Local corticosteroid injection for carpal tunnel syndrome

Carpal tunnel syndrome: a review of the recent literature

Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition present in 3.8% of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies. This review aims to provide an overview of this common condition, with an emphasis on the pathophysiology involved in CTS. The clinical presentation and risk factors associated with CTS are discussed in this paper. Also, the various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging.

Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study

INTRODUCTION AND PURPOSE

Unlike carpal tunnel syndrome, little is known about injection with corticosteroids in patients with an ulnar neuropathy at the elbow (UNE). The purpose of this feasibility study is to see whether injection with corticosteroids is safe in patients with UNE and whether there are grounds to launch a prospective placebo-controlled study on the effects of corticosteroids.

METHODS

Patients with clinical symptoms of UNE and a nerve conduction study compatible with UNE or thickened ulnar nerve at the elbow (> 10 mm(2)) by ultrasonography were included. All included patients received an ultrasound-guided injection of 1 ml containing 40 mg methylprednisoloneacetate and 10 mg lidocainhydrochloride (Depo-Medrol(®)). Complications of the injection were monitored. After 3 months, nerve conduction studies and ultrasonography were repeated and a clinical outcome determined.

RESULTS

Eight patients with nine UNE were included. None of the patients mentioned increase in the symptoms directly after the injection nor had an infection on the injection site or haematoma. After 3 months, there was improvement of the symptoms in five patients. One patient deteriorated and three had no change of the symptoms at all. Overall, there was no significant change of the thickness of the ulnar nerve with mean difference -0.056 mm(2) (95% CI -2.56 to 2.45 mm(2)).

CONCLUSION

We showed that injection with corticosteroids in patients with UNE is easy and safe, and based on this result, we found enough arguments to launch a prospective, placebo-controlled trial to explore the effectiveness of corticosteroids in patients with UNE.

Ergonomic positioning or equipment for treating carpal tunnel syndrome

BACKGROUND

Non-surgical treatment, including ergonomic positioning or equipment, are sometimes offered to people experiencing mild to moderate symptoms from carpal tunnel syndrome (CTS). The effectiveness and duration of benefit from ergonomic positioning or equipment interventions for treating CTS are unknown.

OBJECTIVES

To assess the effects of ergonomic positioning or equipment compared with no treatment, a placebo or another non-surgical intervention in people with CTS.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 2, in The Cochrane Library), MEDLINE (1966 to June 2011), EMBASE (1980 to June 2011), CINAHL Plus (1937 to June 2011), and AMED (1985 to June 2011). We also reviewed the reference lists of randomised or quasi-randomised trials identified from the electronic search.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing ergonomic positioning or equipment with no treatment, placebo or another non-surgical intervention in people with CTS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of included studies. We calculated risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for the primary and secondary outcomes. We pooled results of clinically and statistically homogeneous trials, where possible, to provide estimates of the effect of ergonomic positioning or equipment.

MAIN RESULTS

We included two trials (105 participants) comparing ergonomic versus placebo keyboards. Neither trial assessed the primary outcome (short-term overall improvement) or adverse effects of interventions. In one small trial (25 participants) an ergonomic keyboard significantly reduced pain after 12 weeks (MD -2.40; 95% CI -4.45 to -0.35) but not six weeks (MD -0.20; 95% CI -1.51 to 1.11). In this same study, there was no difference between ergonomic and standard keyboards in hand function at six or 12 weeks or palm-wrist sensory latency at 12 weeks. The second trial (80 participants) reported no significant difference in pain severity after six months when using either of the three ergonomic keyboards versus a standard keyboard. No trials comparing (i) ergonomic positioning or equipment with no treatment, (ii) ergonomic positioning or equipment with another non-surgical treatment, or (iii) different ergonomic positioning or equipment regimes, were found.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to determine whether ergonomic positioning or equipment is beneficial or harmful for treating carpal tunnel syndrome.

