Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome

Platelet-rich plasma (PRP) in nerve repair

Platelet-rich plasma (PRP) has the capability of assisting in the recovery of damaged tissues by releasing a variety of biologically active factors to initiate a hemostatic cascade reaction and promote the synthesis of new connective tissue and revascularization. It is now widely used for tissue engineering repair. In addition, PRP has demonstrated nerve repair and pain relief, and has been studied and applied to the facial nerve, median nerve, sciatic nerve, and central nerve. These suggest that PRP injection therapy has a positive effect on nerve repair. This indicates that PRP has high clinical value and potential application in nerve repair. It is worthwhile for scientists and medical workers to further explore and study PRP to expand its application in nerve repair, and to provide a more reliable scientific basis for the opening of a new approach to nerve repair.

Injection therapy for carpal tunnel syndrome: A systematic review and network meta-analysis of randomized controlled trials

Various injectants are available for the treatment of carpal tunnel syndrome. This systematic review and network meta-analysis was conducted to investigate the effectiveness of different injection therapies in alleviating the symptoms of carpal tunnel syndrome. Various databases were searched for relevant studies from inception until May 10, 2023. Eligible studies were identified using the patient (P), intervention (I), comparison (C), and outcomes (O) model, which involved (P) participants with carpal tunnel syndrome, (I) an intervention based on injection therapy, (C) the use of placebo or another injectant as a control treatment, and (O) the measurement of clinical and electrodiagnostic outcomes of interest. A total of 18 studies were included in the analysis. The network meta-analysis revealed that platelet-rich plasma is effective in the treatment of carpal tunnel syndrome in terms of symptom and pain relief and functional improvement in both the short and long term, whereas steroids are effective only in the short term. Additionally, injections of dextrose solution may offer long-term pain relief as well as short- and long-term symptom alleviation and functional improvement. The study findings suggest that platelet-rich plasma should be used as the first-line treatment for carpal tunnel syndrome, with dextrose and steroids serving as alternative treatment options.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Elbow and Upper Extremity: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the elbow and upper extremity, including the tendons (lateral epicondylitis, medial epicondylitis, biceps tendonitis, triceps tendonitis), articular cartilage (osteoarthritis, osteochondral lesions), and bone (fractures, nonunions, avascular necrosis, osteonecrosis). Promising and established treatment modalities include hyaluronic acid; botulinum toxin; corticosteroids; leukocyte-rich and leukocyte-poor platelet-rich plasma; autologous blood; bone marrow aspirate comprising mesenchymal stromal cells (alternatively termed medicinal signaling cells and frequently mesenchymal stem cells [MSCs]) and bone marrow aspirate concentrate; MSCs harvested from adipose and skin (dermis) sources; vascularized bone grafts; bone morphogenic protein scaffold made from osteoinductive and conductive β-tricalcium phosphate and poly-ε-caprolactone with hydrogels, human MSCs, and matrix metalloproteinases; and collagen sponge. Autologous blood preparations such as autologous blood injections and platelet-rich plasma show positive outcomes for nonresponsive tendinopathy. In addition, cellular therapies such as tissue-derived tenocyte-like cells and MSCs show a promising ability to regulate degenerative processes by modulating tissue response to inflammation and preventing continuous degradation and support tissue restoration.

Ultrasound-Guided Sciatic Nerve Hydrodissection Can Improve the Clinical Outcomes of Patients with Deep Gluteal Syndrome: A Case-Series Study

Deep gluteal syndrome (DGS) is caused by sciatic nerve entrapment. Because fascial entrapment neuropathies may occur in multiple locations, ultrasound-guided nerve hydrodissection is a key component of DGS treatment. In this study, we examined the clinical outcomes of patients with DGS undergoing ultrasound-guided sciatic nerve hydrodissection. A 10 mL mixture consisting of 5% dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve hydrodissection. Clinical outcomes were evaluated using Numeric Rating Scale (NRS) scores of pain, the proportion of patients with favorable outcomes (reduction of ≥50% in pain), the duration for which patients exhibited favorable outcomes (percentage of follow-up duration), and the occurrence of major complications and minor side effects. A total of 53 patients were consecutively included and followed up for 3 to 19 months. After the initial injection, the NRS scores significantly improved at 1 week, 1 month, 3 months, and the final follow-up. Specifically, 73.6%, 71.7%, 64.2%, and 62.3% of the patients exhibited favorable outcomes at 1 week, 1 month, 3 months, and the final follow-up, respectively. The median duration for which the patients exhibited favorable outcomes was 84.7% of the follow-up period. Three patients (5.7%) experienced transient dizziness and vomiting, which resolved without further treatment. No vessel or nerve puncture was observed. Overall, ultrasound-guided sciatic nerve hydrodissection is a safe procedure that mitigates the pain associated with DGS. To achieve favorable outcomes, three consecutive injections 3 weeks apart are required.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis

BACKGROUND

Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS.

METHODS

Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed.

RESULTS

From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63.

CONCLUSIONS

PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.

