Ali Rıza SONKAYA, Fatma SİMSEK, Mustafa CEYLAN

Clinical and laboratory efficacy of repetitive triamcinolone injections in carpal tunnel syndrome

Aim:Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the upper extremity. There are many surgical and non-surgical treatment options and it is not clear which approach is more effective. Corticosteroid injections are known to be effective on both CTS symptoms and electrophysiological parameters. Many different techniques are used for injection. It is recommended to use a maximum of 3 injections at intervals of 2-3 months. In our study, we aimed to examine the clinical and electrophysiological efficacy of triamcinolone injection performed in the cases with a rarely used technique.Material and Methods: This is a retrospective study.Patients who were diagnosed with mild to moderate CTS between December 2012 and June 2018 treated with 40 mg triamcinolone injection were evaluated. Ages of patients were between 18 to 65 years. The changes in the electrophysiological parameters, clinical and examination findings, and visual analog scale (VAS) of 121 patients were examined before and after the injections.Results: Clinical and examination findings were consistent with previous studies. The second injection was applied to 43.9% and the third injection to 16.4% of the cases. After the third injection, mild to moderate CTS was detected in 6.9% of the cases. The statistically significant changes were observed in the clinical, examination findings and VAS values of the cases before and after the injection. Besides, a significant statistical difference was determined in all parameters of the sensory conductions and in the distal latency of the motor conduction, before and after the injection.Conclusion: It was determined that 40 mg of triamcinolone caused a significant change in VAS values, and the clinical and examination findings of CTS. There were no complications associated with injection. Consequently, 40 mg of triamcinolone, applied approximately 3 cm distal to the carpal tunnel, is as effective as the more frequently applied techniques.

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1. Atroshi, I, Gummesson, C, Johnsson, R. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282:153-8.
2. Fernández-de-Las-Peñas C, Cleland J, Palacios-Ceña M, et al. The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2017;47:151-61.
3. Burke FD, Ellis J, McKenna H, et al. Primary care management of carpal tunnel syndrome. Postgrad Med J. 2003;79:433-7.
4. Kim HJ, Park SH. Median nerve injuries caused by carpal tunnel injections. Korean J Pain. 2014; 27:112-7.
5. Cranford CS, Ho JY, Kalainov DM, Carpal tunnel syndrome. J Am Acad Orthop Surg 2007;15:537-48.
6. Lee JH, An JH, Lee SH, et al. Effectiveness of steroid injection in treating patients with moderate and severe degree of carpal tunnel syndrome measured by clinical and electrodiagnostic assessment. Clin J Pain 2009;25:111-5.
7. Ozturk K1, Esenyel CZ, Sonmez M, et al. Comparison of carpal tunnel injection techniques: a cadaver study. Scand J Plast Reconstr Surg Hand Surg 2008;42:300-4.
8. Racasan O, Dubert TH. The safest location for steroid injection in the treatment of carpal tunnel syndrome. J Hand Surg Br 2005;30:412-4.
9. Visser LH, Ngo Q, Groeneweg SJ, et al. Long term effect of local corticosteroid injection for carpal tunnel syndrome: a relation with electrodiagnostic severity. Clin Neurophysiol 2012;123:838-41.
10. Chen LC, Ho CW, Sun CH, et al. Ultrasound-Guided Pulsed Radiofrequency for Carpal Tunnel Syndrome: A Single-Blinded Randomized Controlled Study. PLoS One 2015;10: e0129918.
11. Jenkins PJ, Duckworth AD, Watts AC, et al. Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis. Hand (N Y) 2012;7:151-6.
12. Graham B, Peljovich AE, Afra R, et al. The American academy of orthopaedic surgeons evidence-based clinical practice guideline on: management of carpal tunnel syndrome. J Bone Joint Surg Am 2016;98:1750-4.
13. Huisstede BM, Fridén J, Coert JH, et al. Carpal tunnel syndrome: hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline-results from the European HANDGUIDE Study. Arch Phys Med Rehabil 2014;95:2253-63.
14. Habib, GS, Badarny, S, Rawashdeh, H. A novel approach of local corticosteroid injection for the treatment of carpal tunnel syndrome. Clin Rheumatol 2006;25:338-40.
15. Ata AM, Şahin Onat Ş, Kara M, et al. Ultrasound-guided injection of carpal tunnel: do you mind the retinaculum? Am J Phys Med Rehabil 2016;95:e22.
16. Cartwright MS, White DL, Demar S,et al. Median nerve changes following steroid injection for carpal tunnel syndrome. Muscle Nerve 2011;44:25-9.
17. Dubert T, Racasan O. A reliable technique for avoiding the median nerve during carpal tunnel injections. Joint Bone Spine 2006;73:77-9.
18. Hong JP, Lew HL, Lee CH,et al. Ultrasound-guided injection for the treatment of carpal tunnel syndrome. Am J Phys Med Rehabil 2015;94:119-20.
19. Mohja Ahmed Abdel-Fattah EL-Badawy. Electrophysiological and clinical comparison of local steroid injection by means of proximal versus distal approach in patients with mild and moderate carpal tunnel syndrome. Egy Rheumatol Rehabil 2015;42:120-7.
20. American Association of Electrodiagnostic Medicine, American Academy of Neurology, and American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement. Muscle Nerve 2002;25:918-22.
21. Bland JD. A neurophysiological grading scale for carpal tunnel syndrome. Muscle Nerve 2000;23:1280-3.
22. Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 2001;38:633-8.
23. Bongers FJ, Schellevis FG, van den Bosch WJ, van der Zee J. Carpal tunnel syndrome in general practice (1981-2001): incidence and role of occupational and no occupational factors. Br J Gen Pract 2007;57:36-9.
24. Harris-Adamson C1, Eisen EA2, Kapellusch J3,Harris-Adamson C, Eisen E, Kapellusch J, Garg A, Hegmann KT, Thiese MS, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med 2015;72:33-41.
25. Raman SR, Al-Halabi B, Hamdan E, et al. Prevalence and risk factors associated with self-reported carpal tunnel syndrome among office workers in Kuwait. BMC Res Notes 2012;13:289.
26. Yoshii Y, Zhao C, Schmelzer JD, et al. The effects of hypertonic dextrose injection on connective tissue and nerve conduction through the rabbit carpal tunnel. Arch Phys Med Rehabil 2009;90:333-9.
27. Huisstede BM, Hoogvliet P, Randsdorp MS, et al. Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review. Arch Phys Med Rehabil 2010;91:981-1004.
28. O’ Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis 2000;59:918-9.
29. Evers S, Bryan AJ, Sanders TL, et al. Corticosteroid Injections for Carpal Tunnel Syndrome: Long-Term Follow-Up in a Population-Based Cohort. Plast Reconstr Surg 2017;140:338-47.
30. Frederick HA, Carter PR, Littler JW. Injection injuries to the median and ulnar nerves at the wrist. J Hand Surg Am 1992;17:645-7.
31. Phalen GS. The carpal-tunnel syndrome. Seventeen years’ experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am 1966;48:211-28.
32. Schuchmann JA, Melvin JL, Duran RJ, et al. Evaluation of local steroid injection for carpal tunnel syndrome. Arch Phys Med Rehabil 1971;52:253-5.
33. 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;62:1181-4.
34. Ustün N, Tok F, Yagz AE, et.al. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: A single-blind randomized prospective study. Am J Phys Med Rehabil. 2013;92:999-1004.
35. MacLennan A, Schimizzi A, Meier KM, et al. Comparison of needle position proximity to the median nerve in 2 carpal tunnel injection methods: a cadaveric study. J Hand Surg Am 2009;34:875-9.