Evidences for antinociceptive effect of 17-α-hydroxyprogesterone caproate in carpal tunnel syndrome

Growing evidence of neuroprotective and analgesic effects by progesterone (PROG) has been obtained in experimental animal models of neuropathy. In this paper, we report the results of the first experimental study to test the efficacy of PROG in a human neuropathy. The effects of a local administration of 17-alpha-hydroxyprogesterone caproate (17HPC) has been studied in patients with carpal tunnel syndrome (CTS) and compared with those of a local administration of corticosteroid (CS) in a analogous CTS group. Sixteen women affected by mild CTS were selected. Clinical, electrophysiological and ultrasonographic data of the median nerve were quantified at 0 (pre-injection), 1 and 6 months after CS or 17HPC injection. One month after injection, both 17HPC and CS groups exhibited similar reduction in pain scores, whereas only the 17HPC-treated group still manifested symptoms relief 6 months after. Only in CS-treated patients, improvement of the clinical data correlated with ultrasonographic and electrophysiological changes of the median nerve. The present study indicates that intra-carpal injection with a long-acting PROG derivative is effective for relief of symptoms in CTS. This effect is apparently mediated by a mechanism distinct from that of the CS.

Carpal tunnel syndrome: the role of occupational factors

Carpal tunnel syndrome (CTS) is a fairly common condition in working-aged people, sometimes caused by physical occupational activities, such as repeated and forceful movements of the hand and wrist or use of hand-held, powered, vibratory tools. Symptoms may be prevented or alleviated by primary control measures at work, and some cases of disease are compensable. Following a general description of the disorder, its epidemiology and some of the difficulties surrounding diagnosis, this review focusses on the role of occupational factors in causation of CTS and factors that can mitigate risk. Areas of uncertainty, debate and research interest are emphasised where relevant.

Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review

Background

Carpal tunnel syndrome is a common disorder in hand surgery practice. Both surgical and conservative interventions are utilized for the carpal tunnel syndrome. Although certain indications would specifically indicate the need for surgery, there is a spectrum of patients for whom either treatment option might be selected. The purpose of this systematic review was to compare the efficacy of surgical treatment of carpal tunnel syndrome with conservative treatment

Methods

We included all controlled trials written in English, attempting to compare any surgical interventions with any conservative therapies. We searched Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1980 to June 2010), EMBASE (1980 to June 2010), PEDro (searched in June 2010), international guidelines, computer searches based on key words and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality and data extraction independently of each other. Weighted mean differences and 95% confidence intervals for patient self-reported functional and symptom questionnaires were calculated. Relative risk (RR) and 95% confidence intervals for electrophysiological studies and complication were also calculated.

Results

We assessed seven studies in this review including 5 RCTs and 2 controlled trials. The methodological quality of the trials ranged from moderate to high. The weighted mean difference demonstrated a larger treatment benefit for surgical intervention compared to non surgical intervention at six months for functional status 0.35( 95% CI 0.22, 0.47) and symptom severity 0.43 (95% CI 0.29, 0.57). There were no statistically significant difference between the intervention options at 3 months but there was a benefit in favor of surgery in terms of function and symptom relief at 12 months ( 0.35, 95% CI 0.15, 0.55 and 0.37, 95% CI 0.19 to 0.56). The RR for secondary outcomes of normal nerve conduction studies was 2.3 (95% CI 1.2, 4.4), while RR was 2.03 (95% CI 1.28 to 3.22) for complication, both favoring surgery.

Conclusion

Both surgical and conservative interventions had treatment benefit in carpal tunnel syndrome. Surgical treatment has a superior benefit, in symptoms and function, at six and twelve months. Patient underwent surgical release were two times more likely to have normal nerve conduction studies but also had complication and side effects as well. Given the treatment differential and potential for adverse effects and that conservative interventions benefitted a substantial proportion of patients, current practice of a trial of conservative management with surgical release for severe or persistent symptoms is supported by evidence.

Effects of topical corticosteroids on the sciatic nerve: an experimental study to adduce the safety in treating carpal tunnel syndrome

Despite known detrimental effects on the blood flow and histology of nerves after intraneural corticosteroid injection, the neurotoxic effect of corticosteroids remains unclear. We investigated the effect of topical dexamethasone on nerve function. Two sponge strips soaked with dexamethasone at doses of 0.8, 1.6, and 3.2 mg were placed under and over the left sciatic nerve of adult Wistar rats for 30 minutes. Mixed-nerve-elicited somatosensory evoked potentials and dermatomal somatosensory evoked potentials were evaluated immediately and repeated together with functional tests and histology 2 weeks later. Evoked potential amplitude was dose-dependently lower and latency was prolonged in dexamethasone-treated sciatic nerves compared to controls. The suppression persisted with incomplete recovery for at least 4 hours, but differences between treated and control nerves were not significant after 2 weeks. Topical dexamethasone adversely affected neural conduction in a dose-dependent manner. Our results suggest that caution is required when using large doses of corticosteroid for injection of the carpal tunnel.

