Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial

Ultrasonographic Contrast and Therapeutic Effects of Hydrogen Peroxide-Responsive Nanoparticles in a Rat Model with Sciatic Neuritis

Purpose

Peripheral nerve damage lacks an appropriate diagnosis consistent with the patient's symptoms, despite expensive magnetic resonance imaging or electrodiagnostic assessments, which cause discomfort. Ultrasonography is valuable for diagnosing and treating nerve lesions; however, it is unsuitable for detecting small lesions. Poly(vanillin-oxalate) (PVO) nanoparticles are prepared from vanillin, a phytochemical with antioxidant and anti-inflammatory properties. Previously, PVO nanoparticles were cleaved by H2O2 to release vanillin, exert therapeutic efficacy, and generate CO2 to increase ultrasound contrast. However, the role of PVO nanoparticles in peripheral nerve lesion models is still unknown. Herein, we aimed to determine whether PVO nanoparticles can function as contrast and therapeutic agents for nerve lesions.

Methods

To induce sciatic neuritis, rats were administered a perineural injection of carrageenan using a nerve stimulator under ultrasonographic guidance, and PVO nanoparticles were injected perineurally to evaluate ultrasonographic contrast and therapeutic effects. Reverse transcription-quantitative PCR was performed to detect mRNA levels of pro-inflammatory cytokines, ie, tumor necrosis factor-α, interleukin-6, and cyclooxygenase-2.

Results

In the rat model of sciatic neuritis, PVO nanoparticles generated CO2 bubbles to increase ultrasonographic contrast, and a single perineural injection of PVO nanoparticles suppressed the expression of tumor necrosis factor-α, interleukin-6, and cyclooxygenase-2, reduced the expression of F4/80, and increased the expression of GAP43.

Conclusion

The results of the current study suggest that PVO nanoparticles could be developed as ultrasonographic contrast agents and therapeutic agents for nerve lesions.

Ulnar neuropathy

Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.

The Potential of Glucose Treatment to Reduce Reactive Oxygen Species Production and Apoptosis of Inflamed Neural Cells In Vitro

Neuroinflammation is a key feature in the pathogenesis of entrapment neuropathies. Clinical trial evidence suggests that perineural injection of glucose in water at entrapment sites has therapeutic benefits beyond a mere mechanical effect. We previously demonstrated that 12.5-25 mM glucose restored normal metabolism in human SH-SYFY neuronal cells rendered metabolically inactive from TNF-α exposure, a common initiator of neuroinflammation, and reduced secondary elevation of inflammatory cytokines. In the present study, we measured the effects of glucose treatment on cell survival, ROS activity, gene-related inflammation, and cell cycle regulation in the presence of neurogenic inflammation. We exposed SH-SY5Y cells to 10 ng/mL of TNF-α for 24 h to generate an inflammatory environment, followed by 24 h of exposure to 3.125, 6.25, 12.5, and 25 mM glucose. Glucose exposure, particularly at 12.5 mM, preserved apoptotic SH-SY5Y cell survival following a neuroinflammatory insult. ROS production was substantially reduced, suggesting a ROS scavenging effect. Glucose treatment significantly increased levels of CREB, JNK, and p70S6K (p < 0.01), pointing to antioxidative and anti-inflammatory actions through components of the MAPK family and Akt pathways but appeared underpowered (n = 6) to reach significance for NF-κB, p38, ERK1/2, Akt, and STAT5 (p < 0.05). Cell regulation analysis indicated that glucose treatment recovered/restored function in cells arrested in the S or G2/M-phases. In summary, glucose exposure in vitro restores function in apoptotic nerves after TNF-α exposure via several mechanisms, including ROS scavenging and enhancement of MAPK family and Akt pathways. These findings suggest that glucose injection about entrapped peripheral nerves may have several favorable biochemical actions that enhance neuronal cell function.

Conservative Treatment of Ulnar Nerve Compression at the Elbow: A Systematic Review and Meta-Analysis

Background  The clinical results of conservative treatment options for ulnar compression at the elbow have not been clearly determined. The aim of this review was to evaluate available conservative treatment options and their effectiveness for ulnar nerve compression at the elbow. Methods  In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, a systematic review and meta-analysis of studies was performed. Literature search was performed using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Results  Of the 1,079 retrieved studies, 20 were eligible for analysis and included 687 cases of ulnar neuropathy at the elbow. Improvement of symptoms was reported in 54% of the cases receiving a steroid/lidocaine injection (95% confidence interval [CI], 41-67) and in 89% of the cases using a splint device (95% CI, 69-99). Conclusions  Conservative management seems to be effective. Both lidocaine/steroid injections and splint devices gave a statistically significant improvement of symptoms and are suitable options for patients who refuse an operative procedure or need a bridge to their surgery. Splinting is preferred over injections, as it shows a higher rate of improvement.

