Ultrasound-Guided Versus Landmark-Guided Local Corticosteroid Injection for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Carpal tunnel syndrome: updated evidence and new questions

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.

Dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release: technical innovation and case study

Background

Minimally invasive carpal tunnel release has recently emerged as the primary surgical approach for recalcitrant carpal tunnel syndrome. A major concern related to surgical failure with this technique is the incomplete release of the flexor retinaculum.

Case presentation

We developed a technique using dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release. This novel imaging method was applied to two patients who showed significant symptom relief after the intervention. This case study also provides details of the dynamic ultrasound protocol and highlights the advantages of this technique.

Conclusion

Dynamic ultrasound imaging can be used to confirm the completeness of carpal tunnel decompression. A large-scale prospective trial should be conducted to validate whether additional dynamic ultrasound examination can improve the outcome of minimally invasive carpal tunnel release.

Comparison Between Distal and Proximal Approaches for Local Corticosteroid Injection in Carpal Tunnel Syndrome Management: A Randomized Controlled Trial

BACKGROUND

The present, open-labeled study aimed to compare the distal approach (DA) for local corticosteroid injection (LCI) with the conventional proximal approach (PA) in alleviating the symptom and improving the electrodiagnostic parameters of the patients with carpal tunnel syndrome (CTS).

METHODS

A total of 60 participants with nonsevere CTS were included in the present randomized controlled trial (RCT), of which 29 and 31 were assigned to the DA and PA groups, respectively. Each group received a single, landmark-guided injection of local methylprednisolone. The participants were assessed preintervention and 3 months later using the measures of visual analog scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand grip strength, and nerve conduction study (NCS).

RESULTS

Following a 3-month follow-up, both groups had significant improvements in VAS, both functional and severity subscales of BCTQ, hand grip strength, and some electrodiagnostic parameters (all P-values < .05). Moreover, the DA group had a significantly lower procedure duration than the PA group (9.80 ± 1.12 vs. 27.61 ± 1.77; P < .001).

CONCLUSIONS

LCI using the DA should be considered a feasible, safe, and effective therapeutic method in patients with mild to moderate CTS. It had a shorter procedure duration than conventional PA, while their clinical and electrophysiological results were similar.

Effect of ultrasound-guided versus landmark-guided local corticosteroid injection for carpal tunnel syndrome: a systematic review and meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS), the commonest neuropathy of the upper limb, can be managed with different therapeutic approaches. Local corticosteroid injection has been adopted widely in clinical practice, as it showed great efficacy in treating CTS. However, the best injection technique continues to be a subject of controversy. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) corticosteroid injection on the clinical and electrophysiological outcomes in patients with CTS.

METHODS

We performed a systematic literature search in Medline, Embase, and CENTRAL, from which we included randomized controlled trials (RCTs) that compared US-guided and LM-based corticosteroid injection in treating individuals with CTS. We evaluated the following outcomes: Boston carpal tunnel questionnaire functional status scale (BCTQ-FSS) and symptom severity scale (BCTQ-SSS), and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes, while the risk ratio (RR) was used to represent dichotomous outcome.

RESULTS

A total of 8 RCTs that enrolled 500 wrists were deemed eligible. US-guided injection showed a significantly better BCTQ-FSS (SMD = -0.22, 95% CI -0.39 to -0.04), BCTQ-SSS (SMD = -0.77, 95% CI -1.22 to -0.31), and adverse event rate (RR = 0.32, 95% CI 0.21 to 0.49) compared to LM-based injection.

CONCLUSION

This meta-analysis showed the superiority of US-guided corticosteroid injection over LM-guided corticosteroid injection in enhancing functional status, improving symptom severity, and reducing the adverse event rate in individuals with CTS.

Manual Therapy and Related Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Objective: Systematic review and meta-analysis to assess the efficacy of Manual therapy and related interventions in the treatment of carpal tunnel syndrome (CTS) based on Boston carpal tunnel questionnaire. Design: Systematic review and meta-analysis. Subjects: Carpal tunnel syndrome. Interventions: Manual therapy and related interventions versus other therapies or manual therapy and related interventions plus other therapies versus other therapies. Outcomes measures: Boston carpal tunnel questionnaire. Results: A total of 6 studies were included, including 211 cases in the manual therapy group and 211 cases in the control group. The quality of the included articles was high, and the results of meta-analysis showed that manual therapy and related interventions were superior in terms of improving the Boston carpal tunnel questionnaire Symptom Severity score in patients with CTS (standardised mean difference [SMD] -1.13, 95% CI -1.40 to -0.87), were superior to control groups in terms of improving the Boston carpal tunnel questionnaire functional capacity scale in patients with CTS (SMD -1.01,95% CI -1.24 to -0.77). Conclusion: The results of this meta-analysis suggested that manual therapy and related interventions were better than control groups in treating CTS. Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS. Registration: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; No. CRD 42020201389). Contribution of the Article: Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS.