Local injection therapy for carpal tunnel syndrome: a network meta-analysis of randomized controlled trial

Objective: Clinical research has shown that local injections for carpal tunnel syndrome reduce the symptoms of patients and enhance their quality of life considerably. However, there are several therapy options, and the optimal choice of regimen remains uncertain. Therefore, we comprehensively evaluated the variations in clinical efficacy and safety of several medications for treating carpal tunnel syndrome. Methods: Computer searches of Embase, PubMed, Cochrane Library, and Web of Science databases were used to collect articles of randomized controlled trials on local injections for treating carpal tunnel syndrome from database creation till 10 June 2023. Two researchers independently screened the literature, extracted information, evaluated the risk of bias in the included studies, and performed network Meta-analysis using Stata 17.0 software. Drug efficacy was assessed using symptom severity/function and pain intensity. Surface under the cumulative ranking curve (SUCRA) ranking was used to determine the advantage of each therapy. Results: We included 26 randomized controlled trials with 1896 wrists involving 12 interventions, such as local injections of corticosteroids, platelet-rich plasma, 5% dextrose, progesterone, and hyaluronidase. The results of the network meta-analysis showed the following: (i) symptom severity: at the 3-month follow-up, D5W combined with splinting (SUCRA = 95%) ranked first, and hyaluronidase (SUCRA = 89.6%) at 6 months; (ii) functional severity: either at the 3-month follow-up (SUCRA = 89.5%) or 6 months (SUCRA = 83.6%), iii) pain intensity: 5% dextrose in water combined with splinting was the most effective at the 3-month (SUCRA = 85%) and 6-month (SUCRA = 87.6%) follow-up. Conclusion: Considering the combination of symptoms/function and pain intensity, combining 5% dextrose in water with splinting is probably the treatment of choice for patients with carpal tunnel syndrome. It is more effective than glucocorticoids and no adverse effects have been observed. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022370525.

Ultrasound-guided nerve hydrodissection of cervical nerve roots for cervical radicular pain in patients with mild and moderate to severe stenosis: a retrospective cohort study

Because fascial entrapment neuropathy can occur in multiple locations, ultrasound-guided nerve hydrodissection has become a key component of the treatment of cervical radicular pain. In this paper, we propose a combination of injectates used for nerve hydrodissection of the cervical nerve roots and compare the clinical outcomes of this treatment among patients with different severities of stenosis. This is a retrospective cohort study designed to compare outcomes between patients with mild stenosis and moderate to severe stenosis. Forty-four patients with mild cervical stenosis and 30 patients with moderate to severe cervical stenosis were consecutively enrolled into two groups. A 10-mL mixture in a single level consisting of 5% in Dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve roots hydrodissection. The two groups were compared with regard to their numeric rating scales (NRS) of pain, proportion of patients who exhibited a favorable outcome (a reduction of pain ≥ 50%), duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects. The follow-up period ranged from 3 to 20 months. The NRS of both groups improved significantly by 1 week, 1 month, 3 months, and final follow-up after the initial injection. Differences in the groups' NRS, proportion of patients who exhibited a favorable outcome, duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects were nonsignificant. There were 4 patients (5.4%) experienced dizziness in that resolved without further treatment. Ultrasound-guided nerve hydrodissection of cervical nerve roots is a safe procedure that reduces pain associated with cervical radicular pain, even in patients with moderate to severe stenosis.

The Effect of Ultrasound-Guided Treatment of Symptomatic Partial Rotator Cuff Injury Under the Background of Deep Learning

Deep learning is one of the most powerful machine learning algorithms at present. The convolutional neural network model has the ability to automatically learn features, and has a greater performance advantage than other deep learning models in the field of image processing. Based on deep learning, the effects of platelet-rich plasma injection of betamethasone on shoulder pain and function in patients with partial rotator cuff injury were investigated. Eighty patients with tendinosis or a partial tear (<1.0 cm) were recruited between 2021 and 2022. Mixed injection of 1 mL betamethasone and 5 mL lidocaine, following 5 mL PRP injected in 7-day intervals, were infiltrated directly into the lesion of supraspinatus interstitial RCT under ultrasound control. The patients were assessed by the SPADI, CMS and ASES before and 1, 3, 6, 9 months after injection. MRI was also performed before and 6 months after injection. All patients had significant better ASES, SST, CMS score and improvement of motion and pain relief after PRP injection, compared with the baseline before injection (p < 0.05). In the MRI data, statistical pre- and post-comparisons revealed significant differences between location of partial rupture and grade of tendinopathy. There were no mortality and major complications observed during follow-up. Under the background of deep learning, ultrasound-guided injection of PRP with betamethasone can progressively relieve shoulder joint pain and improve motor function in patients with partial rotator cuff injury. Ultrasound-guided injection of PRP with betamethasone is safe and useful for rotator cuff disease.

