Predictive Variables for Sonographically Guided Corticosteroid Injection in Mild-to-Moderate Carpal Tunnel Syndrome

What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review

BACKGROUND

Cortico-Steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain.

OBJECTIVES

To identify factors that influence improvements in pain for patients with GTPS treated with CSI.

DESIGN

Systematic review.

METHODS

A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion if they investigated factors that influenced changes in pain experienced by patients with GTPS who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk Of Bias 2 (ROB2) tools were used to assess bias.

RESULTS

The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores.

CONCLUSIONS

Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance.

Outcome predictors of platelet-rich plasma injection for moderate carpal tunnel syndrome

INTRODUCTION

Platelet-rich plasma (PRP) injection is effective for mild-to-moderate carpal tunnel syndrome (CTS), and physicians have been using PRP injections to treat CTS. However, the predictive factors of PRP injections have not been evaluated. This retrospective study sought to identify the predictive factors of PRP injections in patients with moderate CTS.

METHODS

Seventy-one patients with moderate CTS receiving single PRP injections were enrolled. The outcomes at the third- and sixth-month postinjection visits were categorised into good and poor groups according to the following: (1) good outcome, with visual analogue scale (VAS) score decrease ≧50% and (2) poor outcome, with VAS score decrease <50% of preinjection scores. Significant variables between groups were entered into a binary logistic regression to determine the predictive factors.

RESULTS

The baseline body weight (BW), distal motor latency (DML), sensory nerve conduction velocity (SNCV), and cross-sectional area (CSA) of the median nerve were significantly different between the groups in the third month. The odds ratios (ORs) of all features were significant, except for SNCV (BW, OR: 0.911; P = .016; DML, OR: 0.383; P = .028; CSA, OR: 0.694; P = .003), and they remained significant in the sixth month (BW, OR: 0.909; P = .004; DML, OR: 0.530; P = .011; CSA, OR: 0.828; P = .032).

CONCLUSION

Lower BW, DML, and CSA values of the median nerve predict better outcomes after perineural injection of PRP for moderate CTS at the 3- and 6-month follow-ups.

Prognostic factors in carpal tunnel syndrome treated with 5% dextrose perineural injection: A retrospective study

Background: Perineural injection therapy with 5% dextrose water (D5W) is a potential and innovative treatment with long-term efficacy for carpal tunnel syndrome (CTS). However, the prognostic factors of this management are lacking; hence, the aim of this retrospective study was to identify the prognostic factors of D5W perineural injection therapy for mild-to-moderate CTS. Methods: A total of 52 patients (52 wrists) diagnosed with mild-to-moderate CTS and treated with a single ultrasound-guided 5cc D5W perineural injection were retrospectively reviewed. Patient-reported injection outcomes (visual analog scale, VAS) at 6 months post-injection were categorized into two groups; (1) Good outcome, when symptom relief ≥50% compared to pre-injection and (2) Poor outcome, when symptom relief < 50% compared to pre-injection. Significant variables between groups were entered into a binary logistic regression with forward stepwise regression to determine the prognostic factors for these outcomes. Results: The treatment outcome was significantly related to body height and sensory nerve conduction velocity (SNCV) (159.1 ± 1.0 vs. 155.0 ± 1.8, p=0.04; 33.6 ± 0.8 vs. 28.3 ± 1.2, p=0.001, good vs. poor outcomes). However, only SNCV remained significantly correlated with the outcomes after conducting stepwise logistic regression (ORs: 1.201; 95% CI 1.05-1.38; p=0.01). Conclusions: SNCV was found to be a significant prognostic factor of treatment outcome for patients with mild-to-moderate CTS 6 months after a D5W perineural injection.

High-resolution ultrasonography in carpal tunnel syndrome: role of ancillary criteria in diagnosis and response to steroid injection

OBJECTIVES

(1) Development and validation of a composite ultrasound score (cUSS) for the diagnosis of carpal tunnel syndrome (CTS). (2) To predict treatment response after local corticosteroid injection.