Ultrasonography for the diagnosis of carpal tunnel syndrome: an umbrella review

BACKGROUND

Numerous sonographic modalities and parameters have been used to diagnose carpal tunnel syndrome (CTS), with varying accuracy. Our umbrella review aimed to summarize the evidence from systematic reviews and meta-analyses regarding the use of ultrasound imaging to diagnose CTS.

METHODS

Systematic reviews and meta-analyses meeting the inclusion criteria were searched in PubMed, Embase, Medline, Web of Science, and Cochrane databases from inception to March 2022. Critical appraisal, data extraction, and synthesis were performed in accordance with the criteria for conducting an umbrella review.

RESULTS

Sixteen reviews were included. Three reviews were classified as high quality, one as moderate, four as low, and eight as critically low. The cross-sectional area (CSA) of the median nerve at the carpal tunnel inlet demonstrated the best reliability and diagnostic accuracy among multiple parameters. A cutoff CSA value of 9-10.5 mm² gave the highest diagnostic performance in the general population. The degree of CSA enlargement was correlated with CTS severity. Sonoelastography and Doppler ultrasound might provide additional insights into CTS evaluation as median nerve stiffness and vascularity at the wrist were increased in these patients.

CONCLUSIONS

Sonography is a reliable tool to diagnose CTS, with inlet CSA being the most robust parameter. Sonoelastography and Doppler ultrasound can serve as auxiliary tools to confirm CTS diagnoses. Further studies are needed to expand the use of sonography for diagnosing CTS, especially in the presence of concomitant neuromuscular disease(s).

Ultrasound-guided carpal tunnel injections

Background

Carpal tunnel syndrome (CTS), one of the most common entrapment neuropathies, can, in fact, be considered as a socio-economic issue that reduces work productivity, increases disability, and requires prolonged rehabilitation. The imaging modality of choice in CTS imaging is the ultrasound (US), as several morphological parameters can be used in CTS diagnosis and follow-up. In recent years, US-guided CTS injection therapy has become an established treatment option for mild to moderate CTS. The authors of this review performed a literature search that revealed several differences in US-guided carpal tunnel injection in an attempt to unify individual stages of CTS injections protocol for future guidance: patient preparation, injection approach, needle positioning, injected medications, and injectate volume. The three approaches to carpal tunnel injections described in the literature, that is, the ulnar, radial, and longitudinal, can be implemented with single or multiple deposits and different injection volumes. Medications used for injections are corticosteroids, local anaesthetics, dextrose, saline, platelet-rich plasma, and progesterone.

Conclusions

Although no consensus has yet been reached as to which protocol should be used, the ulnar approach with a single deposit injected in large volumes should be considered as the first choice, while dextrose should be the first-line medication option. Furthermore, as terminological differences make it difficult to draw a uniform comparison the presented steps for US-guided carpal tunnel injection might serve as a guideline for future studies.

Quality analysis of prior systematic reviews of carpal tunnel syndrome: an overview of the literature

BACKGROUND

Carpal tunnel syndrome (CTS) is a common condition greatly affects patients' quality of life and ability to work. Systematic reviews provide useful information for treatment and health decisions.

OBJECTIVE

This study aimed to assess the methodological quality of previously published systematic reviews on the treatment of CTS.

DESIGN AND SETTING

Overview of systematic reviews conducted at the Brazilian public higher education institution, São Paulo, Brazil.

METHODS

We searched the MEDLINE and Cochrane Library database for systematic reviews investigating the treatment of CTS in adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and measurement tool to assess systematic reviews (AMSTAR) were applied by two independent examiners.

