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Couch B, Hayward D, Baum G, Sakthiyendran NA, Harder J, Hernandez EJ, MacKay B. A systematic review of steroid use in peripheral nerve pathologies and treatment. Front Neurol 2024; 15:1434429. [PMID: 39286807 PMCID: PMC11402678 DOI: 10.3389/fneur.2024.1434429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Background The use of corticosteroids has become a part of the standard of care in various pathologies but their use in peripheral nerve injury treatment is limited. Given corticosteroids' anti-inflammatory properties and their regulatory role in neuronal protein production and myelination, corticosteroids could serve as an adjunct therapy for peripheral nerve injuries. This review aims to systematically investigate the current use of corticosteroid treatment in peripheral nerve pathologies. Methods The systematic search was performed on PubMed, MEDLINE, EMBASE, Scopus, Cochrane, and Web of Science using keywords such as "corticosteroid treatment," "peripheral nerve damage," "peripheral neuropathy," and "complications." The PRISMA guidelines were used to conduct the systematic review and all articles were reviewed by the corresponding author. After the initial search, individual study titles and abstracts were further screened and categorized using an inclusion and exclusion criteria followed by a final full-text review. Results Out of the total 27,922 identified records, 203 studies were included based on the selection criteria. These studies focused on the use and efficacy of steroids across a spectrum of compression and non-compression peripheral neuropathies such as cubital tunnel syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Various studies noted the promising role of steroids in offering pain relief, nerve block, and nerve regeneration effects. Additionally, safety considerations and potential complications regarding steroid use in peripheral nerve injuries were analyzed. Conclusion While there is currently limited clinical utilization of corticosteroids in peripheral nerve pathologies, the anti-inflammatory and regenerative effects that steroids provide may be a beneficial tool in managing various peripheral neuropathies and their associated pain. Additional clinical trials and investigation into the mechanism of action could improve the reputation of steroid use as peripheral nerve injury treatment.
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Affiliation(s)
- Brandon Couch
- Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Dan Hayward
- Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Gracie Baum
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | | | - Justin Harder
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Evan J Hernandez
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Brendan MacKay
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
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Billig JI, Kotsis SV, Kong L, Wang L, Chung KC. Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative. Plast Reconstr Surg 2024; 153:1075-1082. [PMID: 37384880 DOI: 10.1097/prs.0000000000010899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short term, and many patients go on to receive carpal tunnel release (CTR). The purpose of this study was to determine the variation in steroid injection use by hand surgeons. METHODS The authors analyzed data from a nine-center hand surgery quality collaborative. Data from 1586 patients (2381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates. RESULTS Steroid injection use significantly varied by practice, ranging from 12% to 53% of patients. The odds of receiving a steroid injection were 1.4 times higher for women ( P < 0.01), 1.6 times higher for patients with chronic pain syndrome ( P < 0.01), 0.5 times lower for patients with moderate electromyography (EMG) classification, and 0.4 times lower for patients with severe EMG classification (both P < 0.01). Patients with high scores on the Six-Item CTS Scale ( P = 0.02) and patients with moderate ( P = 0.04) or severe EMG ( P = 0.05) classification had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with a high Six-Item CTS Scale score ( P = 0.03) and patients with severe EMG classification ( P = 0.02). CONCLUSIONS The authors found wide patient-level and practice-level variation in the use of steroid injections before CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
| | | | | | - Lu Wang
- Department of Biostatistics, University of Michigan
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Malik AT, Lin JS, Jain S, Awan H, Khan SN, Goyal KS. Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release. Hand (N Y) 2024:15589447241233710. [PMID: 38420784 DOI: 10.1177/15589447241233710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.
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Affiliation(s)
| | - James S Lin
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sonu Jain
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hisham Awan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kanu S Goyal
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Bland JDP. Use of nerve conduction studies in carpal tunnel syndrome. J Hand Surg Eur Vol 2023; 48:976-985. [PMID: 37812524 DOI: 10.1177/17531934231191685] [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: 10/11/2023]
Abstract
This review article examines the use of nerve conduction studies in the management of carpal tunnel syndrome. These studies should be understood not as a test that determines the diagnosis but as a measure of impaired nerve function. They are sensitive indicators of local demyelination and axonal loss that can detect and quantify these changes before the appearance of clinical signs, providing information that cannot be obtained with the unaided senses of the physician, nor by any other investigation. They are the best available indicator of overall disease severity, correlating with symptoms and anatomical change in the median nerve. They have some prognostic value for surgical outcome and are sufficiently sensitive to change for the evaluation of treatment response. When surgery does not yield the expected improvement in symptoms, they can help to establish whether decompression has been achieved provided preoperative results are available for comparison.
