Carpal tunnel syndrome happens when a nerve in the wrist (the median nerve) becomes compressed. This can cause:

• Pain, tingling or numbness in the thumb, index and middle fingers
• Symptoms that are worse at night
• In severe cases, muscle weakness or wasting at the base of the thumb

Some people get better on their own or with basic treatment such as splints or a steroid injection.

The surgery is a common, often outpatient, procedure that cuts the transverse carpal ligament to relieve pressure on the median nerve. Between August 2024 and July 2025 there were 1,877 surgeries undertaken in Lancashire and South Cumbria.

The policy aims to avoid unnecessary surgery because many people improve without an operation.

Currently, NHS Lancashire and South Cumbria ICB funds carpal tunnel surgery only when specific criteria are met. Before surgery, most people must try eight weeks of non-surgical treatment, such as night splints, activity changes, or one steroid injection, unless symptoms are severe. Surgery is only offered when:

• Symptoms disturb sleep or daily activities and don’t improve after non-surgical treatment
• There is loss of feeling, muscle weakness, or thenar muscle wasting
• Symptoms are severe or worsening, where urgent surgery is needed
• In pregnancy‑related cases, surgery is only considered 12 weeks after birth

The current policy can be found at: https://www.healthierlsc.co.uk/application/files/7316/7576/5524/LSCICB_Clin16_Policy_for_Carpal_Tunnel_Syndrome_Surgery_v2.3_with_Pathway.pdf

Under the new policy there is a more flexible 6–12 week non‑surgical period. The criteria for immediate surgery have been broadened to include allowance for people who have recurring cases which wasn’t covered before.  

We have also updated guidance around pregnancy‑related carpal tunnel saying surgery should be avoided if possible. This is because it is usually only temporary during pregnancy and we want to avoid unnecessary surgery, but there is no longer a restriction of waiting 12 weeks after birth because this was not supported by any evidence.

Overall, this should mean that more people are able to have the surgery but still only when it is absolutely necessary.

You can read the full new wording below:

New wording in full:

Surgery for carpal tunnel syndrome is routinely commissioned for patients with mild or moderate symptoms when:

• Symptoms significantly impact sleep or function.

AND

• A 6–12-week course of conservative therapy (for example, night splinting and/or one corticosteroid injection) has been trialled as appropriate.

Surgery is also routinely commissioned for patients in the following circumstances, with no requirement for a trial of conservative therapy prior to surgery:

• When there are any of the following: persistent paraesthesia/hypoesthesia/weakness; constant pain; absence of pain in advanced disease; objective sensory loss or motor weakness; thenar wasting.

OR

• When there are recurrent symptoms following previous carpal tunnel surgery.

For patients with a reversible cause of carpal tunnel syndrome (for example, pregnancy) surgery should be avoided if possible.

Exclusions:

• Emergency presentations are excluded and therefore not restricted by this policy.
• Surgery for presentations suggestive of malignancy are excluded and therefore not restricted by this policy.

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Sacral neuromodulation (SNM) is a treatment where a small device sends gentle electrical signals to nerves in the lower back (sacral nerves). This can help people with certain bladder problems when other treatments haven’t worked. The treatment starts with a short “trial phase.” If the trial helps, a permanent device may be implanted.

Between November 2024 and October 2025 there were just 30 people who had the treatment.

Under the current policy SNM is only offered to patients with idiopathic chronic non-obstructive urinary retention which is a condition that prevents people from being able to completely empty their bladder. Even then it is only allowed if:

• It is done in a specialist unit
• The care team is experienced in bladder dysfunction
• The patient has a successful trial period with a temporary device

You can read the full wording of our current policy here https://www.healthierlsc.co.uk/application/files/8016/7576/5525/LSCICB_Clin32_Policy_for_Sacral_Neuromodulation_v1.1.pdf

The proposed policy expands access, so it aligns with NICE recommendations. If approved the new policy will allow SNM for:

• Chronic non‑obstructive urinary retention (men & women) – same criteria as now
• Overactive bladder in men – when conservative treatments have failed
• Overactive bladder in women, if:
  • Reviewed by a local/regional multi-disciplinary team (specialists from different fields working together to make joint decisions)
  • Non‑surgical treatments and medicines have not worked
  • Botulinum toxin A (a medicine) has not worked or is not acceptable to the patient

There are conditions that patients must have had a good response to the trial phase and have a clear understanding of risks, long‑term commitment, and possible need for revision surgery.

