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

Minimal Clinically Important Differences in Hand Pain Intensity (Numerical Pain Rate Scale) and Related-Function (Boston Carpal Tunnel Questionnaire) in Women With Carpal Tunnel Syndrome

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) for hand pain intensity and the Boston Carpal Tunnel Questionnaire (BCTQ) in a sample of women with carpal tunnel syndrome (CTS).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

A Hospital Rehabilitation Unit.

PARTICIPANTS

One hundred twenty women with clinical and electromyographic diagnosis of CTS who were randomly assigned into 2 groups (N=120).

INTERVENTIONS

One group received 3 sessions of manual physical therapy (n=60) and the other group received surgery (n=60).

MAIN OUTCOME MEASURES

Mean and the worst pain intensity (numerical pain rate scale, 0-10 points) and functional status and symptoms' severity subscales of the BCTQ questionnaire were assessed before and 1 month after treatment. The Global Rating of Change (GROC) was used as the anchor variable for determining the MCID.

RESULTS

A change of 1.5 and 2.5 points in mean and the worst pain intensity represents the MCID for Numerical Pain Rating Scale, whereas a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for each subscale of the BCTQ. All variables showed acceptable discrimination between patients classified as "improved" and those classified as "stable/not improved" (area under the curve≥0.72). Mean pain intensity (Youden index, 0.53; sensitivity: 73.3%; specificity: 80%) and symptoms' severity (Youden index, 0.69; sensitivity: 90%; specificity: 77.8%) showed the best discriminative ability expressed as a percentage of prediction. Participants classified as "improved" had significantly greater improvements in pain intensity, functional status, and symptoms' severity compared with those classified as "stable/not improved".

CONCLUSION

A change of 1.5 and 2.5 points in mean and the worst pain and a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for pain intensity and BCTQ in women with CTS 1 month after treatment.

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.

Study on the effect, safety, prognosis quality and application value of extracorporeal shock wave based neural activity in carpal tunnel syndrome patients

BACKGROUND

Mild to moderate CTS is the most common median nerve compression disease in middle-aged and elderly women, mainly manifested by hand numbness and pain. This paper analyzes the extracorporeal shock wave of patients with mild to moderate CTS after nerve mobilization.

METHODS

The clinical data of 92 patients with CTS from June 2020 to June 2022 are analyzed and randomly divided into extracorporeal shock wave group (n = 47) and routine group (n = 45). The routine group undergoes nerve mobilization, and the extracorporeal shock wave group receives extracorporeal shock wave therapy on the basis of the routine group. The clinical efficacy, symptom improvement, pain score, median nerve electrophysiological examination results, upper limb symptom and function scores, and ADL scores before and after treatment are observed. The Spearman correlation coefficient is used to analyze the correlation between upper limb function and ADL score, and the incidence of complications after treatment is analyzed.

RESULTS

The clinical efficacy, symptom improvement, pain score, median nerve electrophysiological examination results, upper limb symptom and function score, ADL score and the incidence of complications in the extracorporeal shock wave group are significantly better than those in the conventional group (P < 0.05). ADL scores are negatively correlated.

CONCLUSION

Extracorporeal shock wave combined with nerve mobilization has a significant effect in the treatment of CTS patients, which can significantly improve the symptoms and pain scores of patients, and enhance the function of patients' upper limbs. At the same time, the incidence of complications in patients is less, and it has high safety.

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.

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.

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.

Effectiveness of therapeutic ultrasound for the treatment of carpal tunnel syndrome (the USTINCTS trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

There has no consensus on optimal management of carpal tunnel syndrome (CTS), the most common compression neuropathy. Conservative therapy is generally accepted as first-line intervention. Therapeutic ultrasound has been widely reported to be treatment beneficial in nerve regeneration and conduction, and further accelerate compression recovery. The purpose of this study is to investigate the effectiveness of therapeutic ultrasound for CTS treatment.