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Affiliation(s)
- Jeremy D P Bland
- Department of Clinical Neurophysiology, East Kent Hospitals University Foundation NHS Trust, Canterbury, Kent, UK
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Kumar N, Chandan SK, Jalan D, Sinha S, Jaiswal B, Singh DK. Ultrasound-guided interventions in primary carpal tunnel syndrome: perineural injection to thread carpal tunnel release. Br J Radiol 2023; 96:20230552. [PMID: 37660684 PMCID: PMC10546448 DOI: 10.1259/bjr.20230552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023] Open
Abstract
Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, is compression of the median nerve deep to transverse carpal ligament at wrist. Ultrasonography and electrophysiological study are complementary in the diagnosis and grading of CTS in appropriate clinical settings. The initial management of patients with CTS is conservative with medical therapy and splinting. However, surgical interventions are indicated in patients in whom medical management has failed. With evolution of the concept of safe zone on ultrasonography and identification of the sonoanatomical landmarks of carpal tunnel in greater detail, Ultrasonography-guided interventions are safer and preferred over surgical management in CTS. The primary ultrasonography-guided interventions include perineural injection, perineural hydrodissection and ultrasonography-guided release of transverse carpal ligament. This review article presents the principles of ultrasonography-guided perineural injection, perineural hydrodissection in CTS, the merits and demerits of injectant used in perineural injection/ hydrodissection, and percutaneous ultrasonography-guided thread release of transverse carpal ligament utilizing the concept of safe zone of the ultrasonography-guided interventions for CTS.
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Affiliation(s)
- Nishith Kumar
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shishir Kumar Chandan
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Divesh Jalan
- Central Institute of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Skand Sinha
- Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Binita Jaiswal
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Dharmendra Kumar Singh
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Mubin NF, Mubin AN, Fogel J, Morrison E. Progression From Steroid Injection to Surgery in Carpal Tunnel Syndrome Patients With Concurrent Ulnar Nerve Compression: A Retrospective Analysis. Hand (N Y) 2023:15589447231198270. [PMID: 37746706 DOI: 10.1177/15589447231198270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Steroid injections are a common treatment option in the management of carpal tunnel syndrome (CTS). This study assesses various prognostic factors for progression to carpal tunnel release (CTR) after a first-time steroid injection for CTS with specific focus on concomitant ulnar nerve compression (UNC). METHODS This is a retrospective study of 426 hands with CTS treated with a first-time steroid injection in the Long Island region of New York. The main predictor variable was UNC measured in two analytical models of positive UNC and location of UNC (wrist or elbow). Multivariate logistic regression analyses adjusted for demographic, medical, and CTS-related variables for 2 study outcomes occurring within 1 year: (1) CTR; and (2) steroid reinjection. RESULTS Overall progression to CTR within 1 year of steroid injection was 23.0%. Ulnar nerve compression was present in 16.7% of patients and was significantly associated with increased odds for CTR but not with steroid reinjection. These results were further localized to be specific for UNC at the elbow. A moderate or severe result on electrodiagnostic studies was associated with increased odds for CTR. Increased age was associated with slightly increased odds of steroid reinjection while a history of distal radius fracture was associated with decreased odds of steroid reinjection. CONCLUSIONS Carpal tunnel syndrome patients with UNC may benefit from earlier definitive treatment with CTR rather than attempting steroid injections, as they are more likely to seek reintervention within 1 year of their initial injection.
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Affiliation(s)
| | | | - Joshua Fogel
- Nassau University Medical Center, East Meadow, NY, USA
- Brooklyn College, Brooklyn, NY, USA
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O'Donnell M, Eadie P, Dorairaj J, Stapleton T. Advanced practice occupational therapy led triage and treatment clinic for patients with carpal tunnel syndrome in an Irish public hospital. Musculoskeletal Care 2023; 21:633-643. [PMID: 36760197 DOI: 10.1002/msc.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION A pilot CTS Triage and Treat clinic led by an Advanced Practice Occupational Therapist was established to address the CTS wait list at a large urban hospital. The aims of this pilot were to develop a clinical triage and screening protocol to inform the stratification of patients for suitable treatment options and to reduce waiting time. METHODS A cross sectional study with follow up was conducted, patients on the wait list at time of commencement of the pilot and subsequent referrals over a 1-year period were recruited. Triage consisted of tests of sensibility, self-rating measures, provocative tests and detailed patient to inform the subsequent treatment stratification, conservative, injection, surgery, or further investigation. Nonparametric analyses were used to test relationships between the test scores and to complete subgroup comparisons. RESULTS Eighty-nine patients were triaged over the pilot period, 62 (70%) had a positive Phalen's at triage. Following triage 48 (54%) patients were stratified for conservative management, injection (n = 23, 26%) and surgery/differential diagnosis (n = 18, 20%). Statistically significant differences in BCTQ (SSS and FSS) and Q-DASH scores were noted across the three outcome groups, with lower scores among those commenced on conservative management. BCTQ (SSS) scores were aligned with the Semmes Weinstein Monofilaments sensibility thresholds. Wait times showed a marked decrease from 10 to 2 months over the period of the pilot. DISCUSSION Findings highlight the positive impact of occupational therapy led triage and treat approach in the reduction of wait time for assessment and treatment for patients with CTS.
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Affiliation(s)
- Michelle O'Donnell
- Department of Occupational Therapy, St James's Hospital, Dublin, Ireland
| | | | | | - Tadhg Stapleton
- Discipline of Occupational Therapy, Trinity College Dublin, Dublin, Ireland
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Kirby D, Donnelly M, Catalano W, Buchalter D, Glickel S, Hacquebord J. The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release. Hand (N Y) 2023; 18:430-435. [PMID: 34308719 PMCID: PMC10152525 DOI: 10.1177/15589447211032331] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. METHODS A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. RESULTS Of 3234 patients who underwent trigger finger release, 58 (1.8%) were identified with postoperative infections, 6 (0.2%) of which were deep infections. History of corticosteroid injection was significantly more common in patients with postoperative infection. Compared with an age-matched, gender-matched, and body mass index-matched cohort, patients with postoperative infection had significantly increased rate of diabetes mellitus at 34.5% to 19% (P = .04). CONCLUSIONS While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.
