Steroid injections are a common treatment option in the management of carpal tunnel syndrome (CTS). This study assesses various prognostic factors for progression to carpal tunnel release (CTR) after a first-time steroid injection for CTS with specific focus on concomitant ulnar nerve compression (UNC).
Methods:
This is a retrospective study of 426 hands with CTS treated with a first-time steroid injection in the Long Island region of New York. The main predictor variable was UNC measured in two analytical models of positive UNC and location of UNC (wrist or elbow). Multivariate logistic regression analyses adjusted for demographic, medical, and CTS-related variables for 2 study outcomes occurring within 1 year: (1) CTR; and (2) steroid reinjection.
Results:
Overall progression to CTR within 1 year of steroid injection was 23.0%. Ulnar nerve compression was present in 16.7% of patients and was significantly associated with increased odds for CTR but not with steroid reinjection. These results were further localized to be specific for UNC at the elbow. A moderate or severe result on electrodiagnostic studies was associated with increased odds for CTR. Increased age was associated with slightly increased odds of steroid reinjection while a history of distal radius fracture was associated with decreased odds of steroid reinjection.
Conclusions:
Carpal tunnel syndrome patients with UNC may benefit from earlier definitive treatment with CTR rather than attempting steroid injections, as they are more likely to seek reintervention within 1 year of their initial injection.
AtroshiIGummessonCJohnssonR, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153-158. doi:10.1001/jama.282.2.153.
2.
FerrySPritchardTKeenanJ, et al. Estimating the prevalence of delayed median nerve conduction in the general population. Br J Rheumatol. 1998;37(6):630-635. doi:10.1093/rheumatology/37.6.630.
3.
Centers for Disease Control and Prevention. QuickStats: percentage of employed adults* aged 18—64 years who had carpal tunnel syndrome† in the past 12 months, by sex and age group—National Health Interview Survey, 2010§. Morb Mortal Wkly Rep. 2011;60(49):1680. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6049a4.htm?s_cid=mm6049a4_w. Accessed August 11, 2022.
4.
TostiRIlyasAM.Acute carpal tunnel syndrome. Orthop Clin North Am. 2012;43(4):459-465. doi:10.1016/j.ocl.2012.07.015.
5.
BickelK.Carpal tunnel syndrome. J Hand Surg Am. 2010;35(1):147-152. doi:10.1016/j.jhsa.2009.11.003.
6.
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. https://www.aaos.org/ctscpg. Published February 29, 2016. Accessed August 11, 2022.
7.
CalandruccioJHThompsonNB.Carpal tunnel syndrome: making evidence-based treatment decisions. Orthop Clin North Am. 2018;49(2):223-229. doi:10.1016/j.ocl.2017.11.009.
8.
BergerMVermeulenMKoelmanJH, et al. The long-term follow-up of treatment with corticosteroid injections in patients with carpal tunnel syndrome. When are multiple injections indicated?J Hand Surg Eur Vol. 2013;38(6):634-639. doi:10.1177/1753193412469580.
9.
BlazarPEFloydWE4thHanCH, et al. Prognostic indicators for recurrent symptoms after a single corticosteroid injection for carpal tunnel syndrome. J Bone Joint Surg Am. 2015;97(19):1563-1570. doi:10.2106/JBJS.N.01162.
10.
EversSBryanAJSandersTL, et al. Influence of injection volume on rate of subsequent intervention in carpal tunnel syndrome over 1-year follow-up. J Hand Surg Am. 2018;43(6):537-544. doi:10.1016/j.jhsa.2018.02.024.
11.
EversSBryanASandersT, et al. Corticosteroid injections for carpal tunnel syndrome. Plast Reconstr Surg. 2017;140(2):338-347. doi:10.1097/prs.0000000000003511.
12.
Jerosch-HeroldCShepstoneLHoughtonJ, et al. Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study. Muscle Nerve. 2019;60(1):32-40. doi:10.1002/mus.26459.
13.
JenkinsPJDuckworthADWattsAC, et al. Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis. Hand (N Y). 2012;7(2):151-156. doi:10.1007/s11552-012-9390-8.
14.
MeysVThissenSRozemanS, et al. Prognostic factors in carpal tunnel syndrome treated with a corticosteroid injection. Muscle Nerve. 2011;44(5):763-768. doi:10.1002/mus.22183.
15.
ShulmanBBekiszJLopezC, et al. The association between concomitant ulnar nerve compression at the elbow and carpal tunnel syndrome. Hand (N Y). 2020;15(3):335-340. doi:10.1177/1558944718813669.
16.
AnTWEvanoffBABoyerMI, et al. The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. metropolitan cohort. J Bone Joint Surg Am. 2017;99(5):408-416. doi:10.2106/JBJS.15.01162.
17.
vanVeenKEAlblasKCAlonsIM, et al. Corticosteroid injection in patients with ulnar neuropathy at the elbow: a randomized, double-blind, placebo-controlled trial. Muscle Nerve. 2015;52(3):380-385. doi:10.1002/mus.24551.