Conditions such as constipation and faecal incontinence are not offered SNM which is the same as the current policy and Faecal incontinence is actually covered by an NHS England policy.

Overall, this will improve access to the treatment for more people.

The new wording in full

Sacral neuromodulation (SNM)* is routinely commissioned in:- 

1. Idiopathic, chronic non-obstructive urinary retention in men or women if ALL of the following criteria are satisfied: 
   1. the treatment is being carried out in a specialist unit

AND 

1. 2. the clinical team are experienced in the assessment, treatment and long-term care of patients with bladder dysfunction.

Or

2. Overactive bladder in men with detrusor overactivity whose symptoms have not responded to conservative management (in line with CG 97).

Or

3. Overactive bladder in women if ALL of the following criteria are satisfied: 
   1. They have been reviewed by a local or regional MDT 

AND

1. 2. They have not responded to non-surgical management including medicines (in line with NG 123)

AND

1. 3. Their symptoms have not responded to botulinum toxin type A (unless the woman is not prepared to accept the risks of needing catheterisation associated with administration of botulinum toxin type A). 

Patients who are eligible for SNM must also satisfy ALL of the following additional criteria:- 

• Have achieved a good response to a short trial phase using an external (temporary) device. 
• The long-term implications of therapy including the need for the initial test phase (above), the risk of failure, the long-term commitment, the possible need for surgical revision and/or device removal and potential adverse effects have been discussed. 

Sacral neuromodulation (SNM) is not routinely commissioned for constipation.  

Exclusion: Management of faecal incontinence is outside the scope of this policy as this is commissioned by NHS England.  

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Trigger finger happens when a tendon in the finger becomes swollen or irritated and struggles to glide smoothly. This makes the finger:

• Painful
• Stiff
• “Catch” or “lock” when bent or straightened

It is common and often improves with simple treatments. If it doesn’t improve then a surgical release may be necessary. The surgery is an outpatient procedure usually performed under local anaesthesia.

Between September 2024 and August 2025, 262 people underwent the surgery to release the trigger finger.

The idea behind the policy is that many people improve with simple treatments like splints or steroid injections, so surgery is reserved for those who don’t.

The current policy says that surgery for trigger finger can be funded when one or more of the following apply:

• The person has not improved after up to two steroid injections. 
• Splinting the finger for 3–12 weeks has not helped.
• Symptoms come back after splinting or an injection.
• The finger becomes stuck in a bent position and cannot be straightened.
• Two other trigger fingers were already treated conservatively but did not improve.
• The patient has diabetes. (This was included as an automatic qualifier for surgery.)

You can read the full policy wording here: https://www.healthierlsc.co.uk/application/files/2516/7576/5524/LSCICB_Clin18_Policy_for_Surgical_Release_of_Trigger_Finger_v2.1.pdf

In order to bring the policy in line with new evidenced based guidance we are proposing some changes as follows:

• The new policy adds additional criteria including that symptoms must interfere with daily activities or cause pain.
• Additional clarity has been added by changing the wording of the steroid injection criteria to “one or two” injections.
• The required splinting period changes from 3–12 weeks to “at least 3 weeks”, making it more flexible.
• Diabetes is removed as an automatic reason for surgery
  • The previous policy worked on the basis that diabetes could make the non-surgical treatments less effective and so people with diabetes could effectively go straight to surgery. Newer evidence shows diabetes alone does not make conservative treatment less effective and so this clause has been removed.
• Addition of 'multiple trigger digits'
  • People with several fingers affected may qualify for surgery sooner because this increases the chance that non‑surgical treatments won’t work.

The removal of the diabetes criteria is not expected to affect many people however the addition of the criteria around pain or interfering with daily activities may mean fewer people are eligible for the treatment. On the other hand, the addition of the criteria around multiple fingers affected may mean some people can access surgery sooner.

The new wording in full

The ICB will commission the surgical release of trigger finger when symptoms interfere with activities or cause pain AND one or more of the following criteria are met: 

• The patient has failed to respond to one or two steroid injections. 

OR  

• The patient has failed to respond to splinting of the affected finger for at least three weeks. 

OR 

• Triggering has recurred after splinting or injection treatment.  

OR 

• The patient has a fixed deformity that cannot be corrected. 

OR 

• The patient has previously had 2 other trigger digits unsuccessfully treated with appropriate non-operative methods. 

OR 

• The patient has multiple trigger digits.

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