Process Optimization and Efficacy Assessment of Standardized PRP for Tendinopathies in Sports Medicine: Retrospective Study of Clinical Files and GMP Manufacturing Records in a Swiss University Hospital

Platelet-rich plasma (PRP) preparations have recently become widely available in sports medicine, facilitating their use in regenerative therapy for ligament and tendon affections. Quality-oriented regulatory constraints for PRP manufacturing and available clinical experiences have underlined the critical importance of process-based standardization, a pre-requisite for sound and homogeneous clinical efficacy evaluation. This retrospective study (2013–2020) considered the standardized GMP manufacturing and sports medicine-related clinical use of autologous PRP for tendinopathies at the Lausanne University Hospital (Lausanne, Switzerland). This study included 48 patients (18–86 years of age, with a mean age of 43.4 years, and various physical activity levels), and the related PRP manufacturing records indicated a platelet concentration factor most frequently in the range of 2.0–2.5. The clinical follow-up showed that 61% of the patients reported favorable efficacy outcomes (full return to activity, with pain disappearance) following a single ultrasound-guided autologous PRP injection, whereas 36% of the patients required two PRP injections. No significant relationship was found between platelet concentration factor values in PRP preparations and clinical efficacy endpoints of the intervention. The results were in line with published reports on tendinopathy management in sports medicine, wherein the efficacy of low-concentration orthobiologic interventions appears to be unrelated to sport activity levels or to patient age and gender. Overall, this study confirmed the effectiveness of standardized autologous PRP preparations for tendinopathies in sports medicine. The results were discussed in light of the critical importance of protocol standardization for both PRP manufacturing and clinical administration to reduce biological material variability (platelet concentrations) and to enhance the robustness of clinical interventions (comparability of efficacy/patient improvement).

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

Injections for treatment of carpal tunnel syndrome: A narrative review of the literature

Background

Carpal tunnel syndrome is an extremely common condition in the general population. Nonoperative treatment is a mainstay of management prior to surgical carpal tunnel release. Injections are frequently used as treatment, especially corticosteroid injections, but there is little consensus in the literature regarding injection number, volume, corticosteroid dose, and technique.

Methods

A comprehensive literature search was performed of PubMed to identify papers relating to corticosteroid injections as well as other injections performed in patients with carpal tunnel syndrome.

Results

A total of 45 articles were selected for inclusion in this review. Corticosteroid injections for carpal tunnel syndrome are discussed in detail, including injection number, volume, and technique as well as corticosteroid dose. Alternative injections for management of carpal tunnel syndrome are also discussed.

Conclusions

Corticosteroid injections have been identified as a safe, effective short term management option for carpal tunnel syndrome. However, there is no standardized recommendation for specifics of their use in relation to corticosteroid dose, number of injections, injectate volume, and use of ultrasound guidance. Further research is required to better establish the optimal role for corticosteroid injections in the treatment of carpal tunnel syndrome. Platelet rich plasma, lidocaine, and hyaluronic acid, among others, are additional injections that warrant further exploration for use in management of carpal tunnel syndrome.

Role for platelet rich plasma as an adjuvant therapy in wound healing and burns

Background

Platelet rich plasma (PRP) contains high concentrations of growth factors. Intuitively, these were thought to be of potential benefit in healing of chronic wounds, skin grafts and graft donor sites. This was echoed in retrospective studies and an individual case basis but had not been randomized.

Methods

A systematic search was carried out by two individuals, independently, on the MEDLINE, EMBASE and COCHRANE databases, according to PRISMA guidelines. All data analysis and statistics was pooled and analysed using the Cochrane RevMan Software.

Results

Split thickness grafts have been described by numerous authors, but PRP use did not offer a significant advantage in graft take in pooled results (MD 5.83, 95% CI − 0.69 to 12.25, random-effects, p = 0.08). The analysis of included randomized controlled trials has shown favourable split-thickness skin graft donor site healing in the PRP group (MD − 5.55, 95% CI − 7.40 to − 3.69, random-effects, p =  < 0.00001) compared to the control group. For carpal tunnel syndrome, the pooled results showed no difference in functional scores vs steroid injections (SMD − 0.68, 95% CI − 1.47 to 0.10, randomeffects, p = 0.09) or indeed splinting groups.

Conclusions

With the current body of evidence, we conclude that the use of PRP as an adjuvant therapy in skin grafts, burns, carpal tunnel surgery or scars cannot be rationalised. A potential use of PRP is in donor site management but the cost of this would be difficult to justify.

Level of evidence: Not ratable.

Efficacy and safety of platelet-rich plasma in the treatment of carpal tunnel syndrome: A network meta-analysis of different injection treatments