METHODS AND ANALYSIS

This study protocol entails a three-arm, prospective, multicentre, randomised controlled trial. 162 eligible adult participants diagnosed with mild to moderate CTS by using criteria developed from a consensus survey by the UK Primary Care Rheumatology Society will be assigned to either (1) therapeutic ultrasound, (2) night splint or (3) therapeutic ultrasound +night splint (combined) group. Primary outcome will be difference in Symptom Severity Scale of Boston Carpal Tunnel Questionnaire (BCTQ-SSS) at 6-week between night splint and therapeutic ultrasound +night splint groups. Secondary outcomes include Functional Status Scale of BCTQ, sleep questionnaire for interrupted sleep, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Work Limitations Questionnaire-25 for functional limitations at work, Global Rating of Change for treatment success and recurrence rate, physical examination, electrophysiological and ultrasound parameters. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-152. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050701.

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, $p=0.012$ ).

Comparison of ultrasound-guided pulsed radiofrequency versus steroid injection in the treatment of carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is the most widespread form of nerve entrapment neuropathy results from increase compression pressure of the median nerve at the wrist under the transverse carpal ligament.

AIMS

To compare ultrasound (US)-guided median nerve steroid injection and pulsed radiofrequency (PRF) on pain intensity, functional status, and patient satisfaction in the treatment of CTS.

METHODS

A total of 90 hands of 59 patients who underwent steroid injection at the level of proximal carpal tunnel or PRF for CTS were retrospectively analyzed. Demographic and clinical characteristics of the patients were recorded. The pain severity was assessed using the Numerical Rating Scale (NRS), and the functional status and clinical outcomes were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ) before the procedure and at Week 1, Month 1, and Month 3 after the procedure. Time to pain relief was evaluated at week 1. Patient satisfaction was evaluated at Month 3.

RESULTS

There was no significant difference in the NRS and BCTQ scores between the two treatment methods (p > 0.05 for both). In addition, a significant decrease in the NRS and BCTQ scores were detected at all follow-ups compared to baseline in treatment groups (p < 0.001). The mean time to pain relief was significantly shorter in the PRF group (p < 0.001). Patient satisfaction was similar at Month 3 between the treatment methods (p > 0.05).

CONCLUSIONS

Our study results suggest that both US-guided steroid injection to the median nerve and PRF are effective and safe methods in the short-term in the treatment of CTS.

Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial

Background: Despite the wide use of corticosteroid hydrodissection for carpal tunnel syndrome (CTS), there is insufficient evidence to confirm its efficacy. This study aimed to compare the effectiveness of corticosteroid hydrodissection vs. corticosteroid perineural injection alone on clinical and electrophysiological parameters in patients with CTS. Method: This prospective randomized controlled trial (RCT) was conducted in a tertiary care center with a follow-up period of 12 weeks. Subjects were randomly assigned to either ultrasound-guided hydrodissection with a mixture of 1 mL of triamcinolone acetonide (10 mg/mL), 1 mL of 2% lidocaine, and 8 mL normal saline or ultrasound-guided perineural injection with 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of 2% lidocaine. The primary outcome measure was the symptom severity subscale (SSS) of Boston Carpal Tunnel Questionnaire (BCTQ) scores at baseline and at 6 and 12 weeks' post-treatment. The secondary outcomes included the functional status subscale (FSS) of BCTQ and the distal motor latency and sensory nerve conduction velocity of the median nerve. The effect of interventions on the designated outcome was analyzed using a 3 × 2 repeated measures analysis of variance. The within-subject and among-subject factors were differences in time (before the intervention, and 6 and 12 weeks after injection) and intervention types (with or without hydrodissection), respectively. Results: Sixty-four patients diagnosed with CTS were enrolled. Both groups experienced improvement in the SSS and FSS of BCTQ and median nerve distal motor latency and sensory nerve conduction velocity. However, group-by-time interactions were not significant in any outcome measurements. No serious adverse events were reported in either group, except for two patients in the hydrodissection group who reported minor post-injection pain on the first day after the intervention, which resolved spontaneously without the need for additional treatments. Conclusion: Hydrodissection did not provide an additional benefit compared to corticosteroid perineural injection alone. More prospective studies are needed to investigate the long-term effectiveness of corticosteroid hydrodissection, as well as its influence on median nerve mobility.