METHODS

Wrists of CTS patients and controls were evaluated with high-resolution ultrasound and cross-sectional area of median nerve at carpal tunnel inlet (CSAp) and outlet (CSAd) and bowing of flexor retinaculum (FRB), flexor tenosynovitis, and intraneural vascularity and echogenicity changes were noted. Patients were prospectively followed after ultrasound-guided corticosteroid injection.

RESULTS

We studied 479 wrists of 141 patients and 99 controls. Optimal cut-offs for diagnosing CTS were 9.5 mm² and 10.5 mm², respectively, for CSAp and CSAd. A cUSS consisting of the following parameters was developed: age, CSAp, CSAd, FRB, and flexor tenosynovitis and echogenicity changes. External validation of cUSS yielded sensitivity, specificity, and diagnostic accuracy of 91.7%, 87.1%, and 89.8%, respectively. Treatment responses from 88 injections (median duration of follow-up of 6 months) were available with satisfactory initial responses in 69.32% (61/88) and relapses in 30.86% (25/81). Median time to relapse was 2 months. Initial response was predicted by FRB (odds ratio (OR): 5.43, 95% confidence interval (CI): 1.45-20.3, p = 0.012). Relapse was predicted by age (hazard ratio (HR) 1.168, 95% CI: 1.076-1.268, p = 0.0002), male gender (HR: 8.1.02, 95% CI: 2.394-27.422, p = 0.0007), FRB, (HR: 46.982, 95% CI: 5.048-437.293, p = 0.0008), and higher body mass index (HR: 0.238, 95% CI: 0.064-0.892, p = 0.0332).

CONCLUSIONS

The developed cUSS has a diagnostic accuracy of 88% for diagnosing CTS. Ultrasound parameters could predict both initial treatment response and relapse.

KEY POINTS

• Anatomical ultrasound parameters in addition to nerve cross-sectional area is important for diagnosis of CTS. • A composite US score for diagnosis of CTS was developed with accuracy 88.6%. • Bowing of flexor retinaculum predicts short and long term response to local steroid injection.

Etiopathogenic Value of the Associated Pathology in Carpal Tunnel Syndrome

The present study focused on highlighting the pathology associated with carpal tunnel syndrome. Carpal tunnel syndrome is a susceptible neuropathy of the upper limb, its appearance being favored by the coexistence of other chronic pathologies.

The study group consisted of 163 patients treated in the Plastic Surgery Clinic of the Emergency County Hospital in Constanţa, men and women of adulthood. The only exclusion criteria was non-compliant patients.

The results were consistent with other studies published in the literature, with an over three times higher incidence of female sex.

The decades of age most prone to the disease were the fourth, fifth, and sixth.

Approximately one third of patients experienced bilateral carpal tunnel syndrome.

A particularly important presence of the triad was found: hygh blood pressure, obesity and diabetes mellitus, at least one of which was present in over 70% of patients.

The etiopathogenicity of the carpal tunnel syndrome is becoming clearer, the “Golden Trio” dominating the clinical picture in most patients.

Medical Ultrasound in the Evaluation of the Carpal Tunnel: A Critical Review

The use of medical ultrasound as an imaging modality in the evaluation of the carpal tunnel syndrome has been growing. Technical progress and the introduction of new, high-quality devices and ultra-high frequency transducers with smaller dimensions have led to a better quality of acquired images and the development of new examination methodologies. The sonographic method has a number of advantages: available, non-invasive, cheaper, and allows an easier and faster evaluation and diagnosis of carpal tunnel syndrome, along with the possibility to assess various parameters of the median nerve, including its size, blood flow, and mobility. In addition, medical ultrasound may be used to detect anatomical variations and space-occupying lesions in the carpal tunnel to monitor the therapeutic response in patients suffering from carpal tunnel syndrome and to evaluate median nerve injuries. Herein, we present a review of the pertinent literature with regard to the diagnostic potential of medical ultrasound in the evaluation of pathological changes in the carpal tunnel.