The Effectiveness of Hydrodissection with 5% Dextrose for Persistent and Recurrent Carpal Tunnel Syndrome: A Retrospective Study

Patients with failure of primary surgery for carpal tunnel syndrome (CTS) present a frustrating clinical problem because there are no relevant treatment guidelines, and the effect of current conservative management or revision surgery is unsatisfactory. Hydrodissection with 5% dextrose is emerging as an effective treatment for primary CTS and may be an effective alternative treatment method for persistent or recurrent post-surgical CTS. We retrospectively investigated the long-term effectiveness of hydrodissection with 5% dextrose for persistent or recurrent CTS. Thirty-six of forty consecutively-treated patients with either persistent or recurrent symptoms of CTS after surgery, who were treated with ultrasound-guided hydrodissection of the median nerve using 10 mL of 5% dextrose, were available to provide outcome data by a structured phone interview at least six months after treatment completion. Symptom relief ≥ 50% represented an effective outcome, while symptom relief < 50% was rated as a poor outcome. Nearly 2/3 (61.1%) of patients reported an effective outcome after a mean of 3.1 injections, with a post-injection follow-up mean of 33 (6−67) months. A non-significant trend toward a more frequently-effective outcome was observed in those with recurrent versus persistent symptoms following CTS (76.9% vs. 52.2%, p = 0.165). However, a significantly higher percentage of those with recurrent symptoms reported an excellent outcome, defined as a greater than 70% improvement (8/13 [61.6%] vs. 3/23 [13%], p = 0.006). The percentage of patients achieving an effective outcome was not significantly different between <2, 2−4, and >4 years of post-treatment follow-up (36.4% vs. 77.8% vs. 57.1%; p = 0.077). Hydrodissection with 5% dextrose may result in a clinically important and durable benefit in those experiencing persistent or recurrent CTS after surgery.

Conservative therapy in ulnar neuropathy at the elbow (Review)

Ulnar neuropathy at the elbow (UNE) is the second most frequent entrapment syndrome in the upper limb after carpal tunnel syndrome. Clinical features are validated through electromyographic and sonographic examination. Although the two aforementioned entrapment syndromes share common pathophysiological traits, the conservative treatment approach for mild and moderate cases of UNE differs from that for median nerve entrapment. The present study identified 23 different types of scientific articles aimed to address this issue. The research stressed the importance of patient education and activity modification. Night splinting offers clinical and functional improvement. Although corticosteroid injections play a role in selected cases, their utility remains to be validated. Physiotherapy trials evaluated ultrasound, low-level laser therapy, diathermy, extracorporeal shock wave therapy and dry cupping. Neurodynamic mobilization may add value to therapeutic approaches and should be a part of it.

Effect of Perineural Dextrose Injection on Ulnar Neuropathy at the Elbow: A Randomized, Controlled, Double-Blind Study

OBJECTIVE

To compare perineural dextrose injection efficacy in the treatment of ulnar neuropathy at the elbow with a control group.

DESIGN

Prospective, double-blind, randomized, control study.

SETTINGS

Training and Research Hospital Participants: The study was completed with 40 patients with ulnar neuropathy at the elbow Intervention: Normal saline (0.9% NaCl) was injected to the control group (n=20; mean age=38.1 ± 10.7 years; median duration of symptoms = 4.5 months), while 5% dextrose (D5W) was injected to the dextrose group (n=20; mean age=43.6 ±13.5 years; median duration of symptoms = 5 months), perineurally under ultrasound guidance twice at two-week intervals. US-guided perineural injection of 1 cc each was administered into the ulnar nerve, 2 cm and 4 cm distal to the medial epicondyle, at the level of the medial epicondyle, and 2 cm and 4 cm proximal to the medial epicondyle. Amount of total fluid injected was 5 cc.

MAIN OUTCOME MEASURE(S)

At baseline, weeks 2, 4, and 12, the patients were evaluated with the Visual Analog Scale for pain and the Disabilities of the Arm Shoulder and Hand (Quick-DASH) questionnaire for disability. Electrophysiological evaluation was performed with ulnar nerve conduction studies, and the ulnar nerve cross-sectional area (CSA) was measured on ultrasonography.

RESULTS

The improvements in pain, disability, ulnar motor nerve velocity and CSA in the dextrose group were superior to those in the control group, especially at weeks 4 and 12 (p<0.001, using independent-samples t-test).

CONCLUSION

Perineural D5W may be an effective alternative therapy for those with ulnar neuropathy at the elbow for up to the 12^th week.