RESULTS

Fifty-five studies were included. Considering the stratification within the AMSTAR measurement tool, we found that more than 76% of the analyzed studies were "low" or "very low". PRISMA scores were higher when meta-analysis was present (15.61 versus 10.40; P = 0.008), while AMSTAR scores were higher when studies performed meta-analysis (8.43 versus 5.59; P = 0.009) or when they included randomized controlled trials (7.95 versus 6.06; P = 0.043). The intra-observer correlation demonstrated perfect agreement (> 0.8), a Spearman's correlation coefficient of 0.829, and an ICC of0.857. The inter-observer correlation indicated that AMSTAR was more reliable than PRISMA.

CONCLUSION

Overall, systematic reviews of the treatment of CTS are of poor quality. Reviews with better-quality conducted meta-analysis and included randomized controlled trials. AMSTAR is a better tool than PRISMA because it has a better performance and should be recommended in future studies.

REGISTRATION NUMBER IN PROSPERO

CRD42020172328 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42020172328).

Ultrasound-guided local corticosteroid injection for carpal tunnel syndrome: A meta-analysis of randomized controlled trials

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) local corticosteroid injection for carpal tunnel syndrome (CTS).

METHODS

Database including Pubmed, Embase, and Cochrane Library were searched to identify relevant randomized controlled trials (RCTs). The outcomes mainly included Boston Carpal Tunnel Questionnaire (BCTQ): Symptom Severity Scale (BCTQs), Functional Status Scale (BCTQf); and electrophysiological indexes: distal motor latency (DML), sensory distal latency (SDL), compound muscle action potential (CAMP), sensory nerve action potential amplitude (SNAP), and sensory nerve conduction velocity (SNCV). Adverse events were also recorded.

RESULTS

Overall, nine RCTs were finally screened out with 469 patients (596 injected hands). Pooled analysis showed that US-guided injection was more effective in BCTQs (SMD, -0.69; 95% CI, -1.08 to -0.31; P = 0.0005), BCTQf (SMD, -0.23; 95% CI, -0.39 to -0.07; P = 0.005), CAMP (MD, 0.64; 95% CI, 0.35-0.94; P < 0.0001) improvement, and a lower rate of adverse events (RR, 0.34; 95% CI, 0.22-0.52; P < 0.00001). Subgroup analysis revealed that the US-guided injection had significantly better CMAP than the LM-guided for the in-plane approach (MD, 0.69; 95% CI, 0.36-1.01; P < 0.0001) but not for the out-plane approach (MD, 0.39; 95% CI, -0.39 to 1.17; P = 0.33).

CONCLUSIONS

US-guided injection was superior to LM-guided injection in symptom severity, functional status, electrodiagnostic, and adverse events improvement for CTS. To some extent, the in-plane approach yields better results compared with the out-plane process under US guidance.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies

ABSTRACT

Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

Ultrasound-guided corticosteroid injection for patients with carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials

Carpal tunnel syndrome (CTS) refers to the symptoms and signs caused by the compression of the median nerve in the carpal tunnel. It can be treated by corticosteroid injection into the carpal tunnel. Two methods for injection have been employed, namely ultrasound-guided and landmark-guided injection. This systematic review and meta-analysis was conducted to compare these methods in terms of several outcomes. A search of the PubMed, Cochrane Library, and Embase databases was performed from the date of their inception to October 7, 2020 to identify randomized controlled trials (RCTs). Results for continuous variables are expressed as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. The analysis included eight RCTs published between 2013 and 2019 with a total of 448 patients. Ultrasound-guided injection yielded more favorable results than landmark-guided injection for the Boston Carpal Tunnel Syndrome Questionnaire, Symptom Severity Scale [SMD =  − 0.43, 95% CI (− 0.68, − 0.19), P = 0.0005] and Boston Carpal Tunnel Syndrome Questionnaire, Functional Status Scale [SMD =  − 0.50, 95% CI (− 0.84, − 0.15), P = 0.005]. Ultrasound-guided corticosteroid injection is recommended for patients with CTS.