Purpose: Carpal tunnel syndrome (CTS) is a common form of median nerve compression in the wrist caused by focal peripheral neuropathy. Platelet-rich plasma (PRP) therapy could improve the healing ability by exposing the injured tissues to high concentrations of autologous growth factors. Our study aims to compare all injective treatments for CTS and assess the efficacy and priority of PRP therapy. Methods: We searched Medline, Embase, Web of Science, Cochrane databases, and Clinicaltrial.gov until 17 October 2022. We only included data from randomized controlled trials (RCTs) that evaluated PRP injection therapy or drug injection therapy. The included RCTs measured at least one of the following three outcomes with validated instruments: in the visual analog scale (VAS), symptom severity scale (SSS), and functional status scale (FSS). Results: Overall, 19 studies with 1,066 patients were included in this study. We used the SUCRA rankings to determine the merits of various therapies. In all, 5% dextrose injections were the best treatment strategy for the VAS (MD -1.22, 95% CI -2.66 to 0.23; SUCRA = 79.2%), followed by triamcinolone (high-dose) injections (MD -0.69, 95% CI -2.11 to 0.73; SUCRA = 62.7%) and PRP injections (MD -0.39, 95% CI -1.67 to 0.89; SUCRA = 60.0%). In the SSS, the most effective intervention was hydroxyprogesterone injections (MD -0.62, 95% CI -1.09 to -0.16; SUCRA = 91.0%). The SUCRA ranking of PRP was second only to steroids and estrogen (MD -0.39, 95% CI -0.60 to -0.18; SUCRA = 60.8%). In the FSS, the best regimen strategy was hydroxyprogesterone injections (MD 0.12, 95% CI -0.30 to 0.54; SUCRA = 99.5%), followed by triamcinolone (low-dose) injections (MD -0.02, 95% CI -0.54 to 0.49; SUCRA = 87.4%) and PRP injections (MD -0.26, 95% CI -0.43 to -0.09; SUCRA = 77.1%). Conclusion: PRP is an alternative choice for CTS treatment. PRP injection is second only to steroids and estrogen in the treatment efficacy of CTS, with a wide indication and safe outcome.

The Effectiveness of Plasma Rich in Growth Factors (PRGF) in the Treatment of Nerve Compression Syndromes of the Upper Extremity: A Retrospective Observational Clinical Study

Background: Nerve compression syndromes of the upper extremity are a common cause of neuropathic pain and functional impairment. Recently, platelet-rich plasma (PRP) infiltrations have emerged as an effective biological approach to the treatment of this type of injury. The objectives of this retrospective observational study were to assess clinical improvement in patients with median and ulnar nerve entrapment syndrome after undergoing biologically-assisted nerve release surgery with plasma-rich-in-growth-factors (PRGF) technology. Methods: Participants (n = 39) with moderate-to-severe nerve compression syndrome of the upper limb diagnosed by both electromyography and clinical examination, and who were treated with PRGF, were identified from the center’s medical records. The evaluation was based on patient-reported outcomes. Pre- and post-treatment differences in the Visual analog scale (VAS), the Boston carpal tunnel questionnaire (BCTQ), and the Quick-DASH score were assessed. Results: Three study groups were conducted: patients with carpal tunnel syndrome (n = 16), with recurrent carpal tunnel syndrome (n = 8), and with ulnar nerve entrapment (n = 15). The median follow-up was 12 months (interquartile range (IQR), 9−16). In comparison to pre-treatment values, all three study groups obtained statistically significant improvements for the three analyzed scales at the end of the follow-up, with p < 0.001 for all scales in the carpal tunnel syndrome and ulnar nerve entrapment groups and p < 0.01 for all scales in the recurrent carpal tunnel syndrome group. There were no serious adverse effects in the analyzed patients. Conclusion: PRGF-assisted open surgical nerve release treatment (intraneural and perineural liquid PRGF infiltrations and nerve wrapping with PRGF membrane) exerts long-term beneficial effects on pain reduction and functional improvement in the nerve and nerve−muscle unit in patients with upper extremity compression syndromes.

Effectiveness of Platelet-Rich Plasma for Patients With Carpal Tunnel Syndrome: A Systematic Review and meta-Analysis of Current Evidence in Randomized Controlled Trials

Background: Recently, there was a series of clinical studies focusing on local injection of platelet-rich plasma (PRP) for treatment of patients with carpal tunnel syndrome (CTS). However, the safety and efficacy of PRP in these CTS patients remains controversial. Therefore, we performed a systematic review to compare PRP with other conservative treatments in treatment of CTS patients.

Methods: We systematically searched from electronic databases (Cochrane, PubMed, Web of Science, and EMBASE) up to 10 December 2021. The data of clinical results were extracted and analyzed by RevMan Manager 5.4.

Results: Finally, eight randomized controlled studies, involving 220 CTS patients undergoing local injection of PRP were enrolled in this systematic review. All enrolled trials were considered to be of high quality. In the short-term efficacy, the PRP group was significantly lower in symptom severity scale (SSS) compared with the control group (MD = −2.00; 95% CI, −3.15 to −0.85; p = 0.0007; I² = 0%). In the mid-term efficacy, the PRP group was significantly effective than the control group in the visual analogue scale (MD = −0.63; 95% CI, −1.22 to −0.04; p = 0.04; I² = 61%), SSS (MD = −3.56; 95% CI, −4.93 to −2.18; p < 0.00001; I² = 0%), functional status scale (MD = −2.29; 95% CI, −3.03 to −1.56; p < 0.00001; I² = 45%), sensory peak latency (MD = −0.39; 95% CI, −0.58 to −0.19; p = 0.0001; I² = 0%) and cross-sectional area of median nerve (MD = -0.20; 95% CI, −0.31 to −0.10; p = 0.0002; I² = 0%). In the mid-long-term efficacy, the PRP group was only significantly lower in SSS compared with the control group (MD = −2.71; 95% CI, −4.33 to −1.10; p = 0.001; I² = 38%).