Mechanism of Glucose Water as a Neural Injection: A Perspective on Neuroinflammation

The entrapment of peripheral nerves is associated with chronic neuroinflammation and neuropathic pain, and perineural injection therapy with glucose is emerging as an effective treatment for peripheral entrapment neuropathy. However, the mechanism underlying the pharmacological effect of glucose on nerves remains unclear. One of the hypothesized mechanisms is that glucose reduces neurogenic inflammation. Therefore, we investigated the effects of high glucose concentrations on cytokine-induced neuroinflammation in vitro. Human SH-SY5Y neuronal cells were challenged with 10 ng/mL TNF-α for 16 h and subsequently treated with different glucose concentrations (0–25 mM) for 24 h. Cell viability was evaluated using the diphenyltetrazolium bromide assay, and proinflammatory cytokine levels were assessed using ELISA and quantitative PCR. In addition, mRNA levels of NF-κB and cyclooxygenase-2 were analyzed using quantitative PCR. Exposure to 10 ng/mL TNF-α resulted in decreased viability of SH-SY5Y cells and significant upregulation of IL-6, IL-1β, NF-κB, and cyclooxygenase-2. Subsequent exposure to high glucose levels (25 mM) markedly reduced the upregulation of IL-6, IL-1β, cyclooxygenase-2, and NF-κB, and restored the functional metabolism of SH-SY5Y cells, compared with that of the normal glucose control. Our findings suggest that high glucose concentrations can mitigate TNF-α-induced NF-κB activation, upregulation of proinflammatory cytokines, and metabolic dysfunction.

A Novel Somatic Treatment for Post-traumatic Stress Disorder: A Case Report of Hydrodissection of the Cervical Plexus Using 5% Dextrose

Despite years of standard treatments, a Marine veteran and former firefighter, disabled due to severe post-traumatic stress disorder (PTSD), worsened over ten weeks while receiving usual care. Bilateral injection of 10 mL of 5% dextrose in water using a 30-gauge needle just under the sternocleidomastoid muscle was performed at weeks 10, 12, 14, 16, and 18. Clinically important improvements were observed by 18 weeks on a 0-10 anxiety rating scale (57%), the PTSD checklist for civilians (41%), EuroQol overall quality of life scale (40%), and the Hospital Anxiety and Depression Scale (28%). Improvements were stable through 22 weeks. He reported symptomatic benefit on anxiety within 20 minutes of injection, suggesting a neurogenic mechanism, potentially related to a therapeutic effect on the nearby sympathetic trunk/superior sympathetic ganglion. Advantages of this procedure over stellate ganglion blockade include its safety (no lidocaine), bilateral treatment option, simplicity, and comfort.

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.

Efficacy of 5% Dextrose Water Injection for Peripheral Entrapment Neuropathy: A Narrative Review

Current non-surgical treatment for peripheral entrapment neuropathy is considered insignificant and unsustainable; thus, it is essential to find an alternative novel treatment. The technique of perineural injection therapy using 5% dextrose water has been progressively used to treat many peripheral entrapment neuropathies and has been proven to have outstanding effects in a few high-quality studies. Currently, the twentieth edition of Harrison’s Principles of Internal Medicine textbook recommends this novel injection therapy as an alternative local treatment for carpal tunnel syndrome (CTS). Hence, this novel approach has become the mainstream method for treating CTS, and other studies have revealed its clinical benefit for other peripheral entrapment neuropathies. In this narrative review, we aimed to provide an insight into this treatment method and summarize the current studies on cases of peripheral entrapment neuropathy treated by this method.

Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment

Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.

The Benefit of Perineural Injection Treatment with Dextrose for Treatment of Chondromalacia Patella in Participants Receiving Home Physical Therapy: A Pilot Randomized Clinical Trial

Introduction: Chondromalacia patella is the degeneration of articular cartilage on the posterior facet of the patella and may indicate the onset of osteoarthritis. Conservative management is the main treatment option, and surgical intervention is considered the last option in a small percentage of patients. Perineural Injection Treatment (PIT) is a recently developed treatment option that is directed adjacent to the peripheral nerves that are the source of pathology causing neurogenic inflammation and pain. Objective: The objective of this study was to evaluate the efficacy of PIT combined with a home physical therapy program in patients with a diagnosis of chondromalacia patella compared with a control group receiving physical therapy only. Methods: Two patient groups were involved in this randomized clinical trial. The first received PIT combined with physical therapy (PIT + PT group) and the second was managed with physical therapy alone (PT group). Both groups were indicated to follow a 6-week home therapy plan afterward. The Western Ontario and McMaster Osteoarthritis Index was used to assess the patients at baseline and 6 months after therapy interventions. Results: Fifty patients (38 women and 12 men, median age 54.7 ± 14.8 years) were included; sex distribution and age did not differ between groups. Both groups had chondromalacia grade II or III, but the degree of gonarthrosis did not differ significantly between groups. The PIT + PT group outperformed PT group for pain (7.3 ± 3.5 vs. 3.2 ± 2.9 points; p < 0.010), stiffness (3 ± 1.69 vs. 1.6 ± 1.5 points; p < 0.010), and functional capacity (23.2 ± 10.7 vs. 11.1 ± 8.9 points; p < 0.010). Conclusions: Compared with physical therapy alone, PIT plus physical therapy reduced pain and stiffness and restored functional capacity. ClinicalTrials.gov Register Number #NCT03515720.