Procedure that requires prior approval
Application form: - Carpal Tunnel Syndrome (CTS) – Surgical Management

Name of Referring Clinician
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
Please note: Carpal tunnel syndrome is normally diagnosed in primary care and the management of mild to moderate syndrome is conservative as per local DES (Directed Enhanced Services) contract for general practitioners. Therefore funding will not be made available for this patient group.
Patient should have followed the recommended care pathway including the local MSK service where available.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service:or consideration.
The policy statements are available at
Clinical Criteria required for consideration of treatment / Please Tick
  1. Which wrist is to being treated?
☐Right
☐Left
☐Bilateral (Evidence must be provided to support both wrists if bilateral is to be considered)
  1. Has the patient mild symptoms?
Mild symptoms: including intermittent paraesthesia (sensation of tingling, tickling, pricking or burning) in the correct distribution; nocturnal symptoms (or pain/paraesthesia exacerbated at night). / YES☐NO☐
  1. Has the patient moderate or severe symptoms?
Moderate symptoms - Intermittent paraesthesia in the correct distribution, regular night waking and No persistent hypoesthesia (numbness)
AND ALL OF THE FOLLOWING CONSERVATIVE MANAGEMENT HAS BEEN TRIED AND FAILED
- Physiotherapy: median nerve mobilisation techniques
- Night time splinting for at least 8 weeks
- Steroid injections (up to 3)
Clinical evidence must be attached to confirm completion of all conservative management.
OR
Severe symptoms - Sudden and severe symptoms, symptoms that are moderate to severe or deteriorating, daily symptoms, frequent night waking, persistent symptoms causing functional impairment not responding to 12 weeks of evidence based non-surgical treatments (including treatments received in primary care) / YES☐NO☐
  1. Patient’s Body Mass Index:
BMI / kg/m2
Height / cm
Weight / kg
  1. Is the patient a non-smoker?
/ YES☐NO☐

South, Central and West Commissioning Support Unit April 2018 TVPC19 BW