What's new in the diagnosis and treatment of peripheral nerve entrapment neuropathies

Entrapment neuropathies can be common conditions with the potential to cause significant disability. Correct diagnosis is essential for proper management. This article is a review of recent developments related to diagnosis and treatment of various common and uncommon nerve entrapment disorders. When combined with classical peripheral nerve examination techniques, innovations in imaging modalities have led to more reliable diagnoses. Moreover, innovations in conservative and surgical techniques have been controversial as to their effects on patient outcome, but randomized controlled trials have provided important information regarding common operative techniques. Treatment strategies for painful peripheral neuropathies are also reviewed.

MRI-Based Identification of an Appropriate Point of Needle Insertion for Patients with Idiopathic Carpal Tunnel Syndrome to Avoid Median Nerve Injury

To identify a safe entry point for needle insertion in patients with idiopathic carpal tunnel syndrome (CTS), cross-sectional images of the wrist MRI of 45 normal volunteers and 180 consecutive patients with idiopathic CTS were reviewed. Insertion of the needle from the five different entry points into the carpal tunnel was simulated by drawing a 1-pixel line, and the incidence of contact with the median nerve was compared. In the CTS patients, the lowest incidence was 3% when inserted at one-third of the length between the FCR and FCU tendons on the ulnar side at the level of the distal part of the distal radioulnar joint and 4% at the mid point between the palmaris longus tendona and the flexor carpi ulnaris tendon. It was greater in the advanced stage of CTS than the less severe CTS. We recommend those two entry points.

Assessment of phonophoresis and iontophoresis in the treatment of carpal tunnel syndrome: a randomized controlled trial

To define the role of phonophoresis and iontophoresis of corticosteroids in conjunction with wrist splint use in the treatment of carpal tunnel syndrome (CTS) compared to wrist splint use alone, 52 CTS subjects were analyzed based on clinical and electrophysiological criteria. A prospective, randomized controlled trial was carried out to assess symptom severity, motor skills, and hand function according to the Boston Symptom Severity Scale (BSSS), grip strength, and nine-hole peg test (NHPT), respectively, on the initial visit and in the 3rd month after treatment. The patients underwent conservative interventions randomly as follows: (1) 3 weeks of phonophoresis with betamethasone in conjunction with wrist splint use (group I, n: 18) or (2) 3 weeks of iontophoresis with betamethasone in conjunction with wrist splint use (group II, n: 16) or (3) wrist splint use alone (control, group III, n: 18). The mean age of the patients was 43.7 ± 8.4 (range 24-57) years. Groups I, II, and III showed a significant and further improvement in BSSS at the 3rd month evaluations compared with baseline (P < 0.001, P = 0.001, P < 0.001, respectively), but no significant change was observed in grip strength or NHPT (P > 0.05). There was a statistically significant difference between the phonophoresis and control groups after treatment only regarding BSSS, in favor of phonophoresis (P = 0.012). We recommend the use of wrist splints especially with phonophoresis for relief of symptoms in patients with CTS. Our results demonstrated no superiority among the treatment groups. Further, transdermal steroid treatments are not key determinants of efficacy with respect to motor skills and hand dexterity.

Is there Light at the End of the Tunnel? Controversies in the Diagnosis and Management of Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common disorder responsible for considerable patient suffering and cost to health services. Despite extensive research, controversies still exist with regards to best practice in diagnosis, treatment, and service provision. Current best practise would support the use of history, examination and electro-diagnostic studies. The role for ultrasound scanning in diagnosis of carpal tunnel syndrome is yet to be proven. It appears magnetic resonance image scanning has a role where a rare cause for carpal tunnel syndrome may be suspected and also in the detailed reconstruction of the anatomy to aid endoscopic procedures. Treatment options can be surgical or non-surgical and patient choice will dictate the decision. For non-surgical interventions many options have been trialled but until now only steroid use, acupuncture, and splinting have shown discernable benefits. Open surgical decompression of the carpal tunnel appears to be more simple and cost-effective than minimally invasive interventions. For those patients who reject surgery, splinting, acupuncture, and steroid injection can play a role. Recent work looking at different service delivery options has shown some positive results in terms of decreasing patient waiting time for definitive treatment. However, no formal cost-effectiveness analysis has been published and concerns exist about the impact of a stream-lined service on surgical training. In this review, we look at the different diagnostic and treatment options for managing carpal tunnel syndrome. We then consider the different service delivery options and finally the cost-effectiveness evidence.

