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Ashworth NL, Bland JDP, Chapman KM, Tardif G, Albarqouni L, Nagendran A. Local corticosteroid injection versus placebo for carpal tunnel syndrome. Cochrane Database Syst Rev 2023; 2:CD015148. [PMID: 36722795 PMCID: PMC9891198 DOI: 10.1002/14651858.cd015148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated. OBJECTIVES To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection. SEARCH METHODS We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8. ADVERSE EVENTS We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events. AUTHORS' CONCLUSIONS Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.
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Affiliation(s)
| | - Jeremy D P Bland
- Electroencephalography (EEG) Department, East Kent Hospitals University NHS Trust, Canterbury, UK
| | - Kristine M Chapman
- Neuromuscular Disease Unit, Diamond Health Care Centre, Vancouver, Canada
| | - Gaetan Tardif
- Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, Canada
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Arjuna Nagendran
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neurophysiology, London North West University Healthcare NHS Trust, London, UK
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Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9745322. [PMID: 35224104 PMCID: PMC8872692 DOI: 10.1155/2022/9745322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Abstract
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 (
), 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,
; 1st-month BCTQ-symptom, PRP vs. HA,
; 1st- and 6th-month BCTQ-function, D5W vs. HA,
and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA,
). For reducing CSA, PRP and HA seemed more effective than D5W (
on the 1st month and HA vs. D5W,
;
on the 6th month and PRP vs. D5W,
).
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Chen SR, Ho TY, Shen YP, Li TY, Su YC, Lam KHS, Chen LC, Wu YT. Comparison of short- and long-axis nerve hydrodissection for carpal tunnel syndrome: A prospective randomized, single-blind trial. Int J Med Sci 2021; 18:3488-3497. [PMID: 34522175 PMCID: PMC8436111 DOI: 10.7150/ijms.63815] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/02/2021] [Indexed: 01/04/2023] Open
Abstract
Background: This study is to compare the efficacy of short-axis hydrodissection with long-axis hydrodissection for patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: Forty-seven patients with mild-to-moderate CTS were enrolled in a prospective, randomized, single-blinded, controlled trial (6 months follow-up). With ultrasound guidance, patients in both groups (short-axis or long-axis groups) were injected with normal saline (5 mL per session). Assessments were performed before and 2 weeks after the injection, as well as at 1, 3, and 6 months post-intervention. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score and secondary outcomes included the cross-sectional area of the median nerve and electrophysiological studies. Results: Forty-four patients (21 wrists in the short-axis group and 23 wrists in the long-axis group) completed the study. Compared with the baseline, both groups showed improved BCTQ and cross-sectional area at all follow-up assessments (p<0.05). The short-axis group was not more effective except significant improvements in BCTQ-severity and BCTQ-function 1 month post-injection compared to the long-axis group (p = 0.031 and p = 0.023, respectively). Conclusions: Both short- and long-axis hydrodissection were effective for patients with mild-to-moderate CTS and the short-axis approach was not more effective than long-axis injection. Further studies with larger sample sizes, multiple injections, and larger injection volume are encouraged in the future.
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Affiliation(s)
- Si-Ru Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Tsung-Yen Ho
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Department of Physical Medicine and Rehabilitation, Taichung Armed Forces General Hospital, No. 348, Sec. 2, Chungshan Road, Taiping District, Taichung City, Taiwan, Republic of China
| | - Yu-Ping Shen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Tsung-Ying Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - King Hei Stanley Lam
- The Hong Kong Institute of Musculoskeletal Medicine, Hong Kong.,Department of Family Medicine, the Chinese University of Hong Kong, Hong Kong.,Department of Family Medicine, the University of Hong Kong, Hong Kong
| | - Liang-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
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Abstract
Background: Corticosteroid injection into the carpal tunnel is both a diagnostic test and a therapeutic modality in the treatment of carpal tunnel syndrome. Many injection techniques are described in the literature. Improper placement of injection may result in damage to neurovascular structures in the carpal canal or decrease efficacy of the test and/or therapy. The purpose of this study is to determine if carpal tunnel injection using anatomic landmarks is reproducible and safe. A review of the senior author's injection technique is presented. Methods: Over 8 years, there were 756 attempted placements of a 25-gauge needle into the carpal tunnel in a simulated carpal tunnel injection prior to open carpal tunnel release. The needle was inserted at the wrist crease, just ulnar to palmaris longus. Open carpal tunnel release was subsequently performed, and position of the needle was recorded. Results: In 572 patients (75.7%), the needle was found to be in the carpal tunnel without penetration of contents. The needle was in the carpal tunnel but piercing the median nerve in 66 attempts (8.7%). The carpal tunnel was missed in 118 attempts (15.6%). Conclusions: This is the largest study looking at accuracy of carpal tunnel injection using anatomic landmarks. Our injection accuracy (75.7%) is less than reported in previous studies, which note 82% to 100% accuracy using the same injection technique. This may indicate that carpal tunnel injection is less reliable than previously thought. Safety of carpal tunnel injection remains an important concern. The median nerve was penetrated in 8.7% of attempts.
