Carpal tunnel syndrome

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a common mononeuropathy due to entrapment of the median nerve in the carpal tunnel.

Symptoms :

-         - hand paresthesia

-        -  numbness

-         - pain in the median nerve distribution of the hand

Indications

See the list below:

• Electromyographic studies consistent with mild to moderate median nerve entrapment
• Symptoms not relieved with [other] conservative measures

Contraindications

See the list below:

• Active infection over the area
• Adverse reaction to steroid
• Uncontrolled diabetes mellitus
• Immunosuppression
• Adverse reaction to local anesthetic

Equipment

See the list below:

• Antiseptic solution (iodine, chlorhexidine)
• Syringe 5mL x2
• Needle, 1 inch, 25 or 30 gauge (ga)
• Blunt nerve block needle, 1 or 2 inch, 25 ga
• Lidocaine 1%
• Injectable steroid: Triamcinolone Acetonide 10-20mg or Methylprednisolone Acetate 10-20mg
• Small rolled towel
• Ultrasound machine with a high frequency transducer
• Sterile probe cover for ultrasound transducer

Anesthesia

See the list below:

• Lidocaine 1% without epinephrine, 2-3 mL

Positioning

Have the patient seated or in supine position with affected wrist supinated resting on the small rolled towel allowing for wrist dorsiflexion.

Technique

Landmark Approach

Identify the flexor carpi radialis (lateral) and palmaris longus tendons (medial). Prep the skin using the antiseptic solution.

Using the 25 ga needle make a skin wheel with 1% lidocaine just medial to the palmaris longus tendon and approximately 1 centimeter proximal to the wrist crease.

In a separate syringe draw up the steroid and enter the skin at the skin wheel just medial to the palmaris longus tendon using blunt tip 25 ga needle. Direct the needle toward the third digit at a 30 degree angle. Advance the needle approximately 1.5 -2 cm. Aspirate to verify that the needle is not intravascular and inject the steroid with little or no resistance.

Remove the needle and place the wrist in a gravity-dependent position advising the patient to move the fingers for several minutes to facilitate even distribution of the solution.

Complications

Complications may include the following:

• Bleeding
• Infection
• Paresthesia
• Pain
• Median nerve injury ^[4]
• Elevated blood glucose levels (without apparent clinical risk) ^[5]

Referances

1. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003. CD003219. [Medline].

2. Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford). 2012 Aug. 51(8):1447-54. [Medline].

3. Smith J, Wisniewski SJ, Finnoff JT, Payne JM. Sonographically guided carpal tunnel injections: the ulnar approach. J Ultrasound Med. 2008 Oct. 27(10):1485-90. [Medline].

4. Park GY, Kim SK, Park JH. Median nerve injury after carpal tunnel injection serially followed by ultrasonographic, sonoelastographic, and electrodiagnostic studies. Am J Phys Med Rehabil. 2011 Apr. 90(4):336-41. [Medline].

5. Catalano LW 3rd, Glickel SZ, Barron OA, Harrison R, Marshall A, Purcelli-Lafer M. Effect of local corticosteroid injection of the hand and wrist on blood glucose in patients with diabetes mellitus. Orthopedics. 2012 Dec. 35(12):e1754-8. [Medline].

6. [Guideline] Michael Warren Keith, Victoria Masear, Peter C. Amadio, Michael Andary, Richard W. Barth, Brent Graham, et al. Treatment of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009. 17:397-405.

7. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007 Apr 18. CD001554. [Medline]. [Full Text].

8. Hui AC; Wong S; Leung CH; Tong P; Mok V; Poon D; Li-Tsang CW; Wong LK; Boet R. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology. June 28 2005. 64 (12):2074-8. [Medline].

9. Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford). 2012 Aug. 51(8):1447-54. [Medline].

10.         Jarvik JG, Yuen E, Kliot M. Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation. Neuroimaging Clin N Am. 2004 Feb. 14(1):93-102, viii. [Medline

11.         http://emedicine.medscape.com/article/103333-overview#showall