Optimal management of carpal tunnel syndrome

In order to improve health care efficiency and effectiveness, treatments should provide disease improvement or resolution at a reasonable cost. The American Academy of Orthopedic Surgeons (AAOS) published a guideline for treatment of carpal tunnel syndrome (CTS) in 2009 based on review of the literature up to April 6, 2007. We have now reviewed the material published since then. Through reviewing evidence-based articles published during this period, this paper examines the current options and trends for treating CTS. We performed a systematic review of the randomized controlled trials, meta-analyses, systematic reviews, and practice guidelines to present the outcomes of current treatments for this disease. Twenty-five studies met our inclusion criteria. Thirteen randomized, controlled trials and 12 systematic reviews, including three Cochrane database systematic reviews, were retrieved. Our review revealed that most of the recent studies support the AAOS guideline. However, the recent literature demonstrates a trend towards recommending early surgery for CTS cases with or without median nerve denervation, although the AAOS guideline recommends early surgical treatment only for cases with denervation. The usefulness of splinting and steroids as initial treatments for improving patients’ symptoms are also supported by the recent literature, but these effects are temporary. The evidence level for ultrasound treatment is still low, and further studies are needed to determine the effectiveness of this treatment. Finally, our review revealed a paucity of articles comparing the costs of CTS diagnosis and treatment. With the recent focus on health care reform and rising costs, attention to the direct and indirect costs of health care is important for all conditions. Future well designed studies should include cost analyses to help determine the cost burden of CTS.

Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice

Background

Carpal tunnel syndrome is caused by entrapment of the median nerve and results in pain, tingling and numbness in the wrist and hand. It is a common condition in general practice. Effectiveness of treatment by intracarpal corticosteroid injection has never been investigated in general practice. The objective of this study was to determine if corticosteroid injections for carpal tunnel syndrome provided by general practitioners are effective.

Methods

In this study 69 participants with a clinical diagnosis of carpal tunnel syndrome were recruited from 20 general practices. Short-term outcomes were assessed in a randomised, placebo-controlled trial. Long-term results were assessed in a prospective cohort-study of steroid responders.

Participants were randomised to intracarpal injections of 1 ml triamcinolonacetonide 10 mg/ml (TCA) or 1 ml NaCl (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment success, mean score of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the Boston carpal tunnel questionnaire, subjective improvement and proportion of participants with recurrences during follow-up. Duration of follow-up was twelve months.

Results

The TCA-group (36 participants) had better outcomes than the NaCl-group (33 participants) during short-term assessment for outcome measures treatment response, mean improvement of SSS-score (the mean difference in change score was 0.637 {95% CI: 0.320, 0.960; p < 0.001}) and FSS-score (the mean difference in change score was 0.588 {95% CI: 0.232, 0.944; p = 0.002}) and perceived improvement (p = 0.01). The number to treat to achieve satisfactory partial treatment response or complete resolution of symptoms and signs was 3 (95% CI:1.83, 9.72).

49% of TCA-responders (17/35) had recurrences during follow-up. In the group of TCA-responders without recurrences (51%, 18/35) outcomes for SSS-score and FSS-score deteriorated during the follow-up period of 12 months (resp. p = 0.008 and p = 0.012).

Conclusions

Corticosteroid injections for CTS provided by general practitioners are effective regarding short-term outcomes when compared to placebo injections. The short-term beneficial treatment effects of steroid injections deteriorated during the follow-up period of twelve months and half of the cohort of steroid-responders had recurrences.

Trial registration

Current Controlled Trials ISRCTN53171398

Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review

OBJECTIVE

To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs).

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found.

CONCLUSIONS

The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.

Progesterone - new therapy in mild carpal tunnel syndrome? Study design of a randomized clinical trial for local therapy

Background

Local corticosteroid injection for carpal tunnel syndrome (CTS) provides greater clinical improvement in symptoms one month after injection compared to placebo but significant symptom relief beyond one month has not been demonstrated and the relapse of symptoms is possible.

Neuroprotection and myelin repair actions of the progesterone was demonstrated in vivo and in vitro study.

We report the design of a randomized controlled trial for the local injection of cortisone versus progesterone in "mild" idiopathic CTS.