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Affiliation(s)
| | - Brendan J. MacKay
- Texas Tech University Health Sciences
Center, Lubbock, USA
- Brendan J. MacKay, Department of Orthopaedic
Surgery, School of Medicine, Texas Tech University Health Sciences Center, 3601
4th Street, Lubbock, TX 79430, USA.
| | - Steven J. Seiler
- Orthopaedic & Spine Center of the
Rockies, Fort Collins, CO, USA
| | - Michael T. Fry
- Texas Tech University Health Sciences
Center, Lubbock, USA
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Percutaneous Ultrasound-Guided Intervention for Upper Extremity Neural and Perineural Abnormalities: A Retrospective Review of 242 Cases. AJR Am J Roentgenol 2019; 212:W73-W82. [DOI: 10.2214/ajr.18.20047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Jurbala BM, Burbank TA. A Sonographically Guided In-Plane Distal-to-Proximal Transligamentous Approach to Carpal Tunnel Injections. Hand (N Y) 2018; 13:522-528. [PMID: 28825345 PMCID: PMC6109908 DOI: 10.1177/1558944717725375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Several sonographically guided injection methods have been described to treat carpal tunnel syndrome. In most cases, the medication diffuses through the carpal tunnel to the site of maximum compression of the nerve after being injected proximally. In this article, we describe a novel method of sonographically guided carpal tunnel injection that utilizes a distal-to-proximal, in-plane, and transligamentous approach. This novel method may provide ergonomic as well as safety advantages to both clinicians and patients, and should be considered by those performing carpal tunnel injections. METHODS A distal-to-proximal transligamentous approach is taken, utilizing high-resolution ultrasound guidance. Once the median nerve is sonographically visualized longitudinally within the carpal tunnel, an ulnar shift is made with the transducer. With the median nerve out of view, the needle is inserted in-line and distal to the transducer on the palmar side of the hand, at the ulnar portion of Kaplan's cardinal line. Following a trajectory that is nearly parallel to the median nerve, the needle is sonographically guided to the site of maximum nerve compression. CONCLUSIONS This novel method provides an alternative to previous carpal tunnel injections. The use of ultrasound guidance allows the clinician to visualize and avoid the neurovascular structures near the median nerve and guide the needle to the site of maximum nerve compression. It is possible that this parallel trajectory with the median nerve will provide a lower risk of damage to the nerve.
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Affiliation(s)
| | - Troy A. Burbank
- Highland Center for Orthopaedics, Lakeland, FL, USA,Troy A. Burbank, Highland Center for Orthopaedics, 2161 CR 540A #286, Lakeland, FL 33813, USA.
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Comparison Between Effectiveness of Ultrasound-Guided Corticosteroid Injection Above Versus Below the Median Nerve in Mild to Moderate Carpal Tunnel Syndrome. Am J Phys Med Rehabil 2018; 97:407-413. [DOI: 10.1097/phm.0000000000000877] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Guo XY, Xiong MX, Zhao Y, He FD, Cheng XQ, Wu YY, Chen K, Lu M. Comparison of the Clinical Effectiveness of Ultrasound-Guided Corticosteroid Injection with and without Needle Release of the Transverse Carpal Ligament in Carpal Tunnel Syndrome. Eur Neurol 2017; 78:33-40. [PMID: 28586773 DOI: 10.1159/000477719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/10/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS). METHODS Between May 2014 and June 2016, 52 patients (56 wrists) with CTS were included in this study. Among these patients, 28 wrists were treated with ultrasound-guided corticosteroid injection plus needle release of the TCL (group A) and 28 wrists were treated with a single ultrasound-guided corticosteroids injection (group B). The following parameters were assessed and compared including postoperative results of procedure based on relief of symptoms, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of median nerve), and ultrasound parameters (anteroposterior diameter and cross-sectional area of the median nerve at the levels of pisiform and hamate bone, and the thicknesses of TCL on the cross-section at the level of hamate bone). RESULTS The overall excellent and good rate regarding the postoperative results of procedure based on the relief of symptoms at 1 month postoperatively was 82.1% in group A and 46.4% in group B (p = 0.004). There was significant difference in the above electrophysiological and ultrasound parameters between the preoperative and postoperative values in both groups (all p < 0.05). Furthermore, a significant difference was also observed in the postoperative values of the above-mentioned electrophysiological and ultrasound parameters in the 2 groups (all p < 0.05). CONCLUSIONS Both approaches had treatment benefit in CTS. Ultrasound-guided corticosteroid injection in combination with needle release of the TCL is superior to the single ultrasound-guided corticosteroids injection.
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Affiliation(s)
- Xuan-Yan Guo
- Ultrasonic Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
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9
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Abstract
CONTEXT Musculoskeletal ultrasound (US) research is expanding due to increased clinical utility of sonography. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Ultrasound is widely applied in musculoskeletal imaging and sports medicine. The real-time capabilities and favorable cost profile of US make it ideal for use in diagnosis of musculoskeletal conditions. The enthusiasm for the use of US in musculoskeletal imaging has led to an increase in US research to broaden its applications. CONCLUSION Several recent advances have been made in conventional and novel US imaging techniques, quantitative US imaging, and US-guided interventions. STRENGTH OF RECOMMENDATIONS TAXONOMY SORT C.
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Affiliation(s)
- O Kenechi Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York Weill Cornell Medical College of Cornell University, New York, New York
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10
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Abstract
OBJECTIVE Peripheral nerves are well seen using ultrasound (US) imaging, making US an ideal modality for image-guided nerve injections. This article provides a technical guide for common upper and lower extremity peripheral nerve injections, including the median, ulnar, and radial nerves in the upper extremity and the lateral femoral cutaneous, sciatic, common peroneal, tibial, and sural nerves in the lower extremity. CONCLUSION US is an effective modality for use in common upper and lower extremity peripheral nerve injections. With correct technique, peripheral nerve injections can be performed safely and are useful for both diagnostic evaluation of and therapy for peripheral neuropathy.
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