Conclusion: Local PRP injection is more effective than other conservative treatments in terms of mid-term efficacy in relieving pain, improving wrist function and symptoms, reducing MN swelling, and partially improving electrophysiological indicators. However, the long-term adverse side and consensus on standardization of PRP in CTS patients still need further large-scale trials.

Clinical Value Analysis of High-Frequency Ultrasound Combined with Carpal Dorsiflexion Electrophysiological Detection in the Diagnosis of Early Carpal Tunnel Syndrome

Objective

To investigate the clinical value of ultrasound combined with electrophysiological examination in the diagnosis of early carpal tunnel syndrome, we aimed to provide a new EMG (electromyography) method for detecting early carpal tunnel syndrome by exploring the wrist back stretch position and electrophysiological examination.

Methods

For the 82-lateral wrist (case group) of 62 patients with clinical symptoms or confirmed carpal tunnel syndrome and 40 normal healthy patients, neuroelectrophysiological measurements were performed using a Keypoint6.0 EMG evoked potentiometer, measuring each group twice: conventional position (before compression) and dorsal wrist extension position. The measures for each measurement included DSL, DML, and CAMP. Measure sensory conduction first and then measure motor conduction. The measurements were analyzed in a comprehensive comparative analysis. Combined ultrasound examination, the positive rate of combined ultrasound examination and electrophysiological examination was compared, respectively.

Results

In the carpal tunnel syndrome (CTS) group, the anterior and posterior median nerve DSL was (4.27 ± 0.73) ms and (4.82 ± 0.65) ms, and SNAP was (13.32 ± 13.68) UV and (12.19 ± 11.04) UV; the median nerve (wrist-bunions) DML was (5.29 ± 1.26) ms and (5.54 ± 1.29) ms, and CMAP was (6.44 ± 2.40) mV and (6.21 ± 2.46) mV. Mid-median DSL and DM in the CTS group L were significantly longer than before compression; median nerve SNAP and CMAP were significantly reduced compared with before compression.

Conclusion

Electrophysiological testing at the dorsal carpal extension position has high diagnostic value in the diagnosis of mild carpal tunnel syndrome. It helps to improve the diagnostic rate of early carpal tunnel syndrome, while providing a more accurate and effective EMG detection of early carpal tunnel syndrome, and combination examination of neuroelectrophysiology and ultrasound can improve the diagnosis rate of compression peripheral nerve diseases and clarify the site, nature, and scope of compression lesions, which is worthy of clinical application.

Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates

Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome (CTS). The usage of normal saline (NS), 5% dextrose water (D5W), platelet-rich plasma (PRP), and hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic can limit anesthetic-related toxicity and preserve the motor functions of the median nerve. Here, we describe a novel motor-sparing neural injection and compare the effect of these four injectates for severe CTS. We retrospectively reviewed the outcomes of 61 severe CTS cases after a single neural injection with NS, D5W, PRP, or HA. Outcomes were evaluated on the 1st and 6th months postinjection, including the Boston Carpal Tunnel Questionnaire (BCTQ) scores and the nerve cross-sectional area (CSA). The results revealed that PRP, D5W, and HA were more efficient than NS at all measured time points ( $p<0.05$ ), except for CSA at the 1st month between the NS and D5W groups. Single-injections of PRP and D5W seemed more effective than that of HA within 6 months postinjection for symptom and functional improvement (6th-month BCTQ-symptom, D5W vs. HA, $p=0.047$ ; 1st-month BCTQ-symptom, PRP vs. HA, $p=0.018$ ; 1st- and 6th-month BCTQ-function, D5W vs. HA, $p=0.002$ and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA, $p<0.001$ ). For reducing CSA, PRP and HA seemed more effective than D5W ( $\text{HA}>\text{PRP}>\text{D}5\text{W}$ on the 1st month and HA vs. D5W, $p=0.001$ ; $\text{PRP}>\text{HA}>\text{D}5\text{W}$ on the 6th month and PRP vs. D5W, $p=0.012$ ).

The long-term analgesic effectiveness of platelet-rich plasma injection for carpal tunnel syndrome: a cross-sectional cohort study

OBJECTIVE

Interest in perineural platelet-rich-plasma (PRP) injections for the treatment of carpal tunnel syndrome (CTS) has increased in recent years. However, evidence supporting the long-term effectiveness of PRP is lacking. Therefore, the aim of our cross-sectional cohort study was to investigate the long-term results of PRP injections for CTS.

METHODS

Eighty-one patients diagnosed with CTS of any grade who received a single PRP injection at least 2 years prior were enrolled. Through structured telephone interviews, all patients were asked of their post-injection outcomes compared to their pre-injection condition. Symptom relief ≥50%, compared to the pre-injection condition, was considered an effective outcome. Binary logistic regression was applied to analyze each baseline variable as a regressor for determining the prognostic outcome factors.

