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

Comparison of the Impact of Out-of-plane and In-plane Injection Approaches on Injection Pain and Functionality in Patients With Carpal Tunnel Syndrome Undergoing Ultrasound-guided Injection: A Patient- and Assessor-blinded Randomized Study

OBJECTIVES

To compare the out-of-plane (OP) and in-plane (IP) approaches for carpal tunnel syndrome (CTS) in terms of pain during injection and postinjection adverse effects, and to investigate whether these approaches led to any difference in terms of pain/numbness, symptom severity, functionality, and median nerve cross-sectional area and to examine the relationship of these parameters with the pain during injection.

DESIGN

Patient/assessor-blinded randomized study.

SETTING

Hospital outpatient clinic.

PARTICIPANTS

Fifty patients with mild-to-moderate CTS.

INTERVENTIONS

The participants were randomized into OP and IP (both n=25) ultrasound-guided injection groups.

MAIN OUTCOME MEASURES

Each patient reported the pain felt during the injection at 1 hour thereafter, and also any adverse effects at 4 weeks after injection. Before and 4 weeks after injection, patients used a visual analog scale to indicate pain/numbness; symptom severity and functionality were assessed using the Boston Carpal Tunnel Syndrome Questionnaire. The cross-sectional area of the median nerve was also obtained.

RESULTS

The average pain during injection was 2.64±0.82 in the IP group and 1.96±0.86 in the OP group (P=.017). Postinjection adverse effects were similar between the 2 groups (P<.05). After injection, the percentage change in symptom severity was 49.8±11.8 in the IP group and 40.6±11.5 in the OP group (P=.008). In the IP group, day preinjection pain/numbness, night pain/numbness percentage change scores, and symptom severity percentage change scores were moderately correlated with the pain during injection (r=.439, .469, and .429, respectively).

CONCLUSIONS

IP injection caused greater pain during injection than OP injection and led to greater reduction in symptom severity at 1 month after injection. In that group, injection pain was associated with the baseline day pain score, change in night pain score, and change in symptom severity score.

Comparison of Comfort and Patient Preference of Common and a Novel Position for Ultrasound-Guided Carpal Tunnel Injections

OBJECTIVES

This study compared levels of discomfort among three positions for ultrasound-guided carpal tunnel injections (USCTI) to potentially facilitate and improve the procedure's tolerability in treating carpal tunnel syndrome (CTS).

METHODS

Ambulatory Veterans referred for electromyography (EMG) evaluation of CTS were eligible for the study; a total of 30 participants were evaluated. Participants were asked to hold three different positions: 1) Hypersupination, 2) Airplane, and 3) total supported abduction (TSA). Participants rated their pain level, ease of performing/holding each position, exacerbation of underlying symptoms, and position preference. Results were analyzed with two-way repeated measures ANOVA.

RESULTS

Hypersupination was determined to be the least preferred and most painful position to hold, demonstrating a statistically significant increase in the Numeric Rating Scale score for pain during the procedure compared with Airplane and TSA, which were not significantly different from one another. Pre-procedure neck, shoulder, elbow, and wrist pain were not significantly associated with intra-procedure pain.

CONCLUSIONS

When performing USCTI, patient comfort can be optimized by avoiding Hypersupination. Utilizing the Airplane or TSA positions may provide similar access for ulnar approach injections while inducing lower levels of discomfort. Clinical space, resources, patient mobility, and laterality of procedures may further guide one's selection among the positions.

Long-term Efficacy of Corticosteroid Injection for Carpal Tunnel Syndrome: A Systematic Review

Carpal tunnel syndrome (CTS) is a debilitating condition that can cause significant morbidity. Corticosteroid injection (CI) is a popular treatment for CTS. Short-term benefits of CI for CTS have been reported, but there is little evidence on long-term outcomes. We performed a systematic review in the PubMed/MEDLINE and Cochrane Library databases to identify studies which reported outcomes of CI for CTS with at least 1-year follow-up. We identified 20 total studies and extracted data on outcomes such as number of patients needing eventual surgery or reinjection, complications, and functional scores. In included studies, 41.6% of patients underwent eventual carpal tunnel release surgery (CTRS), 29% underwent reinjection, there were no major and approximately 34/1133 (3.0%) minor complications, and median/mean time from CI to eventual CTRS ranged from 128 to 446 days. There was disparity on the long-term efficacy of CI for functional outcomes. The evidence indicates that CI is a very low risk procedure that has potential to improve symptoms enough to either prevent or, in most cases, delay the need for further reintervention. However, our conclusions are limited by the heterogeneity of available studies. There is a need for further, high-quality research on this topic.

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVES

To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).

METHODS

European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.

RESULTS

A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.

