Ann Rehabil Med.  2018 Apr;42(2):213-221. 10.5535/arm.2018.42.2.213.

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

• Chung SY
• Kwak JM
• Kang S
• Son SH
• Kim JD
• Yoon JS

• KMID: 2432191
• DOI: http://doi.org/10.5535/arm.2018.42.2.213

Abstract

OBJECTIVE
To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome.
METHODS
A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome.
RESULTS
The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving.
CONCLUSION
The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.

Keyword

Carpal tunnel syndrome; Ultrasonography; Corticosteroids; Treatment outcome

MeSH Terms

Adrenal Cortex Hormones
Carpal Tunnel Syndrome*
Humans
Median Nerve
Neural Conduction
Observational Study
Prognosis
Prospective Studies
Treatment Outcome
Ultrasonography
Wrist
Adrenal Cortex Hormones

Figure

• 

  Fig. 1 Sonographically guided corticosteroid injection. (A) Needle is inserted parallel to carpal ligament. (B) Arrow with dotted line indicates median nerve; arrowheads indicate inserted needle.

Reference

1. Wong SM, Griffith JF, Hui AC, Tang A, Wong KS. Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis Rheum. 2002; 46:1914–1921. PMID: 12124876.

2. Buchberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: diagnosis with high-resolution sonography. AJR Am J Roentgenol. 1992; 159:793–798. PMID: 1529845.

3. Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol. 1999; 173:681–684. PMID: 10470903.

4. Pastare D, Therimadasamy AK, Lee E, Wilder-Smith EP. Sonography versus nerve conduction studies in patients referred with a clinical diagnosis of carpal tunnel syndrome. J Clin Ultrasound. 2009; 37:389–393. PMID: 19479718.

5. Uchiyama S, Itsubo T, Nakamura K, Kato H, Yasutomi T, Momose T. Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation. J Orthop Sci. 2010; 15:1–13. PMID: 20151245.

6. Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, et al. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology. 2005; 64:2074–2078. PMID: 15985575.

7. Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. London: The Cochrane Library;;2007.

8. Gelberman RH, Aronson D, Weisman MH. Carpal-tunnel syndrome: results of a prospective trial of steroid injection and splinting. J Bone Joint Surg Am. 1980; 62:1181–1184. PMID: 7000789.

9. Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg Br. 1990; 15:106–108. PMID: 2307866.

10. Irwin LR, Beckett R, Suman RK. Steroid injection for carpal tunnel syndrome. J Hand Surg Br. 1996; 21:355–357. PMID: 8771476.

11. Weiss AP, Sachar K, Gendreau M. Conservative management of carpal tunnel syndrome: a reexamination of steroid injection and splinting. J Hand Surg Am. 1994; 19:410–415. PMID: 8056967.

12. Agarwal V, Singh R, Sachdev A, Wiclaff , Shekhar S, Goel D. A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome. Rheumatology (Oxford). 2005; 44:647–650. PMID: 15743755.

13. Ollivere BJ, Logan K, Ellahee N, Miller-Jones JC, Wood M, Nairn DS. Severity scoring in carpal tunnel syndrome helps predict the value of conservative therapy. J Hand Surg Eur Vol. 2009; 34:511–515. PMID: 19587071.

14. Meys V, Thissen S, Rozeman S, Beekman R. Prognostic factors in carpal tunnel syndrome treated with a corticosteroid injection. Muscle Nerve. 2011; 44:763–768. PMID: 21953020.

15. Stevens JC. AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1997; 20:1477–1486. PMID: 9390659.

16. Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993; 75:1585–1592. PMID: 8245050.

17. Delisa JA. Manual of nerve conduction velocity and clinical neurophysiology. Philadelphia: Lippincott Williams & Wilkins;1994.

18. Lee H, Kwon H. Electrophysiologic classification of severity of carpal tunnel syndrome. J Korean EMG Electrodiagn Med. 2004; 6:1–3.

19. Visser LH, Ngo Q, Groeneweg SJ, Brekelmans G. Long term effect of local corticosteroid injection for carpal tunnel syndrome: a relation with electrodiagnostic severity. Clin Neurophysiol. 2012; 123:838–841. PMID: 21962473.

20. O'Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis. 2000; 59:918–919. PMID: 11053073.

21. Naranjo A, Ojeda S, Arana V, Baeta P, Fernandez-Palacios J, Garcia-Duque O, et al. Usefulness of clinical findings, nerve conduction studies and ultrasonography to predict response to surgical release in idiopathic carpal tunnel syndrome. Clin Exp Rheumatol. 2009; 27:786–793. PMID: 19917161.

22. Lee CH, Kim TK, Yoon ES, Dhong ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg. 2005; 54:20–23. PMID: 15613877.

23. Bayrak IK, Bayrak AO, Tilki HE, Nural MS, Sunter T. Ultrasonography in carpal tunnel syndrome: comparison with electrophysiological stage and motor unit number estimate. Muscle Nerve. 2007; 35:344–348. PMID: 17143879.

24. Padua L, Pazzaglia C, Caliandro P, Granata G, Foschini M, Briani C, et al. Carpal tunnel syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment. Clin Neurophysiol. 2008; 119:2064–2069. PMID: 18620908.

25. Leventoglu A, Kuruoglu R. Do electrophysiological findings differ according to the clinical severity of carpal tunnel syndrome? J Neurol Sci Turk. 2006; 23:272–278.

26. You H, Simmons Z, Freivalds A, Kothari MJ, Naidu SH. Relationships between clinical symptom severity scales and nerve conduction measures in carpal tunnel syndrome. Muscle Nerve. 1999; 22:497–501. PMID: 10204785.