18.
GronbeckCWolfJRodnerCM. Ultrasound-guided cubital tunnel injection: a review and exploration of utility as a diagnostic aid in mild or nonclassic cubital tunnel patients. Tech Orthop. 2021;36(3):301-306. doi:10.1097/BTO.0000000000000450.
19.
HongCZLongHAKanakamedalaRV, et al. Splinting and local steroid injection for the treatment of ulnar neuropathy at the elbow: clinical and electrophysiological evaluation. Arch Phys Med Rehabil. 1996;77(6):573-577. doi:10.1016/s0003-9993(96)90297-x.
20.
PodnarSOmejecG. Why do local corticosteroid injections work in carpal tunnel syndrome, but not in ulnar neuropathy at the elbow?Muscle Nerve. 2016;53(4):662-663. doi:10.1002/mus.24956.
21.
DayCSMakhniECMejiaE, et al. Carpal and cubital tunnel syndrome: who gets surgery?Clin Orthop Relat Res. 2010;468(7):1796-1803. doi:10.1007/s11999-009-1210-2.
22.
ChimentiPCMcIntyreAWChildsSM, et al. Combined cubital and carpal tunnel release results in symptom resolution outside of the median or ulnar nerve distributions. Open Orthop J. 2016;10:111-119. doi:10.2174/1874325001610010111.
23.
KaplanSJGlickelSZEatonRG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg Br. 1990;15(1):106-108. doi:10.1016/0266-7681(90)90061-8.
24.
WeissAPSacharKGendreauM. Conservative management of carpal tunnel syndrome: a reexamination of steroid injection and splinting. J Hand Surg Am. 1994;19(3):410-415. doi:10.1016/0363-5023(94)90054-X.
GrahamRGHudsonDASolomonsM, et al. A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Plast Reconstr Surg. 2004;113(2):550-556. doi:10.1097/01.PRS.0000101055.76543.C7.
27.
PopeDTangP. Carpal tunnel syndrome and distal radius fractures. Hand Clin. 2018;34(1):27-32. doi:10.1016/j.hcl.2017.09.003.
28.
ShibayamaMKuniyoshiKSuzukiT, et al. The effects of locally injected triamcinolone on entrapment neuropathy in a rat chronic constriction injury model. J Hand Surg Am. 2014;39(9):1714-1721. doi:10.1016/j.jhsa.2014.05.026.
29.
YangTHGingeryAThoresonAR, et al. Triamcinolone acetonide affects TGF-β signaling regulation of fibrosis in idiopathic carpal tunnel syndrome. BMC Musculoskelet Disord. 2018;19(1):342. doi:10.1186/s12891-018-2260-y.
30.
LeowJMClementNDMcQueenMM, et al. The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius. Eur J Orthop Surg Traumatol. 2021;31(5):981-987. doi:10.1007/s00590-021-02975-5.
31.
ItsuboTHayashiMUchiyamaS, et al. Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists. J Orthop Sci. 2010;15(4):518-523. doi:10.1007/s00776-010-1496-7.
32.
KamelSRSadekHAHamedA, et al. Ultrasound-guided insulin injection for carpal tunnel syndrome in type 2 diabetes mellitus patients. Clin Rheumatol. 2019;38(10):2933-2940. doi:10.1007/s10067-019-04638-7.
33.
CatalanoLW3rdGlickelSZBarronOA, et al. Effect of local corticosteroid injection of the hand and wrist on blood glucose in patients with diabetes mellitus. Orthopedics. 2012;35(12):e1754-e1758. doi:10.3928/01477447-20121120-20.
34.
VisserLHNgoQGroenewegSJ, et al. Long term effect of local corticosteroid injection for carpal tunnel syndrome: a relation with electrodiagnostic severity. Clin Neurophysiol. 2012;123(4):838-841. doi:10.1016/j.clinph.2011.08.022.
35.
TulipanJELutskyKFMaltenfortMG, et al. Patient-reported disability measures do not correlate with electrodiagnostic severity in carpal tunnel syndrome. Plast Reconstr Surg Glob Open. 2017;5(8):e1440. doi:10.1097/GOX.0000000000001440.
36.
ChanLTurnerJAComstockBA, et al. The relationship between electrodiagnostic findings and patient symptoms and function in carpal tunnel syndrome. Arch Phys Med Rehabil. 2007;88(1):19-24. doi:10.1016/j.apmr.2006.10.013.
37.
WangWLButerbaughKKadowTR, et al. A prospective comparison of diagnostic tools for the diagnosis of carpal tunnel syndrome. J Hand Surg Am. 2018;43(9):833-836. doi:10.1016/j.jhsa.2018.05.022.
38.
LevineDWSimmonsBPKorisMJ, 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(11):1585-1592. doi:10.2106/00004623-199311000-00002.