The Modified Ultrasound-Guided Distal-to-Proximal Carpal Tunnel Injection With Median Nerve Hydrodissection: A Retrospective Safety Review of 827 Procedures

Objective: The aim of this report is to describe a new ultrasound guided technique for carpal tunnel injection and median nerve hydrodissection using distal to proximal approach. Methods: From 2015 to 2019, 827 consecutive injections by distal-to-proximal approach were included using coding information to check for post-procedural skin hypopigmentation, hematoma, seroma, nerve injury, or vascular injury. Results: There were no occurrences of post-procedural skin-hypopigmentation, hematoma or seroma formation, or neurovascular injury. Conclusions: The distal approach carpal tunnel injection is a safe and effective method. It may directly inject the medication into carpal tunnel to avoid skin hypopigmentation from steroid side effect with previous report method, also it may release adhesion of median nerve with surrounding soft tissue by hydrodissection. It helps median nerve compression at outlet of carpal tunnel.

Comparison of Ultrasound-Guided Local Ozone (O2-O3) Injection Versus Corticosteroid Injection in Patients With Mild to Moderate Carpal Tunnel Syndrome

OBJECTIVE

Recently, ozone injection has been used to treat various musculoskeletal diseases. This study was performed to compare ultrasound-guided corticosteroid versus ozone injections in the treatment of carpal tunnel syndrome.

DESIGN

Forty patients with mild to moderate carpal tunnel syndrome were enrolled and randomly placed in one of the two groups of receiving a corticosteroid or ozone injection under ultrasound guidance. To determine the effectiveness of both injection techniques and compare their outcomes, visual analog scale and scores of Boston Carpal Tunnel Questionnaire, as well as ultrasound and electrodiagnostic criteria, were followed at 0, 6, and 12 wks after the injection.

RESULTS

Both groups showed improvement in visual analog scale and Boston Carpal Tunnel Questionnaire at week 6, and this improvement continued until the 12th week after the injections. However, electrodiagnostic values of sensory nerve action potentials and compound motor action potentials latency, and ultrasound carpal tunnel syndrome criteria showed significant improvement only among the subjects in the corticosteroid group at 6 and 12 wks after the injection (P < 0.05).

CONCLUSIONS

Ozone might be as effective as corticosteroid injection in reducing pain and improving the function. Objective improvements in electrodiagnostic and ultrasound criteria of carpal tunnel syndrome were shown only among patients after corticosteroid injection.

Comparison of Corticosteroid Injection Dosages in Mild to Moderate Idiopathic Carpal Tunnel Syndrome: A Randomized Controlled Trial

OBJECTIVES

To evaluate whether the therapeutic effect of ultrasound-guided injections with 10 mg or 40 mg triamcinolone acetonide (TA) was dose-dependent in patients with idiopathic mild to moderate carpal tunnel syndrome (CTS).

DESIGN

Prospective, double-blind, randomized controlled study with 12 weeks of follow-up.

SETTING

Rehabilitation outpatient clinic of a single medical center.

PARTICIPANTS

Patients with CTS (N=56).

INTERVENTION

Participants were randomly assigned to 2 treatment groups for injection: (A) 40 mg TA+2% lidocaine hydrochloride or (B) 10 mg TA+2% lidocaine hydrochloride.

MAIN OUTCOME MEASURES

Participants were evaluated using visual analog scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ, including Symptom Severity Scale [SSS] and Functional Status Scale [FSS]) at baseline and 6 and 12 weeks after injection). Nerve conduction studies, including parameters of distal motor latency, amplitude of compound motor action potential, amplitude of sensory nerve action potential and sensory nerve conduction velocity of median nerve, and the patient's subjective impression of improvement, were recorded before injection and 6 and 12 weeks after injection.

RESULTS

No significant differences were observed in baseline demographic characteristics and clinical evaluations. The parameters in group A and B at baseline, 6 weeks, and 12 weeks were (1) SSS: 2.17±0.14, 1.19±0.04, and 1.34±0.09 and 1.87±0.11, 1.21±0.07, and 1.26±0.04; (2) FSS: 1.63±0.07, 1.27±0.06, and 1.33±0.08 and 1.50±0.10, 1.18±0.05, and 1.26±0.05; (3) VAS: 6.4±0.3, 2.2±0.3, and 3.0±0.1 and 6.7±0.3, 2.0±0.3, and 3.1±0.3, respectively, and significantly decreased after 6 and 12 weeks in both treatment groups (P<.05). All parameters of nerve conduction studies improved in both groups after 12 weeks (P<.05). VAS, BCTQ, and nerve conduction studies did not show significant intergroup differences after 6 and 12 weeks.

CONCLUSION

In patients with idiopathic mild to moderate CTS, ultrasound-guided injection with 10 and 40 mg TA yield similar improvements in BCTQ, VAS, and nerve conduction studies at the 12-week follow-up.