Methods

Sixty women with age between 18 and 60 years affected by "mild" idiopathic CTS, diagnosed on the basis of clinical and electrodiagnostic tests, will be enrolled in one centre. The clinical, electrophysiological and ultasonographic findings of the patients will be evaluate at baseline, 1, 6 and 12 months after injection.

The major outcome of this study is to determine whether locally-injected progesterone may be more beneficial than cortisone in CTS at clinical levels, tested with symptoms severity self-administered Boston Questionnaire and with visual analogue pain scale.

Secondary outcome measures are: duration of experimental therapy; improvement of electrodiagnostic and ultrasonographic anomalies at various follow-up; comparison of the beneficial and harmful effects of the cortisone versus progesterone.

Conclusion

We have designed a randomized controlled study to show the clinical effectiveness of local progesterone in the most frequent human focal peripheral mononeuropathy and to demonstrate the neuroprotective effects of the progesterone at the level of the peripheral nervous system in humans.

Local steroid injection for moderately severe idiopathic carpal tunnel syndrome: protocol of a randomized double-blind placebo-controlled trial (NCT 00806871)

BACKGROUND

Patients with idiopathic carpal tunnel syndrome (CTS) are commonly treated with steroid injection into or proximal to the carpal tunnel. However, evidence for its efficacy beyond one month has not been established in randomized placebo-controlled trials. The primary aim of this randomized trial is to assess the efficacy of steroid injection into the carpal tunnel in relieving symptoms of CTS in patients with symptoms of such severity to warrant surgical treatment but have not been treated with steroid injection.

METHODS/DESIGN

The study is a randomized double-blind placebo-controlled trial. Patients referred to one orthopedic department because of CTS are screened. Eligibility criteria are age 18 to 70 years, clinical diagnosis of primary idiopathic CTS and abnormal nerve conduction tests or clinical diagnosis made independently by two orthopedic surgeons, failed treatment with wrist splinting, symptom severity of such magnitude that the patient is willing to undergo surgery, no severe sensory loss or thenar muscle atrophy, and no previous steroid injection for CTS. A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after injection includes validated questionnaires (CTS symptom severity scale, QuickDASH and SF-6D), adverse events, physical examination by a blinded assessor, and nerve conduction tests. The primary outcome measures are change in the CTS symptom severity score at 10 weeks and the rate of surgery at 52 weeks. The secondary outcome measures are the score change in the CTS symptom severity scale at 52 weeks, time to surgery, and change in QuickDASH and SF-6D scores and patient satisfaction at 10 and 52 weeks. The primary analysis will be carried out using mixed model analysis of repeated measures.

DISCUSSION

This paper describes the rationale and design of a double-blind, randomized placebo-controlled trial that aims to determine the efficacy of two different doses of steroid injected into the carpal tunnel in patients with moderately severe idiopathic CTS.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT00806871.

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the upper extremity. The condition is responsible for substantial annual costs to society, both in terms of lost productivity and the costs of treatment. Accurate diagnostic criteria, the selection of treatment strategies based on high-level evidence, and outcomes data have been inconsistent despite the prevalence of the condition. The increased awareness of the need for evidence-based practice guidelines has, however, yielded important data to guide treatment of CTS. Evidence-based guidelines for diagnosis and treatment have been developed and should direct the treatment of CTS.

Evidence-based radiology (part 2): Is there sufficient research to support the use of therapeutic injections into the peripheral joints?

INTRODUCTION

This review article addresses the best evidence currently available for the effectiveness of injection therapy for musculoskeletal conditions involving the peripheral joints. The research is presented by anatomical region and areas of controversy and the need for additional research are identified.

DISCUSSION

Randomized controlled trials, meta-analyses and systematic reviews are lacking that address the effectiveness of therapeutic injections to the sternoclavicular, acromioclavicular, ankle and foot joints. No research studies of any kind have been reported for therapeutic injections of the sternoclavicular joint. With the exception of the knee, possibly the hip and patients with inflammatory arthropathies, research does not unequivocally support the use of therapeutic joint injections for most of the peripheral joints, including the shoulder. Additionally, controversy exists in some areas as to whether or not corticosteroids provide better outcomes compared to local anesthetic injections alone.

CONCLUSION

When viscosupplementation injections are compared to corticosteroids in patients with osteoarthritis of the knee, the evidence supports the use of viscosupplementation for more prolonged improvement in outcomes, with corticosteroids being good for short-term relief.

