Surgical versus non‐surgical treatment for carpal tunnel syndrome

Background Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non‐surgical treatments. It is unclear whether surgery produces a better outcome than non‐surgical therapy. This is an update of a Cochrane review published in 2008. Objectives To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non‐surgical treatment in the short (< 3 months) and long (> 3 months) term. Search methods In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies. Selection criteria We included randomised controlled trials comparing any surgical technique with any non‐surgical therapies for CTS. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results The 14 included studies randomised 1231 participants (1293 wrists). Eighty‐four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet‐rich plasma injection, manual therapy, multimodal non‐operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long‐term effects, this presents only long‐term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate‐certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate‐certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01