A randomized comparative trial of corticosteroid phonophoresis, local corticosteroid injection, and low-level laser in the treatment of carpal tunnel syndrome

Background and aims

Carpal tunnel syndrome is the most prevalent peripheral neuropathy and has a considerable burden on health services. We tried to compare the therapeutic effects of local corticosteroid injection, low-level laser, and corticosteroid phonophoresis in the treatment of carpal tunnel syndrome.

Subjects and methods

We performed a randomized clinical trial with three parallel groups. The study was carried out at a University Hospital. In total, 42 participants including 31(73.8%) women were randomly allocated to the treatment groups with equal sizes. We assessed pain, symptom severity and functional status with Boston Carpal Tunnel Questionnaire, and performed median nerve conduction velocity studies. Evaluations were done before the interventions and in the fourth week of study. For the group corticosteroid, under the guidance of sonography, methylprednisolone with lidocaine was injected into the carpal tunnel. For laser therapy, we administered 10 sessions, each lasting 10 seconds. We used topical hydrocortisone acetate gel 10% as the anti-inflammatory agent with phonophoresis, 3 times per week for 10 sessions.

Results

Within-group analyses with paired t-test showed that local corticosteroid, laser, and phonophoresis are all effective treatments. Between-group analyses with ANOVA indicated that there were significant differences among the groups after four weeks in terms of pain (p = 0.004), in favor of corticosteroid; and in sensory delay (p = 0.001), in favor of laser. For the Boston Carpal Tunnel Questionnaire and median nerve motor latency, the results were not significant. There was no important side-effect after four weeks of follow-up.

Conclusion

The three treatments are comparable and beneficial for carpal tunnel syndrome.

Ultrasound-Guided Corticosteroid Injection in Carpal Tunnel Syndrome: Comparison Between Radial and Ulnar Approaches

Purpose

To compare two common approaches for ultrasonography (US)-guided injection.

Patients and Methods

Sixty patients with mild-to-moderate CTS were included in this double-blind randomized controlled trial (RCT). They received a single shot of corticosteroid injection through either the US-guided in-plane approach: radial or ulnar side. Participants were evaluated using Boston Carpal Tunnel Questionnaire (BCTQ) and visual analogue scale (VAS) for pain, as well as electrodiagnosis (EDX) and US parameters before the intervention, and within 12 weeks of follow-up.

Results

In both groups, all outcomes, except for the electrodiagnostic measures, significantly improved within the follow-up. Pain-VAS and both subscales of BCTQ questionnaire, as our main subjective outcomes, revealed dramatic improvement, with the largest amount of changes in VAS (70%; comparing to baseline value), and about 37% for both of BQSS and BQFS scales, all indicating superiority of radial to ulnar in-plane approach. During the first follow-up, we did not detect any remarkable preference between the groups in either subjective or electrodiagnostic variables. However, there was a significant difference at next follow-up time-points in terms of VAS for pain and BQFS favoring radial approach (Table 3). Furthermore, US-measured parameters including nerve-circumference and CSA improved only in the radial in-plane group.

Conclusion

The current data proved that radial in-plane approach for CTS injection could be at least as effective as the more common ulnar in-plane method. Even the pain-relief effect was longer for the radial in-plane approach. Also, patients’ functional status and objective variables all revealed better outcomes via the new approach.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.

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.

Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb

BACKGROUND

Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence.

METHODS

An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed.

RESULTS

Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).

CONCLUSIONS

This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus.

KEY POINTS

• An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).

Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy: A Systematic Review

OBJECTIVE

To systematically review and evaluate the efficacy and complication profile of prolotherapy using hyperosmolar dextrose solution injection for rotator cuff tendinopathy.

LITERATURE SURVEY

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (from inception to 1 July, 2019).

METHODOLOGY

A comprehensive search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar dextrose solution for rotator cuff tendinopathy. Two reviewers independently screened the titles, abstracts, and full texts, and then extracted data from eligible studies. All reported outcome measures and complications were analyzed descriptively.