RESULTS

In total, 70% of patients reported positive outcomes ≥2 years post-injection. Shorter duration of symptoms before treatment (odds ratio: 0.991; 95% confidence interval [CI] 0.983-0.999; p = 0.023) and lower electrodiagnostic severity of CTS were the main prognostic factors for an effective outcome (mild grade vs. severe grade, odds ratio: 17.652; 95% CI 1.43-221.1; p = 0.025). Although there was a trend toward positive outcomes at longer follow-up durations (2-3 years vs. 3-4 years vs. 4-5 years), the difference was not statistically significant.

CONCLUSION

A single perineural PRP injection has a long-term analgesic effect on CTS, especially in mild-to-moderate cases.

Ring finger sensory latency difference in the diagnosis and treatment of carpal tunnel syndrome

Objective

To explore the sensitivity of median and ulnar nerve sensory latency differences in diagnosing carpal tunnel syndrome (CTS) at different severities.

Methods

CTS patients were divided into three groups based on disease severity (mild, moderate, and severe). Distal latency of sensory nerve action potential (SNAP) for the median and ulnar nerves was recorded. The sensitivity of SNAP distal latency to CTS and its correlation with CTS severity were analyzed.

Results

Significant differences were found in the median nerve sensory action potential distal latency (MSDL) and in the median and ulnar sensory latency difference to ring finger (MUD) but not in the ulnar nerve sensory action potential distal latency (USDL) between CTS and control. The sensitivity and specificity were 92.2 and 99.4% with an MSDL cutoff value of 2.40 ms, respectively, and were both 100% with a MUD cutoff value of 0.33 ms. There was no significant difference in USDL among the CTS and control groups. Significant differences were found in MSDL and MUD among the CTS severities and between mild and moderate CTS, but not between mild and severe CTS or between moderate and severe CTS. Correlations with CTS severity were observed for MSDL and MUD but not for USDL.

Conclusion

The ulnar nerve of the CTS patients was not damaged. A smaller MSDL reflected median nerve damage, which can be used for the early diagnosis of CTS. MUD correlated with CTS severity with a higher sensitivity than MSDL, which can provide therapeutic insight without pain to patients.

Outcome predictors of platelet-rich plasma injection for moderate carpal tunnel syndrome

INTRODUCTION

Platelet-rich plasma (PRP) injection is effective for mild-to-moderate carpal tunnel syndrome (CTS), and physicians have been using PRP injections to treat CTS. However, the predictive factors of PRP injections have not been evaluated. This retrospective study sought to identify the predictive factors of PRP injections in patients with moderate CTS.

METHODS

Seventy-one patients with moderate CTS receiving single PRP injections were enrolled. The outcomes at the third- and sixth-month postinjection visits were categorised into good and poor groups according to the following: (1) good outcome, with visual analogue scale (VAS) score decrease ≧50% and (2) poor outcome, with VAS score decrease <50% of preinjection scores. Significant variables between groups were entered into a binary logistic regression to determine the predictive factors.

RESULTS

The baseline body weight (BW), distal motor latency (DML), sensory nerve conduction velocity (SNCV), and cross-sectional area (CSA) of the median nerve were significantly different between the groups in the third month. The odds ratios (ORs) of all features were significant, except for SNCV (BW, OR: 0.911; P = .016; DML, OR: 0.383; P = .028; CSA, OR: 0.694; P = .003), and they remained significant in the sixth month (BW, OR: 0.909; P = .004; DML, OR: 0.530; P = .011; CSA, OR: 0.828; P = .032).

CONCLUSION

Lower BW, DML, and CSA values of the median nerve predict better outcomes after perineural injection of PRP for moderate CTS at the 3- and 6-month follow-ups.

Orthobiologics in Hand Surgery

Orthobiologic agents are used as innovative adjuvant therapy to treat common upper-extremity pathology, including carpal tunnel syndrome, de Quervain tenosynovitis, and distal radius fractures. In this article, we perform a narrative review and evaluate current literature on orthobiologics in the upper extremity. Orthobiologics evaluated include bone morphogenetic proteins, platelet-rich plasma, bone marrow aspirate concentrate, mesenchymal stem cells, and amniotic membrane. Studies selected include randomized control trials, case studies, and animal studies. Although there is some clinical evidence regarding the use of orthobiologic agents in the treatment of shoulder, elbow, and sports injuries, there is a paucity of literature regarding their use to treat pathology of the hand and wrist. Further investigation is necessary to determine their effectiveness and therapeutic value in treatment of upper extremity injuries.

Platelet-rich plasma in non-operative management of mild to moderate carpal tunnel syndrome - A systematic review & meta-analysis of short-term outcomes

Background

To perform an updated systematic review with meta-analysis on trials focusing on patient-reported outcome measures (PROMs), nerve conduction studies (NCS) result and cross sectional area (CSA) measurements of those who underwent PRP injection for mild to moderate CTS, versus a control.