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Affiliation(s)
- David Kirby
- NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Megan Donnelly
- University of California, Irvine School of Medicine, USA
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Alendijani YA, Abaalkhail BA, Binsaeedu AS, Alandijani AA. Risk factors for carpal tunnel syndrome in patients attending the primary care center of a tertiary hospital in Riyadh, Saudi Arabia: A case-control study. J Family Community Med 2023; 30:81-88. [PMID: 37303839 PMCID: PMC10252633 DOI: 10.4103/jfcm.jfcm_361_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Carpal tunnel syndrome (CTS), the most common entrapment neuropathy in the upper extremity, is known to be a multi-factorial disease that raises medical and nonmedical risk factors. The aim of the current study was to determine the risk factors of CTS in patients attending the primary care center at a tertiary hospital. MATERIALS AND METHODS A case-control study was conducted by reviewing all medical records of patients above the age of 18 years old diagnosed with CTS from 2015 to 2021. The selected cases were evaluated by physical examination and confirmed by a nerve conduction study. Cases and controls were matched by age, gender, and nationality, with a case-to-control ratio of 1:2. Odds ratios were calculated for association between carpel tunnel syndrome and various factors and Chi-sqauare test determined statistical significance. Multiple logistic regression was performed to adjust for confounding. RESULTS The study recruited 144 cases with a mean age of 53.38 ± 12.20 years and 288 controls with a mean age of 53.80 ± 12.27 years. The majority of subjects were female (84.7%) and of Saudi nationality (68.3%). There was a significant difference in body mass index, employment status, number of years of employment, occupation, mean systolic blood pressure, mean low-density lipoprotein cholesterol level, and mean blood urea level between cases and controls (P < 0.05). Laboratory tests that were found to be significantly associated with CTS in univariate analysis were thyroid-stimulating hormone (crude odds ratio [COR] = 0.828) and urea level (COR = 0.802). In fully adjusted analyses, obesity (adjusted odds ratio [AOR] =3.080), chronic kidney disease (AOR = 3.629), and the use of corticosteroid (AOR = 0.470) were also significantly associated with CTS. CONCLUSION Similar to the findings of other studies, this study identified several potential risk factors for CTS. More large-scale longitudinal studies are required to establish a precise causal association.
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Affiliation(s)
- Yaser A. Alendijani
- Department of Family Medicine and Polyclinic, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Bahaa A. Abaalkhail
- Department of Family and Community Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Eberlin KR, Dy CJ, Fischer MD, Gluck JL, Kaplan FTD, McDonald TJ, Miller LE, Palmer A, Walker ME, Watt JF. Trial of ultrasound guided carpal tunnel release versus traditional open release (TUTOR). Medicine (Baltimore) 2022; 101:e30775. [PMID: 36254038 PMCID: PMC9575820 DOI: 10.1097/md.0000000000030775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Carpal tunnel release (CTR) is a surgical treatment option for patients with carpal tunnel syndrome (CTS) symptoms that are unresponsive to conservative treatment. Most patients experience symptomatic relief after CTR regardless of the surgical technique. However, direct comparisons of the safety and effectiveness between CTR surgical techniques are limited. The purpose of this randomized controlled trial is to compare the safety and effectiveness of CTR with ultrasound guidance (CTR-US) versus mini-open CTR (mOCTR) in subjects with symptomatic CTS. DESIGN AND METHODS TUTOR (Trial of Ultrasound guided CTR versus Traditional Open Release) is a randomized controlled trial in which 120 subjects at up to 12 sites in the United States will be randomized (2:1) to receive CTR-US or mOCTR. The primary endpoint of the study is the percentage of patients who return to normal daily activities within 3 days of the procedure. Secondary endpoints of the study are median time to return to normal daily activities, percentage of patients who return to work within 3 days of the procedure, median time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) change score at 3 months, BCTQ Functional Status Scale (BCTQ-FSS) change score at 3 months, Numeric Pain Scale change score at 3 months, EuroQoL-5 Dimension 5-Level (EQ-5D-5L) change score at 3 months, and the incidence of device- or procedure-related adverse events at 3 months. Patient follow-up in this trial will continue for 1 year. ETHICS AND DISSEMINATION This study was approved by a central institutional review board and ongoing trial oversight will be provided by a data safety monitoring board (DSMB). The authors intend to report the results of this trial at medical conferences and peer-reviewed journals. The outcomes of TUTOR will have important clinical and economic implications for all stakeholders involved in treating patients with CTS. STUDY REGISTRATION ClinicalTrials.gov (https://clinicaltrials.gov): NCT05405218. LEVEL OF EVIDENCE 1.