CONCLUSION

These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

Clinical Value Analysis of High-Frequency Ultrasound Combined with Carpal Dorsiflexion Electrophysiological Detection in the Diagnosis of Early Carpal Tunnel Syndrome

Objective

To investigate the clinical value of ultrasound combined with electrophysiological examination in the diagnosis of early carpal tunnel syndrome, we aimed to provide a new EMG (electromyography) method for detecting early carpal tunnel syndrome by exploring the wrist back stretch position and electrophysiological examination.

Methods

For the 82-lateral wrist (case group) of 62 patients with clinical symptoms or confirmed carpal tunnel syndrome and 40 normal healthy patients, neuroelectrophysiological measurements were performed using a Keypoint6.0 EMG evoked potentiometer, measuring each group twice: conventional position (before compression) and dorsal wrist extension position. The measures for each measurement included DSL, DML, and CAMP. Measure sensory conduction first and then measure motor conduction. The measurements were analyzed in a comprehensive comparative analysis. Combined ultrasound examination, the positive rate of combined ultrasound examination and electrophysiological examination was compared, respectively.

Results

In the carpal tunnel syndrome (CTS) group, the anterior and posterior median nerve DSL was (4.27 ± 0.73) ms and (4.82 ± 0.65) ms, and SNAP was (13.32 ± 13.68) UV and (12.19 ± 11.04) UV; the median nerve (wrist-bunions) DML was (5.29 ± 1.26) ms and (5.54 ± 1.29) ms, and CMAP was (6.44 ± 2.40) mV and (6.21 ± 2.46) mV. Mid-median DSL and DM in the CTS group L were significantly longer than before compression; median nerve SNAP and CMAP were significantly reduced compared with before compression.

Conclusion

Electrophysiological testing at the dorsal carpal extension position has high diagnostic value in the diagnosis of mild carpal tunnel syndrome. It helps to improve the diagnostic rate of early carpal tunnel syndrome, while providing a more accurate and effective EMG detection of early carpal tunnel syndrome, and combination examination of neuroelectrophysiology and ultrasound can improve the diagnosis rate of compression peripheral nerve diseases and clarify the site, nature, and scope of compression lesions, which is worthy of clinical application.

Ultrasound-guided carpal tunnel injections

Background

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

Conclusions

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

Value of imaging to guide interventional procedures in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

OBJECTIVES

To summarise current data on the value of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal disease (RMDs) informing an European Alliance of Associations for Rheumatology taskforce.

METHODS

A systematic literature review was conducted to retrieve prospective and retrospective studies published in English and comparing different (imaging) techniques, different settings and procedural protocols to guide interventions in patients with RMDs. MEDLINE, EMBASE, the Cochrane Library and Epistemonikos databases were searched through October 2021. Risk of bias (RoB) was assessed using the Cochrane RoB tool for randomised trials V.2 (ROB2), the RoB tool for Non-Randomised Studies of Interventions and the appraisal tool for cross-sectional studies.

RESULTS

Sixty-six studies were included (most with moderate/high RoB); 49 were randomised controlled trials, three prospective cohort studies and 14 retrospective studies. Fifty-one studies compared either one imaging technique with another imaging technique, or with palpation-guided interventions. Ultrasound (US) was most frequently studied (49/51), followed by fluoroscopy (10/51). Higher accuracy was found for US or fluoroscopy compared with palpation-guided interventions. Studies comparing different imaging techniques (12/51) did not endorse one specific method. Different settings/equipment for imaging-guided procedures (eg, automatic vs manual syringes) were investigated in three studies, reporting heterogeneous results. Fifteen studies compared different imaging-guided procedures (eg, intra-articular vs periarticular injections).

CONCLUSION

Higher accuracy of needle positioning at joints and periarticular structures was seen in most studies when using imaging (especially US) guidance as compared with palpation-guided interventions with the limitation of heterogeneity of data and considerable RoB.

Application of digital infrared thermography for carpal tunnel syndrome evaluation

We investigated the thermographic findings of carpal tunnel syndrome (CTS). We enrolled 304 hands with electrodiagnostically identified CTS and 88 control hands. CTS hands were assigned to duration groups (D1, < 3 months; D2, 3‒6 months; D3, 6‒12 months; D4, ≥ 12 months) and severity groups (S1, very mild; S2, mild; S3, moderate; S4, severe). The temperature difference between the median and ulnar nerve territories (ΔM-U territories) decreased as CTS duration and severity increased. Significant differences in ΔM-U territories between the D1 and D3, D1 and D4, D2 and D4, and S1 and S4 groups (P = 0.003, 0.001, 0.001, and < 0.001, respectively) were observed. Thermal anisometry increased as CTS duration and severity increased. Significant differences in thermal anisometry between the D1 and D4 as well as the D2 and D4 groups (P = 0.005 and 0.04, respectively) were noted. Thermal anisometry was higher in the S4 group than in the S1, S2, and S3 groups (P = 0.009, < 0.001, and 0.003, respectively). As CTS progresses, skin temperature tends to decrease and thermal variation tends to increase in the median nerve-innervated area. Thermographic findings reflect the physiological changes of the entrapped median nerve.

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

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