SYNTHESIS

Five studies satisfied inclusion criteria. Included studies analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months. Prolotherapy differed greatly among studies. Two studies used a multisite enthesis injection protocol while the other three used ultrasound-guided protocols. Two of the studies used an intrasubstance supraspinatus injection and three used a supraspinatus enthesis injection. Control groups consisted of nonoperative rehabilitation including physical therapy and medical management in three studies, supraspinatus saline enthesis injection in one study, and corticosteroid injection in one study. There was statistically significant improvement in pain intensity with multisite injection protocols compared to physical therapy and medical management in both studies. Ultrasound-guided supraspinatus injection trials did not find any statistically significant difference in pain intensity, range of motion, strength, function, or ultrasound characteristics compared to controls of enthesis saline injection or corticosteroid. The complication rate was low, with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1 to 2 days postintervention.

CONCLUSIONS

Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.

Ultrasound in the Evaluation of Radial Neuropathies at the Elbow

There are five sites at which radial nerve entrapment at the elbow has been commonly reported. These include the level of the fibrous bands within the extensor carpi radialis brevis, the thickened fascial tissue at the radiocapitellar joint, the leash of Henry, the arcade of Frohse, and the distal border of the supinator muscle. This review describes the anatomy of the radial nerve at the elbow and the surrounding structures, and then provides an overview of the literature supporting the use of ultrasound to assist in the evaluation of suspected radial neuropathy at the elbow. This review concludes with a suggested ultrasonographic approach for the systematic evaluation of suspected radial neuropathy at the elbow.

Ultrasonographic reference values for the deep branch of the radial nerve at the arcade of Frohse

PURPOSE

The deep branch of the radial nerve (DBRN) enters the forearm as it passes under the arcade of Frohse. This is the most common entrapment site of the DBRN in the forearm. In this study, we investigated the ultrasonographic reference values for the diameters and cross-sectional area (CSA) of the DBRN at the level of the arcade of Frohse in a healthy sample of the population.

METHODS

Sixty-five healthy Caucasian volunteers (130 nerves) were recruited for this study. The reference range [mean ± 2 standard deviations (SD); 2.5th-97.5th quintiles] and the upper limit of the side-to-side difference were determined. The effects of age, gender, handedness, height, and body mass index were examined.

RESULTS

The mean age was 41.8 ± 11.2 years (range 18-75 years). The mean ± 2SD of the CSA was 0.50-1.42 mm². The upper limit of the normal side-to-side difference was 0.35 mm². The differences between males and females and between the dominant and non-dominant arms were not significant. The mean anteroposterior and transverse diameters were 0.83 ± 0.13 and 1.23 ± 0.29 mm, respectively. A significant correlation between the dominant-side CSA and age (r = 0.41; p < 0.001) was observed. The correlations between CSA and height (r = 0.19; p = 0.12) and body mass index (r = 0.22; p = 0.07) were not significant.

CONCLUSION

The measurements obtained in this study are valuable for examining DBRN pathologies using high-frequency ultrasound. The findings showed that age was associated with the DBRN CSA, while gender, height, and body mass index were not.

Ultrasonographic reference values for the median nerve at the level of pronator teres muscle

PURPOSE

The purpose of this study was to investigate the ultrasonographic reference values for diameters and cross-sectional area (CSA) of the median nerve between the two heads of the pronator teres muscle in healthy population as well as to correlate the findings with height, weight, sex and age.

METHODS

Fifty-five healthy Caucasian volunteers (110 median nerves) were included in this study. The reference range (mean ± 2 standard deviations; 2.5th-97.5th quintiles) and the upper limit of side-to-side difference of the median nerve between the two heads of the pronator teres muscle were investigated using high-frequency ultrasound. The effects of age, sex, height, handedness, and body mass index (BMI) were examined.

RESULTS

The mean age was 39.4 ± 10.6 years (range 18-75 years). The mean ± 2SD of the median CSA was 4.9-12.9 mm². The upper limit of normal side-to-side difference was 3.0 mm². The differences between genders and between the dominant and non-dominant hands were not significant. The mean antero-posterior and transverse diameters were 7.2 ± 1.5 and 10.7 ± 2.4 mm, respectively. Significant correlations were observed between the dominant-side CSA and BMI (r = 0.33; p = 0.01) and age (r = 0.31; p = 0.02). The correlation between the CSA and height (r = 0.19; p = 0.16) was not significant.

CONCLUSIONS

The measurements obtained in this study are of importance for examining median nerve entrapments in the forearm using high-frequency ultrasound. Age and BMI showed to be correlated with median nerve CSA; while gender and height were not.