Dynamic Ultrasound Assessment of Median Nerve Mobility Changes Following Corticosteroid Injection and Carpal Tunnel Release in Patients With Carpal Tunnel Syndrome

Decreased median nerve (MN) mobility was found in patients with carpal tunnel syndrome (CTS) and was inversely associated with symptom severity. It is unclear whether MN mobility can be restored with interventions. This study compared the changes in MN mobility and clinical outcomes after interventions. Forty-six patients with CTS received an injection (n = 23) or surgery (n = 23). Clinical outcomes [Visual Analogue Scale; Boston Carpal Tunnel Questionnaire (BCTQ), which includes the Symptom Severity Scale and Functional Status Scale; median nerve cross-sectional area; and dynamic ultrasound MN mobility parameters (amplitude, and R² value and curvature of the fitted curves of MN transverse sliding)] were assessed at baseline and 12 weeks after the interventions. At baseline, the BCTQ-Functional Status Scale and median nerve cross-sectional area showed significant inter-treatment differences. At 12 weeks, both treatments had significant improvements in BCTQ-Symptom Severity Scale and Visual Analogue Scale scores and median nerve cross-sectional area, but with greater improvements in BCTQ-Functional Status Scale scores observed in those who received surgery than in those who received injections. MN mobility was insignificantly affected by both treatments. The additional application of dynamic ultrasound evaluation may help to discriminate the severity of CTS initially; however, its prognostic value to predict clinical outcomes after interventions in patients with CTS is limited.

Ultrasound-guided perineural vs. peritendinous corticosteroid injections in carpal tunnel syndrome: a randomized controlled trial

BACKGROUND

Corticosteroid injections are proven to be effective in the management of carpal tunnel syndrome (CTS); however, the optimal injection site still remains unclear.

AIM

To compare the efficacy of perineural vs. peritendinous target sites for corticosteroid injection in CTS.

DESIGN

A Randomized, Single-Blind, Controlled Trial.

SETTING

Outpatients, tertiary care center.

POPULATION

Forty-six patients were equally randomized into two intervention groups as Group A (18 F and 5 M, mean age;50.0 ± 15.9 years, mean symptom duration;5.9 ± 3.3 months) and Group B (19 F, 4 M patients, mean age;54.3 ± 15.0 years, mean symptom duration;5.9 ± 4.7 months).

METHODS

Methylprednisolone acetate (40 mg) and 1 mL of 1% trimecaine hydrochloride was injected next to the median nerve (Group A) or among flexor tendons away from the nerve (Group B) under ultrasound (US) guidance. The visual analogue scale was used as the primary outcome measure, and the symptom severity scale and functional status scale of the Boston Carpal Tunnel Questionnaire were used as the secondary subjective outcome measures. Twopoint discrimination, grip strength, cross-sectional area, and distal motor latency were assessed as objective outcome measures. The data were collected at baseline and at 2, 6 and 12 weeks after the injection.

RESULTS

Both groups showed improvement in subjective and objective measures at 2 weeks following the injection - also maintained up to 12 weeks during the follow-up (p<0.05). However, no difference was observed between the two groups (p<0.05). No serious adverse effects were observed in either group.

CONCLUSIONS

Both intervention techniques seem to be effective and safe in the conservative treatment of CTS.

CLINICAL REHABILITATION IMPACT

Based on this study results, it might be noteworthy that physicians can opt for perineural or peritendinous injections without compromising the treatment efficacy and safety. Herewith, US guidance is, for sure, necessary for performing safe and accurate injections.