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Affiliation(s)
| | | | | | | | | | | | - Larry E. Miller
- Miller Scientific, Johnson City, TN, USA
- *Correspondence: Larry E. Miller, Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN 37604, USA (e-mail: )
| | | | - Marc E. Walker
- University of Mississippi Medical Center, Jackson, MS, USA
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Katt BM, Imbergamo C, Padua F, Leider J, Fletcher D, Nakashian M, Beredjiklian PK. Diagnostic Value of a Carpal Tunnel Corticosteroid Injection in Patients with Negative Electrodiagnostic Studies. J Hand Microsurg 2022; 14:292-297. [PMID: 36398152 PMCID: PMC9666063 DOI: 10.1055/s-0040-1717830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Introduction There is a known false negative rate when using electrodiagnostic studies (EDS) to diagnose carpal tunnel syndrome (CTS). This can pose a management dilemma for patients with signs and symptoms that correlate with CTS but normal EDS. While corticosteroid injection into the carpal tunnel has been used in this setting for diagnostic purposes, there is little data in the literature supporting this practice. The purpose of this study is to evaluate the prognostic value of a carpal tunnel corticosteroid injection in patients with a normal electrodiagnostic study but exhibiting signs and symptoms suggestive of carpal tunnel, who proceed with a carpal tunnel release. Materials and Methods The group included 34 patients presenting to an academic orthopedic practice over the years 2010 to 2019 who had negative EDS, a carpal tunnel corticosteroid injection, and a carpal tunnel release. One patient (2.9%), where the response to the corticosteroid injection was not documented, was excluded from the study, yielding a study cohort of 33 patients. Three patients had bilateral disease, yielding 36 hands for evaluation. Statistical analysis was performed using Chi-square analysis for nonparametric data. Results Thirty-two hands (88.9%) demonstrated complete or partial relief of neuropathic symptoms after the corticosteroid injection, while four (11.1%) did not experience any improvement. Thirty-one hands (86.1%) had symptom improvement following surgery, compared with five (13.9%) which did not. Of the 32 hands that demonstrated relief following the injection, 29 hands (90.6%) improved after surgery. Of the four hands that did not demonstrate relief after the injection, two (50%) improved after surgery. This difference was statistically significant ( p = 0.03). Conclusion Patients diagnosed with a high index of suspicion for CTS do well with operative intervention despite a normal electrodiagnostic test if they have had a positive response to a preoperative injection. The injection can provide reassurance to both the patient and surgeon before proceeding to surgery. Although patients with a normal electrodiagnostic test and no response to cortisone can still do well with surgical intervention, the surgeon should carefully review both the history and physical examination as surgical success may decrease when both diagnostic tests are negative. Performing a corticosteroid injection is an additional diagnostic tool to consider in the management of patients with CTS and normal electrodiagnostic testing.
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Affiliation(s)
- Brian M. Katt
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, United States
| | - Casey Imbergamo
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Fortunato Padua
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, United States
| | - Joseph Leider
- Georgetown Medical School, Washington, District of Columbia, United States
| | - Daniel Fletcher
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, United States
| | - Michael Nakashian
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, United States
| | - Pedro K. Beredjiklian
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, United States
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Huang B, Chen H, Duan C, Li W. Stability Analysis and Construction Parameter Optimization of Tunnels in the Fractured Zone of Faults. Int J Anal Chem 2022; 2022:2211499. [PMID: 36090807 PMCID: PMC9453103 DOI: 10.1155/2022/2211499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 07/27/2022] [Accepted: 08/16/2022] [Indexed: 11/21/2022] Open
Abstract
In order to improve the construction method of highway tunnel fault, improve the excavation level, improve the construction efficiency, reduce the project cost, and shorten the construction period, so as to find a specific road, this paper puts forward the research method of tunnel stability analysis and construction parameter optimization in the fault fracture zone. First, this paper analyzes the specific geographical and geological environment of the construction site. Second, this paper compares and analyzes the effects of the drilling and blasting method and full-face tunnel boring machine (TBM) in construction and further analyzes the surrounding rock deformation, over excavation, and under excavation, as well as the range of loose circles when the surrounding rock is stable. Then, this paper discusses the minimum smooth blasting parameters under these conditions. Finally, the actual blasting effect of tunnel construction is tested and the optimization algorithm model of tunnel fault drilling and blasting parameters is established. The results show that the proposed optimization model of drilling and blasting construction parameters for highway tunnel faults based on the Support Vector Regression (SVR) algorithm combined with a genetic algorithm (GA) has a short calculation time and high parameter optimization accuracy. It is very feasible to optimize the construction parameters of the fault drilling and blasting method, which can greatly improve the construction efficiency, carry out the detailed simulation, reduce the cost, and increase safety. In summary, it has a certain reference significance for the optimization of highway tunnel construction and future research by drilling and blasting method under complex geological conditions in my country.