The cost-effectiveness of nonsurgical versus surgical treatment for carpal tunnel syndrome

PURPOSE

To compare direct costs and results for patients with electrodiagnostically proven carpal tunnel syndrome treated with surgery versus nonsurgical care.

METHODS

There is a retrospective study of 120 patients divided into 2 groups: subjects in group 1 had chosen nonsurgical treatment, whereas subjects in group 2 had chosen surgery with no nonsurgical treatment. Patients were matched on age, gender, severity of nerve conduction abnormalities, body mass index, smoking history, job category, and insurance coverage. Direct cost of care was measured. An incremental cost-utility ratio was calculated to compare costs between the different management strategies.

RESULTS

Group 1 follow-up averaged 13 +/- 5 months compared to 12 +/- 2 months for group 2. Steroid injections were used in 18 patients in group 1. Thirty-two patients in group 1 elected to have surgery during the follow-up period. Cost of care averaged $3335 +/- $2097 in group 1 and $3068 +/- $983 in group 2.

CONCLUSIONS

The direct cost of nonsurgical care of confirmed carpal tunnel syndrome did not show a significant difference from that of surgical treatment without preoperative splinting or therapy. The incremental cost-utility ratio for carpal tunnel surgery was favorable. Surgery, rather than nonsurgical care, should be considered as the initial form of treatment when patients are diagnosed with carpal tunnel syndrome that is confirmed by nerve conduction studies, as this provides symptom resolution with a favorable cost analysis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis III.

Management decisions in nontraumatic complaints of arm, neck, and shoulder in general practice

OBJECTIVE We wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner (GP), as well as 6 common management decisions, in patients with nontraumatic arm, neck, and shoulder complaints at the time of the first consultation with their physician.

METHODS

We undertook an observational cohort study set in 21 Dutch general practices, including 682 patients with nontraumatic complaints of arm, neck, and shoulder. The outcome measure was application (yes/no) of a specific management option: watchful waiting, additional diagnostic tests, prescription of medication, corticosteroid injection, referral for physiotherapy, and referral for medical specialist care.

RESULTS

Separate multilevel analyses showed that overall, the diagnostic category, having long duration of complaints, and reporting many functional limitations were most frequently associated with the choice of a management option. For watchful waiting, only complaint variables played a role (long duration of complaints, high complaint severity, many functional limitations, recurrent complaint). All these variables were negatively associated with watchful waiting. When opting for 1 of the 5 other management options, several physician characteristics played a role as well. Less clinical experience was associated with additional diagnostic tests and referral to a medical specialist. GPs working in a solo practice more frequently referred to a medical specialist. GPs working in a rural area more frequently referred for physiotherapy. Female GPs prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently.

CONCLUSIONS

Diagnostic category, long duration of complaints, and high functional limitations were key variables in management decisions with these complaints. In addition, several physician characteristics played a role as well.

A one-stop carpal tunnel clinic

INTRODUCTION

By December 2008, 90% of referrals requiring hospital admission will need to be seen and treated within the 18-week patient pathway. Previously, patients within our trust with suspected carpal tunnel syndrome had to wait 3 months to see a specialist in clinic and, once assessed, would have to wait up to a further 6 months for an open carpal tunnel decompression under local anaesthetic (OCTD/LA). We set up a one-stop clinic, where patients would have their out-patient consultation and surgery on the same day. We evaluated the clinic in order to assess whether it led to reduced waiting times whilst maintaining good clinical outcome and patient satisfaction.

PATIENTS AND METHODS

Patients were selected on the basis of the standard referral letter alone. Those selected were then assessed by a single surgeon in the clinic. The patients deemed appropriate underwent an OCTD/LA and were discharged the same day. Patients were followed up with a patient satisfaction and Boston questionnaire.

RESULTS

Forty-six patients underwent 63 OCTD/LA, waiting an average of 2.2 months (9 weeks) from referral. There was high patient satisfaction and improvement in symptoms following treatment in the clinic.

CONCLUSIONS

We believe a one-stop carpal tunnel clinic can be an efficient and cost-effective way of treating this common condition.

Ultrasound-guided interventional procedures of the wrist and hand

This pictorial review will outline the rationale, indications, techniques, controversies and possible complications of ultrasound-guided interventional procedures of the hand and wrist.