Conclusion

This study indicates that there may be a potential role for the use of PRP in the non-operative management of mild to moderate CTS results in improvements in pain scores, functional outcomes as well as CSA measurements of the MN at short-term follow-up. However, PRP does not result in improvements in NCS.

Level of evidence

II; Systematic Review & Meta-Analysis of Prospective Trials;

Use of Intra-uterine Injection of Platelet-rich Plasma (PRP) for Endometrial Receptivity and Thickness: a Literature Review of the Mechanisms of Action

Endometrial receptivity and thickness play an important role in achieving a pregnancy. Intrauterine autologous platelet-rich plasma (PRP) infusion has been used in infertile women with recurrent implantation failure (RIF) and thin endometrial lining thickness (EMT). Literature search was performed in PubMed for studies including in vitro, animal, and human studies as well as in abstracts presented at national conferences. Animal studies demonstrated a decrease in the expression of inflammatory markers and fibrosis, and increased endometrial proliferation rate, increased expression of proliferative genes, and increased pregnancy rates. The in vitro studies showed that PRP was associated with increased stromal and mesenchymal cell proliferation, increased expression of regenerative enzymes, and enhancement in cell migration. In infertile women undergoing assisted reproductive technology, one randomized clinical trial showed that PRP intrauterine infusion improved EMT, implantation rate, and clinical pregnancy rate (CPR) in patients with thin EMT, while 3 other trials involving subjects with RIF showed conflicting results related to CPR. Case series and cohort studies showed conflicting results pertaining to CPR. Data to date suggest that PRP may be beneficial in improving endometrial thickness and endometrial receptivity. However, further large prospective and high-quality trials are needed to assert its effect and to identify the population of patients that would benefit the most.

The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review

Background: Peripheral nerve entrapment syndromes commonly result in pain, discomfort, and ensuing sensory and motor impairment. Many conservative measures have been proposed as treatment, local injection being one of those measures. Now with high-resolution ultrasound, anatomical details can be visualized allowing diagnosis and more accurate injection treatment. Ultrasound-guided injection technique using a range of injectates to mechanically release and decompress the entrapped nerves has therefore developed called hydrodissection or perineural injection therapy. Several different injectates from normal saline, local anesthetics, corticosteroids, 5% dextrose in water (D5W), and platelet-rich plasma (PRP) are available and present clinical challenges when selecting agents regarding effectiveness and safety.

Aims: To systematically search and summarize the clinical evidence and mechanism of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment.

Methods: Four databases, including PubMed, EMBASE, Scopus, and Cochrane were systematically searched from the inception of the database up to August 22, 2020. Studies evaluating the effectiveness and safety of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment were included. Injectate efficacy presents clinical effects on pain intensity, clinical symptoms/function, and physical performance, electrodiagnostic findings, and nerve cross-sectional areas. Safety outcomes and mechanism of action of each injectate were also described.

Results: From ten ultrasound-guided hydrodissection studies, nine studies were conducted in carpal tunnel syndrome and one study was performed in ulnar neuropathy at the elbow. All studies compared different interventions with different comparisons. Injectates included normal saline, D5W, corticosteroids, local anesthetics, hyaluronidase, and PRP. Five studies investigated PRP or PRP plus splinting comparisons. Both D5W and PRP showed a consistently favorable outcome than those in the control group or corticosteroids. The improved outcomes were also observed in comparison groups using injections with normal saline, local anesthetics, or corticosteroids, or splinting. No serious adverse events were reported. Local steroid injection side effects were reported in only one study.

Conclusion: Ultrasound-guided hydrodissection is a safe and effective treatment for peripheral nerve entrapment. Injectate selection should be considered based on the injectate mechanism, effectiveness, and safety profile.

Effectiveness of Conservative Treatment According to Severity and Systemic Disease in Carpal Tunnel Syndrome: A Systematic Review

(1) Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the upper extremity. Conservative treatment has been effective for mild and moderate idiopathic CTS. However, severe CTS and systemic conditions were an exclusion criterion from the studies. The aim of this study is to review the effectiveness of conservative treatment in patients with CTS regardless of the level of severity and the presence or not of systemic diseases in the last ten years. (2) Methods: Randomized controlled clinical trials that compared the effect of conservative treatment on the Boston questionnaire and pain were selected. PubMed, PEDro, Scopus, Cochrane, and Web of Science databases were used. PRISMA statement checklist was performed. (3) Results: 876 studies were recorded, 29 were selected. Pharmacology, Electrotherapy and Manual Therapy had benefits for CTS. Electrotherapy and manual therapy could be effective for severe CTS patients with a systemic condition in the short term, but there was a low percentage of these patients included in the studies. (4) Conclusion: Some pharmacological treatments, manual therapy and electrotherapy have shown benefits for handling CTS, although the most effective combination of techniques is unknown. It would be necessary to include patients with systemic conditions in the selection criteria for future studies.

Effect of Platelet-Rich Plasma Injection on Mild or Moderate Carpal Tunnel Syndrome: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To evaluate efficacy of platelet-rich plasma (PRP) injection in carpal tunnel syndrome (CTS), we conducted this meta-analysis, as well as proposed a protocol for its application in curative processes.