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Affiliation(s)
- Banma Huang
- Qinghai Traffic Engineering Technical Service Center, Xining, Qinghai 810001, China
| | - Haibo Chen
- China-Road Transportation Verification and Inspection Hi-Tech Co., Ltd., Beijing 100088, China
| | - Chenglong Duan
- China-Road Transportation Verification and Inspection Hi-Tech Co., Ltd., Beijing 100088, China
| | - Wenhu Li
- Qinghai Traffic Engineering Technical Service Center, Xining, Qinghai 810001, China
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Salman LA, Omari RY, Moghamis IS, Hantouly AT, Ahmed G. Appropriateness of carpal tunnel syndrome management compared with the AAOS appropriate use criteria: A retrospective review across various specialties. Ann Med Surg (Lond) 2022; 80:104140. [PMID: 36045855 PMCID: PMC9422078 DOI: 10.1016/j.amsu.2022.104140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Loay A. Salman
- Orthopedic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
- Corresponding author. Orthopedic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Rand Y. Omari
- Plastic and Reconstructive Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Isam S. Moghamis
- Orthopedic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ashraf T. Hantouly
- Orthopedic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ghalib Ahmed
- Orthopedic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
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14
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Ly-Pen D, Andreu JL, Millán I, de Blas G, Sánchez-Olaso A. Long-term Outcome of Local Steroid Injections Versus Surgery in Carpal Tunnel Syndrome: Observational Extension of a Randomized Clinical Trial. Hand (N Y) 2022; 17:639-645. [PMID: 32757777 PMCID: PMC9274889 DOI: 10.1177/1558944720944263] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In a previous paper, we have demonstrated that: (1) local injection of corticosteroids for carpal tunnel syndrome (CTS) is as effective as decompressive surgery, at 1-year follow-up; and (2) surgery has an additional benefit in the 2-year follow-up. In this study, we assess the long-term outcomes of both therapies in an observational extension of the patients originally enrolled in our randomized clinical trial. Methods: Patients were included in an open, randomized clinical trial, comparing injections versus surgery in CTS. After the end of the clinical trial, patients received the treatment prescribed by their general practitioner or specialist. Therapeutic failure was defined as the need of any new therapeutic intervention on the involved wrist. Comparison between groups was made using Cox multiple regression analysis. Estimation of the accumulated incidence of new therapeutic failure was made considering the withdrawal as a competitive risk (Gooley's test). Results: Of 163 randomized wrists at the beginning of the study, only 148 were available at the final follow-up. The mean follow-up was 6.3 and the median was 5.9 years. In the long-term follow-up, the accumulated incidence of therapeutic failure in the surgery group was 11.6% versus 41.8% in the injection group. The Cox multiple regression analysis showed a risk of failure associated with injection group of 4.5 (95% confidence interval [CI], 2.1-9.8; P < .0001). Conclusions: In long-term follow-up, surgery seems more effective than local corticosteroid injections in primary CTS. Nonetheless, about 58% of the patients in the injection group will not need further therapeutic interventions during the follow-up.
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Affiliation(s)
- Domingo Ly-Pen
- Abbey House Medical Centre, Navan, Ireland,Domingo Ly-Pen, Abbey House Medical Centre, Abbey Road, Navan C15 D290, Co Meath, Ireland.
| | - José Luis Andreu
- Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Isabel Millán
- Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Gema de Blas
- Hospital Universitario Ramón y Cajal, Madrid, Spain
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15
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Kortlever JTP, Dekker AB, Ring D, Vagner GA, Reichel LM, Schuurman AH, Coert JH. Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow. J Hand Microsurg 2022; 14:170-176. [PMID: 36248236 PMCID: PMC9568369 DOI: 10.1055/s-0040-1718968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE. Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS ( N = 9,522), UNE ( N = 2,507), or both ( N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions. Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status. Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile. Level of Evidence Diagnostic; Retrospective Database Level III study.
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Affiliation(s)
- Joost T. P. Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Anne-Britt Dekker
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Gregg A. Vagner
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Lee M. Reichel
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Arnold H. Schuurman
- Department of Plastic Surgery and Hand Surgery, University Medical Center Utrecht–Utrecht University, Utrecht, The Netherlands
| | - J. Henk Coert
- Department of Plastic Surgery and Hand Surgery, University Medical Center Utrecht–Utrecht University, Utrecht, The Netherlands
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16
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Kirby D, Donnelly M, Buchalter D, Gonzalez M, Catalano L, Hacquebord J. Influence of Corticosteroid Injections on Postoperative Infections in Carpal Tunnel Release. J Hand Surg Am 2021; 46:1088-1093. [PMID: 34474948 DOI: 10.1016/j.jhsa.2021.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/25/2021] [Accepted: 06/30/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Corticosteroid injections (CSIs) are commonly used in carpal tunnel syndrome; however, recent literature has demonstrated risk of postoperative infection associated with preoperative CSIs in other orthopedic fields. The aim of this study was to assess the relationship of CSIs and postoperative infection following carpal tunnel release (CTR). METHODS A single-center retrospective review was conducted from 2010 to 2019 to identify patients who underwent CTR with subsequent antibiotic prescription for chart-documented wound infection. A demographically-matched cohort of 100 patients was identified for comparison. Information on patient demographics, comorbidities, injection history, and presence of postoperative infection was collected. RESULTS Thirty-nine patients (0.67% of all CTR patients) were identified with postoperative infections, 3 of which (0.05% of all CTR patients) were deep infections. In the infection cohort, 16 of 39 (41%) patients received an injection prior to surgery, whereas 16 of 100 (16%) patients in the control cohort received an injection. History of CSI was significantly more common in patients with postoperative infection, and patients in the infection cohort had a significantly shorter average time from injection to surgery by approximately 55 days. CONCLUSIONS Corticosteroid injections in the preoperative period are associated with postoperative infection after CTR. Proximity of injection to time of surgery plays a role, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.
