When should I consider referring a patient with carpal tunnel syndrome for surgical intervention?

Consider referring a patient with carpal tunnel syndrome (CTS) for surgical intervention if:

• The diagnosis is unclear after initial assessment and conservative management.
• Symptoms persist despite a trial of conservative treatments in primary care, typically after 6 weeks.
• There are progressive symptoms or clinical features of severe disease that impact daily function.
• There are recurrent or persistent symptoms following previous carpal tunnel surgery.

Conservative treatments include wrist splinting, corticosteroid injection, and hand exercises. If symptoms do not improve after trying up to two conservative methods, referral should be made to avoid inappropriate delay to surgery, as prolonged symptoms may worsen surgical outcomes.

Nerve conduction studies may be used to confirm diagnosis or exclude other conditions but are not mandatory for referral if clinical features are clear.

Timely referral is important to prevent irreversible motor and sensory damage in cases of severe or progressive symptoms.

Referral can be to a local musculoskeletal service, orthopaedic or hand surgeon, neurologist, or rheumatologist depending on local pathways and clinical judgement.

Patient information leaflets from the Royal College of Surgeons of England and British Society for Surgery of the Hand can support shared decision-making about surgery.

Summary: Refer for surgical assessment if diagnosis is uncertain, symptoms persist after 6 weeks of conservative treatment, symptoms worsen or are severe, or if symptoms recur after surgery.

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