Comparing The Efficacy Of Local Triamcinolone Injection In Carpal Tunnel Syndrome Using Three Different Approaches with or without Ultrasound Guidance

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.

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.

Local corticosteroid injection versus placebo for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated.

OBJECTIVES

To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection.

SEARCH METHODS

We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8.

ADVERSE EVENTS

We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events.

AUTHORS' CONCLUSIONS

Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.

Effect of ultrasound-guided versus landmark-guided local corticosteroid injection for carpal tunnel syndrome: a systematic review and meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS), the commonest neuropathy of the upper limb, can be managed with different therapeutic approaches. Local corticosteroid injection has been adopted widely in clinical practice, as it showed great efficacy in treating CTS. However, the best injection technique continues to be a subject of controversy. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) corticosteroid injection on the clinical and electrophysiological outcomes in patients with CTS.

METHODS

We performed a systematic literature search in Medline, Embase, and CENTRAL, from which we included randomized controlled trials (RCTs) that compared US-guided and LM-based corticosteroid injection in treating individuals with CTS. We evaluated the following outcomes: Boston carpal tunnel questionnaire functional status scale (BCTQ-FSS) and symptom severity scale (BCTQ-SSS), and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes, while the risk ratio (RR) was used to represent dichotomous outcome.

RESULTS

A total of 8 RCTs that enrolled 500 wrists were deemed eligible. US-guided injection showed a significantly better BCTQ-FSS (SMD = -0.22, 95% CI -0.39 to -0.04), BCTQ-SSS (SMD = -0.77, 95% CI -1.22 to -0.31), and adverse event rate (RR = 0.32, 95% CI 0.21 to 0.49) compared to LM-based injection.

CONCLUSION

This meta-analysis showed the superiority of US-guided corticosteroid injection over LM-guided corticosteroid injection in enhancing functional status, improving symptom severity, and reducing the adverse event rate in individuals with CTS.

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.

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.

Ring finger sensory latency difference in the diagnosis and treatment of carpal tunnel syndrome

Objective

To explore the sensitivity of median and ulnar nerve sensory latency differences in diagnosing carpal tunnel syndrome (CTS) at different severities.

Methods

CTS patients were divided into three groups based on disease severity (mild, moderate, and severe). Distal latency of sensory nerve action potential (SNAP) for the median and ulnar nerves was recorded. The sensitivity of SNAP distal latency to CTS and its correlation with CTS severity were analyzed.

Results

Significant differences were found in the median nerve sensory action potential distal latency (MSDL) and in the median and ulnar sensory latency difference to ring finger (MUD) but not in the ulnar nerve sensory action potential distal latency (USDL) between CTS and control. The sensitivity and specificity were 92.2 and 99.4% with an MSDL cutoff value of 2.40 ms, respectively, and were both 100% with a MUD cutoff value of 0.33 ms. There was no significant difference in USDL among the CTS and control groups. Significant differences were found in MSDL and MUD among the CTS severities and between mild and moderate CTS, but not between mild and severe CTS or between moderate and severe CTS. Correlations with CTS severity were observed for MSDL and MUD but not for USDL.

Conclusion

The ulnar nerve of the CTS patients was not damaged. A smaller MSDL reflected median nerve damage, which can be used for the early diagnosis of CTS. MUD correlated with CTS severity with a higher sensitivity than MSDL, which can provide therapeutic insight without pain to patients.

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.

Ultrasound-guided local corticosteroid injection for carpal tunnel syndrome: A meta-analysis of randomized controlled trials

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) local corticosteroid injection for carpal tunnel syndrome (CTS).

METHODS

Database including Pubmed, Embase, and Cochrane Library were searched to identify relevant randomized controlled trials (RCTs). The outcomes mainly included Boston Carpal Tunnel Questionnaire (BCTQ): Symptom Severity Scale (BCTQs), Functional Status Scale (BCTQf); and electrophysiological indexes: distal motor latency (DML), sensory distal latency (SDL), compound muscle action potential (CAMP), sensory nerve action potential amplitude (SNAP), and sensory nerve conduction velocity (SNCV). Adverse events were also recorded.

RESULTS

Overall, nine RCTs were finally screened out with 469 patients (596 injected hands). Pooled analysis showed that US-guided injection was more effective in BCTQs (SMD, -0.69; 95% CI, -1.08 to -0.31; P = 0.0005), BCTQf (SMD, -0.23; 95% CI, -0.39 to -0.07; P = 0.005), CAMP (MD, 0.64; 95% CI, 0.35-0.94; P < 0.0001) improvement, and a lower rate of adverse events (RR, 0.34; 95% CI, 0.22-0.52; P < 0.00001). Subgroup analysis revealed that the US-guided injection had significantly better CMAP than the LM-guided for the in-plane approach (MD, 0.69; 95% CI, 0.36-1.01; P < 0.0001) but not for the out-plane approach (MD, 0.39; 95% CI, -0.39 to 1.17; P = 0.33).