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Affiliation(s)
- David Kirby
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York.
| | - Megan Donnelly
- Irvine School of Medicine, University of California, Irvine, California
| | - Daniel Buchalter
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Matthew Gonzalez
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Louis Catalano
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Jacques Hacquebord
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
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17
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Lo IN, Hsu PC, Huang YC, Yeh CK, Yang YC, Wang JC. Dynamic Ultrasound Assessment of Median Nerve Mobility Changes Following Corticosteroid Injection and Carpal Tunnel Release in Patients With Carpal Tunnel Syndrome. Front Neurol 2021; 12:710511. [PMID: 34512520 PMCID: PMC8432503 DOI: 10.3389/fneur.2021.710511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- I-Ning Lo
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, National Yang-Ming University, Taipei, Taiwan
| | - Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Yi-Chiang Yang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
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18
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Hosseini-Farid M, Schrier VJMM, Starlinger J, Amadio PC. Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1555-1568. [PMID: 33073880 PMCID: PMC8053734 DOI: 10.1002/jum.15535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity. METHODS A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion. RESULTS For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline. CONCLUSIONS This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.
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Affiliation(s)
- Mohammad Hosseini-Farid
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Computing and Engineering, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julia Starlinger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedics and Trauma Surgery, Medical University Vienna, Vienna, Austria
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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19
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Hosseini-Farid M, Schrier VJMM, Starlinger J, Zhao C, Amadio PC. Carpal tunnel syndrome treatment and the subsequent alterations in tendon and connective tissue dynamics. Clin Biomech (Bristol, Avon) 2021; 88:105440. [PMID: 34329857 PMCID: PMC8490321 DOI: 10.1016/j.clinbiomech.2021.105440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carpal tunnel syndrome patients demonstrate diminished motion of the median nerve and fibrotic changes in the subsynovial connective tissue within the carpal tunnel. Currently, there are few prognostic factors to help predict the outcome of commonly performed treatments including surgical carpal tunnel release and corticosteroid injections. This study aimed to non-invasively assess the changes in the dynamic response of the subsynovial tissue relative to tendon motion after the intervention and to correlate this with disease severity. METHODS A total of 145 patients with carpal tunnel syndrome were recruited into this study. Clinical and demographic data, electrophysiological severity and dynamic ultrasound images were collected before and after treatment, either by injection or surgery. The relative motion of the subsynovial tissue with the underlying middle finger flexor digitorum superficialis tendon was measured using a speckle tracking algorithm and was expressed as a shear index (SI). Baseline and follow-up data, the association between change in SI and severity, and the role of treatment modality were analyzed and statistically compared. FINDINGS Overall, there was a significant increase (more relative motion) after treatment in the mean shear index from 79.9% (±15.4% SD) to 82.9% (±14.8% SD) (p = 0.03). Secondary analyses showed that this change was mostly present in those with mild disease severity undergoing surgery (p = 0.01). INTERPRETATION This study shows that the relative subsynovial tissue movement increases in patients after intervention. The present study lays a foundation for future studies to non-invasively assess the role of carpal tunnel dynamics in response to treatment.
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Affiliation(s)
- Mohammad Hosseini-Farid
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; College of Computing and Engineering, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julia Starlinger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Medical University Vienna, Department of Orthopedics and Trauma Surgery, Vienna, Austria
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.
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20
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Ostergaard PJ, Hall MJ, Dowlatshahi AS, Harper CM, Rozental TD. Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection. J Hand Surg Am 2020; 45:986.e1-986.e9. [PMID: 32451202 DOI: 10.1016/j.jhsa.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 02/25/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery. METHODS We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention. RESULTS Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years. CONCLUSIONS In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Peter J Ostergaard
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Matthew J Hall
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Arriyan S Dowlatshahi
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carl M Harper
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tamara D Rozental
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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21
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Schrier VJMM, Brault JS, Amadio PC. Ultrasound-Guided Hydrodissection With Corticosteroid Injection in the Treatment of Carpal Tunnel Syndrome: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1759-1768. [PMID: 32255205 DOI: 10.1002/jum.15279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/04/2020] [Accepted: 03/13/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Corticosteroid injections can provide (temporary) relief in patients with mild to moderate carpal tunnel syndrome (CTS). Hydrodissection as part of an injection has been associated with positive clinical outcomes but data for CTS so far has been scarce. This study is designed to assess patient tolerance and secondarily provide pilot data on the added effect of hydrodissection. METHODS Twenty CTS patients were randomized to an ultrasound-guided betamethasone injection with hydrodissection (5 mL) or without (2 mL). Patient tolerance was assessed directly after intervention and patient-reported outcome after 4 and 24 weeks. Intra-group data were compared using Wilcoxon Signed Rank and inter-group with Wilcoxon rank-sum tests. RESULTS Tolerance and pain scores did not differ between the two groups. Symptom scores decreased in both groups, but to a lesser extent in the hydrodissection group with a mean difference of -0.8 versus -1.5 in the control group at 4 weeks (P = .02). At 6 months, this difference was no longer present (P = .81). No statistically significant differences were found between the hydrodissection and control groups in the function or pain scores at follow-up at either time point. CONCLUSION After injection, both symptomatic and functional scores improved, but the hydrodissected group did not show additional improvement. Data presented can be used to support larger studies to assess the value of hydrodissection in CTS management.
