Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study

Comparative Efficacy of 5% Dextrose and Corticosteroid Injections in Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

This study aims to assess the effectiveness of 5% dextrose (D5W) in comparison to corticosteroids for treating carpal tunnel syndrome (CTS).

DATA SOURCES

A comprehensive systematic search was conducted across MEDLINE (PubMed), Embase, and the Cochrane Central Register of Controlled Trials on November 13, 2023. These were supplemented by manual searches using Google Scholar.

STUDY SELECTION

Two independent authors reviewed the literature, resolving any discrepancies through detailed discussions and consultation with a third author.

DATA EXTRACTION

Data on primary outcomes (pain assessment) and secondary outcomes (symptom severity and functional status using the Boston Carpal Tunnel Questionnaire, electrophysiologic measures, cross-sectional area, and adverse effects) were extracted independently by the 2 authors (M.W. and H.H.).

DATA SYNTHESIS

The analysis included 4 randomized controlled trials and 1 quasi-experimental study, encompassing a total of 212 patients (220 hands) with mild to moderate CTS.

RESULTS

Within 3 months, the D5W injections showed a statistically significant improvement in functional status compared to the corticosteroids with a standard mean difference of -0.34 (95% CI, -0.62 to -0.05). D5W was associated with fewer adverse incidents than corticosteroids (risk ratio, 0.13; 95% CI: 0.03-0.51). No difference was observed between the 2 treatments in other areas.

CONCLUSIONS

For patients with mild to moderate CTS, D5W injections were more effective than corticosteroid injections in improving functional status and demonstrated fewer adverse effects. D5W injections also paralleled corticosteroids in pain reduction, symptom severity, electrodiagnostic measures, and cross-sectional area of nerve, recommending D5W as a preferred treatment for mild to moderate CTS.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative

BACKGROUND

Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short term, and many patients go on to receive carpal tunnel release (CTR). The purpose of this study was to determine the variation in steroid injection use by hand surgeons.

METHODS

The authors analyzed data from a nine-center hand surgery quality collaborative. Data from 1586 patients (2381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates.

RESULTS

Steroid injection use significantly varied by practice, ranging from 12% to 53% of patients. The odds of receiving a steroid injection were 1.4 times higher for women ( P < 0.01), 1.6 times higher for patients with chronic pain syndrome ( P < 0.01), 0.5 times lower for patients with moderate electromyography (EMG) classification, and 0.4 times lower for patients with severe EMG classification (both P < 0.01). Patients with high scores on the Six-Item CTS Scale ( P = 0.02) and patients with moderate ( P = 0.04) or severe EMG ( P = 0.05) classification had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with a high Six-Item CTS Scale score ( P = 0.03) and patients with severe EMG classification ( P = 0.02).

CONCLUSIONS

The authors found wide patient-level and practice-level variation in the use of steroid injections before CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Progression From Steroid Injection to Surgery in Carpal Tunnel Syndrome Patients With Concurrent Ulnar Nerve Compression: A Retrospective Analysis

BACKGROUND

Steroid injections are a common treatment option in the management of carpal tunnel syndrome (CTS). This study assesses various prognostic factors for progression to carpal tunnel release (CTR) after a first-time steroid injection for CTS with specific focus on concomitant ulnar nerve compression (UNC).

METHODS

This is a retrospective study of 426 hands with CTS treated with a first-time steroid injection in the Long Island region of New York. The main predictor variable was UNC measured in two analytical models of positive UNC and location of UNC (wrist or elbow). Multivariate logistic regression analyses adjusted for demographic, medical, and CTS-related variables for 2 study outcomes occurring within 1 year: (1) CTR; and (2) steroid reinjection.

RESULTS

Overall progression to CTR within 1 year of steroid injection was 23.0%. Ulnar nerve compression was present in 16.7% of patients and was significantly associated with increased odds for CTR but not with steroid reinjection. These results were further localized to be specific for UNC at the elbow. A moderate or severe result on electrodiagnostic studies was associated with increased odds for CTR. Increased age was associated with slightly increased odds of steroid reinjection while a history of distal radius fracture was associated with decreased odds of steroid reinjection.

CONCLUSIONS

Carpal tunnel syndrome patients with UNC may benefit from earlier definitive treatment with CTR rather than attempting steroid injections, as they are more likely to seek reintervention within 1 year of their initial injection.

The association of sensory phenotype and concomitant mood, sleep and functional impairment with the outcome of carpal tunnel surgery

BACKGROUND

Up to 25% of people who have had carpal tunnel release surgery (CTR) fail to report improvement; however, evidence for prognostic indicators in this surgical cohort is limited. To identify candidate prognostic factors, this study investigated the association of quantitative sensory testing (QST) derived sensory phenotype and attendant impairment with patient-reported surgical outcome.

METHODS

With ethical approval and informed consent, this prospective observational longitudinal study recruited patients from two London hospitals. Multimodal phenotyping measures including quantitative sensory testing (QST), pain parameters, insomnia, pain-related worry, mood and function, were evaluated prior to; and at 3- and 6-months post-surgery. Pain in median nerve distribution with electrophysiologically confirmed conduction delay and DN4 score ≥ 4 was defined as neuropathic. Primary outcome was patient-rated change at 6 months, dichotomised as poor outcome; "worse" or "no change" and good outcome; "slightly better", "much better" or "completely cured".

RESULTS

Seventy-six patients participated. Prior to surgery, substantial heterogeneity in established categories of somatosensory function was observed with 21% of participants categorised as having a healthy sensory phenotype; 29% with thermal hyperalgesia; 32% mechanical hyperalgesia and 18% sensory loss. Seventy six percent of participants were classified as having neuropathic pain, 33% with high levels of pain related worry and 64% with clinical insomnia. Observed differences in pain, sleep impairment, psychological factors and function, between sensory phenotypic groups, was not significant. At 3- and 6-months post-surgery there was significant improvement in all phenotyping measures with a moderate to large effect size. Thermal and mechanical measures of somatosensation improved (p < 0.001), as did functional ability (p < 0.001). Symptom severity diminished (p < 0.001), as did pain-related worry (p < 0.001), anxiety (p = 0.02) and insomnia (p < 0.001). Patient-rated surgical outcome was good in 92% of the cohort, poor in 8%. Baseline sensory phenotype category was not associated with surgical outcome however pain-related worry, anxiety and functional interference were significantly associated with outcome (p ≤ 0.05).

CONCLUSION

In patients undergoing carpal tunnel surgery, pain-related worry, anxiety and pain functional interference are candidate prognostic outcome factors and require further elucidation.

Sickness absence after carpal tunnel release: a multicentre prospective cohort study

OBJECTIVES

To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence.

DESIGN

Multicentre prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively.

OUTCOMES

The main outcome was duration of work absence from date of surgery to date of first return to work.

RESULTS

254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR.

CONCLUSIONS

There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work.