SRP 032 Carpal Tunnel

Policy number: SRP 032
Policy name: Carpal Tunnel
Status: Individual Funding Approval
Effective date: 30 April 2024
Next review date: 30 April 2026

Mid and South Essex ICB commissions surgery for Carpal Tunnel Syndrome on a restricted basis.

Patients with wasting of the hand muscles should be urgently referred to the acute hospital (outside the scope of this policy).

Nerve conduction studies (EMG) are not indicated in the diagnosis of classical carpal tunnel syndrome and will not generally be funded. These may be done where there is doubt about the diagnosis, which is uncommon.

MSE ICB will only fund surgery in patients diagnosed with Carpal Tunnel Syndrome meeting one of following criteria:

The patient has severe neurological symptoms at presentation – for example, altered sensation, muscle wasting or weakness of thenar abduction (wasting or weakness of abductor pollicis brevis).

The patient has severe symptoms (fewer than 5% of patients) uncontrolled by conservative measures, significantly interfering with activities of daily living.

The patient has moderate symptoms as defined below AND has not responded to a minimum of 6 months of conservative management* before referral for surgery is made.

*Conservative treatment is community based and must include the following before referral is made:

Splinting with a cock-up splint (nighttime only or constant) for at least 12 weeks

AND

Steroid injections-unless contra-indicated – which should be administered at least once prior to referral for consideration of surgery- good evidence for short (8-12 week) term effectiveness.

All GPs should seek access to carpal tunnel steroid injections prior to referral for surgery if they are not able to provide these themselves.

Where applicable, referral letter must detail conservative methods tried and the length of time that each of these was carried out, along with confirmation that the referrer and the patient have discussed treatment options for carpal tunnel syndrome using the Shared Decision tool Decision support tools

Classification for Severity of Carpal Tunnel Syndrome:

Mild: Intermittent paraesthesia with or without pain that may be nocturnal or occurs with a certain hand position.

Moderate: Paraesthesia that interferes with activities of daily living or causes constant night waking and/or reversible numbness and/or pain (perhaps by clenching and unclenching of fist or hand shaking).

Severe: Constant numbness or disabling pain with wasting of thenar muscles and/or weakness of thumb muscles (Abductor Pollicis Brevis and Opponens Pollicis).

Rationale:

Conservative treatment offers short-term benefit (1-3 months) similar to surgery and many patients’ symptoms may resolve for at least a year after conservative treatment. After corticosteroid injection, up to 50% of patients may report minor or no symptoms at one year.

The benefits of conservative therapy are seen early after treatment and then decrease while the benefits of surgery take longer to be fully realised.

Corticosteroid injections and nocturnal splinting are effective conservative therapies. Therefore, patients would not normally be referred for carpal tunnel syndrome unless they have had one local steroid injection into the carpal tunnel together with the provision of night splints.

Electro-diagnostic tests are not indicated in the diagnosis of classical carpal tunnel syndrome. These may be done where there is doubt about the diagnosis, which is uncommon.

In the longer term (3-18 months), surgery is better than conservative therapy with up to 90% of patients reporting complete or much improvement at 18 months.

A trial of conservative therapy offers the opportunity to avoid surgery for some patients.

Funding for patients not meeting the above criteria will only be made available in clinically exceptional circumstances.

Find out more information on applying for funding in exceptional clinical circumstances