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Affiliation(s)
- Verena J M M Schrier
- Departments of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeffrey S Brault
- Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Departments of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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22
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Hsu PC, Liao KK, Lin KP, Chiu JW, Wu PY, Chou CL, Wang NY, Wang JC. Comparison of Corticosteroid Injection Dosages in Mild to Moderate Idiopathic Carpal Tunnel Syndrome: A Randomized Controlled Trial. Arch Phys Med Rehabil 2020; 101:1857-1864. [PMID: 32682938 DOI: 10.1016/j.apmr.2020.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/25/2020] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kwong-Kum Liao
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kon-Ping Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jan-Wei Chiu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pin-Yi Wu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Liang Chou
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Nin-Yi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming University, Taipei, Taiwan.
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23
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Asheghan M, Aghda AK, Sobhani V, Hashemi SE, Hollisaz MT. A randomized comparative trial of corticosteroid phonophoresis, local corticosteroid injection, and low-level laser in the treatment of carpal tunnel syndrome. Laser Ther 2020; 29:11-17. [PMID: 32904004 DOI: 10.5978/islsm.20-or-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/28/2019] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Mahsa Asheghan
- Baqiyatallah University of Medical Sciences, School of Medicine, Department of Physical Medicine and Rehabilitation
| | - Amidoddin Khatibi Aghda
- Shahid Sadoughi University of Medical Sciences, School of Medicine, Department of Physical Medicine and Rehabilitation
| | - Vahid Sobhani
- Baqiyatallah University of Medical Sciences, School of Medicine, Institute of life style, exercise physiology research center
| | - Seyed Ebrahim Hashemi
- Baqiyatallah University of Medical Sciences, School of Medicine, Department of Physical Medicine and Rehabilitation
| | - Mohammad Taghi Hollisaz
- Baqiyatallah University of Medical Sciences, School of Medicine, Department of Physical Medicine and Rehabilitation
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Urits I, Smoots D, Anantuni L, Bandi P, Bring K, Berger AA, Kassem H, Ngo AL, Abd-Elsayed A, Manchikanti L, Urman R, Kaye AD, Viswanath O. Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review. Pain Ther 2020; 9:129-142. [PMID: 32100225 PMCID: PMC7203307 DOI: 10.1007/s40122-020-00158-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Daniel Smoots
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Lekha Anantuni
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Prudhvi Bandi
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Katie Bring
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Anh L Ngo
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
- Harvard Medical School, Boston, MA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Richard Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Li G, Kong L, Kou N, Wang Y, Yu K, Bai J, Tian D. The comparison of limited-incision versus standard-incision in treatment of carpal tunnel syndrome: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e15372. [PMID: 31045782 PMCID: PMC6504321 DOI: 10.1097/md.0000000000015372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. Compared with standard release, the efficacy, safety, and postoperative complications of limited carpal tunnel release remain controversial. The purpose of this study was to compare the effects of the 2 treatments. METHODS The English-language literature was searched using MEDLINE, Web of Science, and Embase. Randomized controlled trials that compared standard and limited incision for carpal tunnel release were included in the meta-analysis. Strength, interval to return to activities, the rate of adverse events, effectiveness, and operative time were compared. RESULTS Thirteen randomized controlled trials (RCTs) containing 1020 patients were included. Limited incision treated patients showed better early recovery of grip strength (mean difference [MD], 4.25 [0.86-7.65]; P = .01) and pinch strength (MD, 1.37 [0.24-2.51]; P = .02) but no advantage after more than 6 months. Patients treated with limited incision showed an earlier return to activities (MD,-8.80 [-9.21 to -8.39]; P < .01) and reduced operative time (standardized mean difference [SMD], -1.68 [-3.24 to-0.12]; P = .04). The rate of adverse event was significantly higher in standard group compared with that in limited group (risk ratio [RR] 0.61, 95% CI 0.38-0.96, P = .03). CONCLUSIONS Limited incision release allows us to return to activities early, reduces operative time, decreases rate of adverse events, and improves strength during the early postoperative period. Results at 6 months or longer are similar according to current data. However, the results of this meta-analysis should be interpreted with caution due to heterogeneity amongst the included studies.
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Affiliation(s)
- Gaocen Li
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang
| | - Lingde Kong
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang
| | | | - Yanxue Wang
- Department of Pharmacy, Ningjin County Hospital of Hebei Province, Xingtai, Hebei, PR China
| | - Kunlun Yu
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang
| | - Jiangbo Bai
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang
| | - Dehu Tian
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang
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Abstract
BACKGROUND Over 500 000 carpal tunnel releases costing over $2 billion are performed each year in the United States. The study's purpose is to perform a cost-minimizing analysis to identify the least costly strategy for carpal tunnel syndrome treatment utilizing existing success rates based on previously reported literature. METHODS We evaluate the expected cost of various treatment strategies based on the likelihood of further treatments: (1) a single steroid injection followed by surgical release; (2) up to 2 steroid injections before surgical release; (3) 3 steroid injections before surgery, and (4) immediate surgical release. To reflect costs, we use our institution's billing charges to private payers and reimbursements from Medicare. A range of expected steroid injection success rates are employed based on previously published literature. RESULTS Immediate surgical release is the costliest treatment with an expected cost of $2149 to $9927 per patient. For immediate surgical release to cost less than a single injection attempt, the probability of surgery after injection would need to exceed 80% in the Medicare reimbursement model and 87% in the institutional billing model. A single steroid injection with subsequent surgery, if needed, amounts to a direct cost savings of $359 million annually compared with immediate surgical release. Three injections before surgery, with "high" expected success rates, represent the cost-minimizing scenario. CONCLUSIONS Although many factors must be considered when deciding upon treatment for carpal tunnel syndrome, direct payer cost is an important component, and the initial management with steroid injections minimizes these direct payer costs.