Methods

All randomized controlled trials (RCTs) of PRP for the management of mild or moderate CTS were included in this study. Database search was conducted from study inception to July 2020, including PubMed, Embase, Web of Science, and Cochrane Library. We used visual analogue scores (VAS) and the Boston Carpal Tunnel Questionnaire (BCTQ) as evaluation tools for primary outcomes. Second outcomes comprised cross-sectional area (ΔCSA) and electrophysiological indexes including distal motor latency (DML), sensory peak latency (SPL), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), compound muscle action potential (CMAP), and sensory nerve action potential (SNAP). The pooled data were analyzed using RevMan 5.3. Subgroup and sensitivity analyses were conducted with the evidence of heterogeneity. Egger' test was used to investigate publication bias.

Results

9 RCTs were finally screened out with 434 patients included. Control groups comprised corticosteroid injection in 5 trials, saline injection in 1 trial, and splint in 3 trials. At the 1st month after follow-up, only ΔCSA between the PRP group and the control group showed significant difference (P < 0.05). In the 3rd month, there were statistically significant differences in VAS, BCTQ, SPL, SNCV, and ΔCSA between two groups (P < 0.05), while no statistically significant differences were found in the remaining outcomes. In the 6th month, there were statistically significant differences at BCTQ (P < 0.05) in primary outcomes and ΔCSA (P < 0.05) in secondary outcomes between two groups. As to adverse events in PRP injection, only one study reported increased pain sensation within 48 h after injections.

Conclusion

This systematic review and meta-analysis demonstrates that the PRP could be effective for mild to moderate CTS and superior to traditional conservative treatments in improving pain and function and reducing the swelling of the median nerve for a mid-long-term effect. To some extent, the electrophysiological indexes also improved after PRP injection compared with others conservative treatments.

Ultrasound-Guided Nerve Hydrodissection for Pain Management: Rationale, Methods, Current Literature, and Theoretical Mechanisms

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Non-Surgical Management and Post-Surgical Rehabilitation of Carpal Tunnel Syndrome: An Algorithmic Approach and Practical Guideline

: One of the most common forms of entrapment neuropathy is Carpal Tunnel Syndrome (CTS). There are various treatment options for CTS. However, there are no clear and structured guidelines. This review classified the existing treatments and developed an algorithm to help physicians to choose the best option for their patients. Treatment options were summarized in three sections: non-surgical management of CTS, post-operative management of CTS, and practical open carpal tunnel release post-op protocol. The physicians can prescribe multiple treatment options to CTS patients. Corticosteroid in oral or injectable form has strong evidence in pain control and functional improvement in the short term. Shockwave therapy and nocturnal wrist splints display moderate therapeutic effects. Post carpal tunnel release rehabilitation can be started a few days after the operation.

Regenerative Injections Including 5% Dextrose and Platelet-Rich Plasma for the Treatment of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-Analysis

This network meta-analysis aimed to integrate the available direct and indirect evidence on regenerative injections—including 5% dextrose (D5W) and platelet-rich plasma (PRP)—for the treatment of carpal tunnel syndrome (CTS). Literature reports comparing D5W and PRP injections with non-surgical managements of CTS were systematically reviewed. The main outcome was the standardized mean difference (SMD) of the symptom severity and functional status scales of the Boston Carpal Tunnel Syndrome Questionnaire at three months after injections. Ranking probabilities of the SMD of each treatment were acquired by using simulation. Ten studies with 497 patients and comparing five treatments (D5W, PRP, splinting, corticosteroid, and normal saline) were included. The results of the simulation of rank probabilities showed that D5W injection was likely to be the best treatment, followed by PRP injection, in terms of clinical effectiveness in providing symptom relief. With respect to functional improvement, splinting ranked higher than PRP and D5W injections. Lastly, corticosteroid and saline injections were consistently ranked fourth and fifth in terms of therapeutic effects on symptom severity and functional status. D5W and PRP injections are more effective than splinting and corticosteroid or saline injection for relieving the symptoms of CTS. Compared with splinting, D5W and PRP injections do not provide better functional recovery. More studies investigating the long-term effectiveness of regenerative injections in CTS are needed in the future.

Ultrasound imaging and guidance in peripheral nerve entrapment: hydrodissection highlighted

Ultrasound (US) imaging has become one of the most useful modalities to assess peripheral nerve disorders. Nowadays, it is as important as nerve conduction studies and electromyography for peripheral nerve entrapment. Additionally, US is also helpful in guiding a possible intervention. As peripheral nerves are tiny, palpation-guided injections are really challenging for precisely targeting the nerves. By using US, perineural injections have significantly become safe and effective. Recently, US-guided hydrodissection has emerged as the mainstream for nerve entrapment. Accordingly, this review aims to summarize and update the mechanism and evidence regarding this imperative procedure for neuropathic pain management. Furthermore, the pathogenesis, anatomic features, US findings and histological correlations of nerve entrapment syndromes will also be discussed in this article.