CONCLUSIONS

US-guided injection was superior to LM-guided injection in symptom severity, functional status, electrodiagnostic, and adverse events improvement for CTS. To some extent, the in-plane approach yields better results compared with the out-plane process under US guidance.

Ultrasound-guided corticosteroid injection for patients with carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials

Carpal tunnel syndrome (CTS) refers to the symptoms and signs caused by the compression of the median nerve in the carpal tunnel. It can be treated by corticosteroid injection into the carpal tunnel. Two methods for injection have been employed, namely ultrasound-guided and landmark-guided injection. This systematic review and meta-analysis was conducted to compare these methods in terms of several outcomes. A search of the PubMed, Cochrane Library, and Embase databases was performed from the date of their inception to October 7, 2020 to identify randomized controlled trials (RCTs). Results for continuous variables are expressed as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. The analysis included eight RCTs published between 2013 and 2019 with a total of 448 patients. Ultrasound-guided injection yielded more favorable results than landmark-guided injection for the Boston Carpal Tunnel Syndrome Questionnaire, Symptom Severity Scale [SMD =  − 0.43, 95% CI (− 0.68, − 0.19), P = 0.0005] and Boston Carpal Tunnel Syndrome Questionnaire, Functional Status Scale [SMD =  − 0.50, 95% CI (− 0.84, − 0.15), P = 0.005]. Ultrasound-guided corticosteroid injection is recommended for patients with CTS.

Comparison of short- and long-axis nerve hydrodissection for carpal tunnel syndrome: A prospective randomized, single-blind trial

Background: This study is to compare the efficacy of short-axis hydrodissection with long-axis hydrodissection for patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: Forty-seven patients with mild-to-moderate CTS were enrolled in a prospective, randomized, single-blinded, controlled trial (6 months follow-up). With ultrasound guidance, patients in both groups (short-axis or long-axis groups) were injected with normal saline (5 mL per session). Assessments were performed before and 2 weeks after the injection, as well as at 1, 3, and 6 months post-intervention. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score and secondary outcomes included the cross-sectional area of the median nerve and electrophysiological studies. Results: Forty-four patients (21 wrists in the short-axis group and 23 wrists in the long-axis group) completed the study. Compared with the baseline, both groups showed improved BCTQ and cross-sectional area at all follow-up assessments (p<0.05). The short-axis group was not more effective except significant improvements in BCTQ-severity and BCTQ-function 1 month post-injection compared to the long-axis group (p = 0.031 and p = 0.023, respectively). Conclusions: Both short- and long-axis hydrodissection were effective for patients with mild-to-moderate CTS and the short-axis approach was not more effective than long-axis injection. Further studies with larger sample sizes, multiple injections, and larger injection volume are encouraged in the future.

Beliefs, attitude, and knowledge of the Iranian physiatrists towards neuromusculoskeletal ultrasound and common barriers in its application

Background

Regarding the increasing application of neuromusculoskeletal sonography among medical specialties, specifically physiatrists, this study aims to assess the knowledge and skill level of these specialists in neuromusculoskeletal sonography in Iran.

Methods

This descriptive, cross-sectional study was performed in 2018. The utilized questionnaire developed based on previous studies in collaboration with 6 university lecturers of Shaheed Beheshti, Iran, and Tabriz medical universities and a physiatrist from Hacettepe University (Turkey); it included questions entailing demographic data, knowledge, and performance levels. Its validity and reliability were evaluated through face validation, pilot study, and the Cronbach α calculated via SPSS. Data extraction and analysis were also performed by SPSS-25.

Results

Of 364 questionnaires distributed, 300 were properly filled and entered into the study, of which, 38% were filled by clinical residents, 10% university lecturers, and 52% other categories (e.g. private sector).

The average number of musculoskeletal patient visits was 140.6 ± 119 and the mean number of musculoskeletal sonographies requested was 8.2 ± 5.2 per month (the three most common indications reported as the shoulder, carpal tunnel syndrome, and tendon injuries).

95% of the participants considered the importance of sonography for physiatrists to be “very high” or “high”; with the most valuable applications “as a guide for procedures (90%), its diagnostic utility (68%), and follow up/evaluating the response to treatment (45%). 86% of physiatrists reported they had participated in musculoskeletal sonography courses, 60% during residency, and the rest through workshops.

Also, the participants mentioned safety (83%), the possibility of performing simultaneous diagnosis and intervention procedures (70%), repeatability (58%), and dynamic imagery (52%) as the major advantages of musculoskeletal ultrasound.

Conclusion

a large number of doctors consider musculoskeletal sonography to be essential for physiatrists, though insufficient education on the subject and the low number of ultrasound devices are some of the obstacles in enhancing the use of this technology in PM&R setting. Presenting certified specific training courses during residency, provision of necessary rotations, using the capacities of the PM&R scientific committee, and the private sector for running workshops and professional training courses are suggested for enhancing the knowledge and skills of neuromusculoskeletal sonography.