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Affiliation(s)
| | - Adnan Karim
- NYU Langone Orthopedic Hospital, New
York, USA
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Jerosch-Herold C, Shepstone L, Houghton J, Wilson ECF, Blake J. Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study. Muscle Nerve 2019; 60:32-40. [PMID: 30815889 DOI: 10.1002/mus.26459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/18/2019] [Accepted: 02/24/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Studies of prognosis for surgery and corticosteroid injection for carpal tunnel syndrome (CTS) have considered only a limited range of explanatory variables for outcome. METHODS Data were prospectively collected on patient-reported symptoms, physical and psychological functioning, comorbidity, and quality of life at baseline and every 6 months for up to 2 years. Outcomes were patient-rated change over a 6-month period and symptom-severity score at 18 months. RESULTS In total, 754 patients with CTS completed baseline questionnaires, and 626 (83%) completed follow-up to 18 months. Multivariable modeling identified, independent of symptom severity at outset, higher health utility, fewer comorbidities, and lower anxiety as significant predictors of better outcome from surgery. In patients treated by steroid injection, independent of symptom severity at outset, shorter duration of symptoms and having no prior injection were significant predictors of better outcome. DISCUSSION These multivariable models of outcome may inform shared decision making about treatment for CTS. Muscle Nerve, 2019.
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Affiliation(s)
- Christina Jerosch-Herold
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, United Kingdom
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Julie Houghton
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, United Kingdom
| | - Edward C F Wilson
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Julian Blake
- Department of Neurophysiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
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Burton CL, Chesterton LS, Chen Y, van der Windt DA. Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care. Clin Epidemiol 2018; 10:739-748. [PMID: 29988741 PMCID: PMC6029610 DOI: 10.2147/clep.s154409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve. This study investigated the value of candidate prognostic factors (PFs) in predicting carpal tunnel release surgery. Patients and methods This is a retrospective cohort study set in the Clinical Practice Research Datalink. Patients ≥18 years presenting with an incident episode of CTS were identified between 1989 and 2013. Candidate PF’s defined in coded electronic patient records were identified following literature review and consultation with clinicians. Time to first carpal tunnel release surgery was the primary end point. A manual backward stepwise selection procedure was used to obtain an optimal prediction model, which included all the significant PFs. Results In total, 91,412 patients were included in the cohort. The following PFs were included in an optimal model (C-statistic: 0.588 [95% CI 0.584–0.592]) for predicting surgical intervention: geographical region; deprivation status; age hazard ratio (HR 1.02 per year, 95% CI 1.01–1.02); obesity (HR 1.23, 95% CI 1.19–1.27); alcohol drinker (HR 1.05, 95% CI 1.00–1.10); smoker (HR 1.06, 95% 1.03–1.10); inflammatory condition (HR 1.13, 95% CI 0.98–1.29); neck condition (HR 1.13, 95% CI 1.03–1.23); and multisite pain (HR 1.10, 95% CI 1.05–1.15). Although not included in the multivariable model, pregnancy (if gender female) within 1 year of the index consultation, reduced the risk of surgery (HR 0.24, 95% CI 0.21–0.28). Conclusion This study shows that patients who are older and who have comorbidities including other pain conditions are more likely to have surgery, whereas patients presenting with CTS during or within a year of pregnancy are less likely to have surgery. This information can help to inform clinicians and patients about the likely outcome of treatment and to be aware of which patients may be less responsive to primary care interventions.
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Affiliation(s)
- Claire L Burton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK,
| | - Linda S Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK,
| | - Ying Chen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK,
| | - Danielle A van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK,
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Sonoo M, Menkes DL, Bland JD, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: Do they add value? Clin Neurophysiol Pract 2018; 3:78-88. [PMID: 30215013 PMCID: PMC6133914 DOI: 10.1016/j.cnp.2018.02.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/31/2022] Open
Abstract
This paper summarises the views of four experts on the place of neurophysiological testing (EDX) in patients presenting with possible carpal tunnel syndrome, in guiding their treatment, and in reevaluations. This is not meant to be a position paper or a literature review, and heterogeneous viewpoints are presented. Nerve conduction studies should be performed in patients presenting with possible carpal tunnel syndrome to assist diagnosis, and may need to be repeated at intervals in those managed conservatively. There is evidence that local corticosteroid injection is safe and effective for many patients, thereby avoiding or deferring surgical decompression. All patients should undergo EDX studies before any invasive procedure for CTS (injection or surgery). Needle EMG studies are not obligatory, but may be needed in those with severe disease and those in whom an alternate or concomitant diagnosis is suspected.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo 1738605, Japan
| | - Daniel L. Menkes
- Department of Neurology, Beaumont Health, Beaumont Neuroscience Building, Royal Oak, MI 48073, United States
| | - Jeremy D.P. Bland
- East Kent Hospitals University NHS Foundation Trust, Ethelbert Road, Canterbury, Kent, UK
| | - David Burke
- Department of Neurology, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
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