feb 2019 4 Referral to Musculoskeletal Interface Service Unsuccessful conservative treatment, including a trial of splinting, for mild carpal tunnel syndrome after 8 weeks. Steroid injection if GP has not already administered. Moderate symptoms, defined as: o Intermittent paraesthesia in a median nerve distribution o Regular night waking o NO persistent hypoesthesia o Objective but mild weakness of the thenar muscles. Diagnostic uncertainty Interface service to ensure PPwT thresholds met and PPwT form sent with referral to secondary care for consideration of surgery. (The surgical unit is responsible for seeking authorisation from the PPwT Office). Patients who need urgent rheumatology assessment e.g. suspicion of inflammatory joint disease. Patients who need emergency orthopaedic assessment e.g. suspected fracture. Anticoagulated, if requiring injection (ESPs may not be able to inject joint under patient group direction) (Consider GP minor surgery scheme if available).
Referral Criteria: Carpal Tunnel Syndrome Feb 2019 5 Referral to Secondary Care Orthopaedics Severe or deteriorating symptoms including: o Persistent paraesthesia in a median nerve distribution o Regular night-waking and day time symptoms o Persistent hypoesthesia or numbness in a median nerve distribution o Moderate or severe weakness, or wasting of the thenar muscles. Moderate to severe symptoms that persist after conservative therapy with either local corticosteroid injection (if appropriate) and/or nocturnal splinting (used for at least 8 weeks): o Intermittent paraesthesia in a median nerve distribution o Regular night waking o NO persistent hypoesthesia o Objective but mild weakness of the thenar muscles. Patient prepared to have surgical intervention following a shared decision-making discussion guided by a decision aid tool: o All treatment options: https://patient.azureedge.net/treatment-options/carpal-tunnel-syndrome.pdf o Surgery: https://www.healthwise.net/ohridecisionaid/content/stddocument.aspx?dochwi D=aa5319 Thresholds for carpal tunnel surgery (NWL PPwT version 4) https://www.hounslowccg.nhs.uk/news,-publications-andpolicies/publications.aspx?n=2010: o Patient has severe symptoms (see above), interfering with activities of daily living that persist after conservative therapy with either local corticosteroid injection and/or nocturnal splinting. o Neurological deficit e.g. sensory blunting, muscle wasting or weakness of thenar abduction. o Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. Suspected fracture or septic arthritis. (Refer to on-call orthopaedic team or A&E). Suspicion of inflammatory joint disease, peripheral vascular disease. (Discuss with on-call specialist, or refer to medical, rheumatology or vascular team, depending on clinical presentation and urgency). Patients who have not been triaged or referred from a community musculoskeletal service (including non-urgent internally generated referrals (consultant to consultant referrals). PPwT form has not been completed by referrer where request is for a procedure covered by the policy. Referral is not accompanied by any pre-requisite imaging or investigations required by the consultant or unit.