Carpal Tunnel Steroid Injection
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Carpal tunnel syndrome (CTS) is a common mononeuropathy due to entrapment of the median nerve in the carpal tunnel. Symptoms include hand paresthesia, numbness, and pain in the median nerve distribution of the hand. Conservative treatment options, in addition to carpal tunnel steroid injection, include rest, splinting, oral steroids, ultrasound, yoga, physical therapy, and ergonomic modification. [1] Surgical intervention is reserved for severe symptoms.
Clinical testing for carpal tunnel syndrome includes the Tinel test, which is performed by lightly tapping the median nerve eliciting paresthesia in the nerve distribution of the hand. Additional testing includes the Phalen test, which increases pressure in the carpal tunnel by forced wrist flexion for several minutes.
Carpal tunnel steroid injection has been shown to reduce short-term symptoms prior to definitive surgical intervention. Local steroid injection and surgical decompression both are effective treatments at 2-year follow-up, with surgical intervention having some additional benefit. [2]
Electrodiagnositc studies such as nerve conduction studies and electromyography can be used to determine median nerve compression severity.
The wrist is a complex joint consisting of the distal portion of the radius and ulna articulating with eight carpal bones which in turn articulate with the proximal aspects of five metacarpal bones. Together, these bones are responsible for flexing and extending, pronating and supinating as well as ulnar and radial deviation.
The carpal tunnel is defined ventrally by the flexor retinaculum, attached radially to the scaphoid and trapezium, and the pisiform and hamate on the ulnar side. The carpal bones define the dorsal border of the carpal tunnel. The carpal tunnel contains four tendons of the flexor digitorum profundus, four tendons of the flexor digitorum superficialis as well as the flexor pollicis longus tendon. Just deep to the flexor retinaculum is where the median nerve traverses the carpal tunnel. This branch of the median nerve supplies the sensory innervation of the first three digits and the radial half of the fourth digit.
For more information about the relevant anatomy, see Wrist Joint Anatomy.
See the list below:
Electromyographic studies consistent with mild to moderate median nerve entrapment
Symptoms not relieved with [other] conservative measures
See the list below:
Active infection over the area
Adverse reaction to steroid
Uncontrolled diabetes mellitus
Immunosuppression
Adverse reaction to local anesthetic
See the list below:
Lidocaine 1% without epinephrine, 2-3 mL
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
Have the patient seated or in supine position with affected wrist supinated resting on the small rolled towel allowing for wrist dorsiflexion.
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.
The landmark procedure is shown in the video below.
Several approaches to ultrasound guided carpal tunnel injections have been described.
Out of plane approach/Short axis view
Using a high frequency ultrasound transducer held transverse across the wrist, the median nerve is identified under the flexor retinaculum. The needle is advanced out of plane, proximal to the ultrasound transducer and directed toward the third digit. Once under the flexor retinaculum the steroid solution is injected with low resistance to surround the median nerve.
In-plane approach/Short axis view
By using a high frequency ultrasound probe the wrist is imaged by placing the probe transverse across dorsiflexed wrist. The median nerve and ulnar artery is identified. At the level of the distal wrist crease, the needle is passed into the skin superficial to the ulnar artery, penetrating the flexor retinaculum. The needle is advanced toward the median nerve. The steroid solution is injected just under the flexor retinaculum then retracted and redirected deeper to the ulnar side of the median nerve. This allows the median nerve to be completely surrounded with the steroid solution. [3]
Sudden pain or paresthesia during the procedure can be indicative of improper needle placement. The needle should be retracted and redirected more medial.
Some patients lack a palmaris longus tendon in which case the insertion point of the needle should be halfway between the radial and ulnar aspects of the wrist and about 1cm proximal to the wrist crease. The needle should be advanced toward the ring finger.
Complications may include the following:
Bleeding
Infection
Paresthesia
Pain
Median nerve injury [4]
Elevated blood glucose levels (without apparent clinical risk) [5]
Overview
What is carpal tunnel steroid injection?
What is the anatomy of the wrist relevant to carpal tunnel steroid injection?
What are indications for carpal tunnel steroid injection?
What are contraindications for carpal tunnel steroid injection?
What anesthesia is used in the administration of a carpal tunnel steroid injection?
What equipment is needed to administer a carpal tunnel steroid injection?
How is the patient positioned for the administration of a carpal tunnel steroid injection?
How are carpal tunnel steroid injections administered with the landmark approach?
How is a carpal tunnel steroid injection administered using an in-plane ultrasound-guided approach?
What are pearls for carpal tunnel steroid injection administration?
What are the possible complications of carpal tunnel steroid injection?
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].
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].
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].
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].
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].
[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.
Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007 Apr 18. CD001554. [Medline]. [Full Text].
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].
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].
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].
El-Hajj T, Tohme R, Sawaya R. Changes in electrophysiological parameters after surgery for the carpal tunnel syndrome. J Clin Neurophysiol. 2010 Jun. 27(3):224-6. [Medline].
MacDermid JC; Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. Apr-Jun 2004. 17:309-19. [Medline].
Karadas Ö, Tok F, Akarsu S, Tekin L, Balaban B. Triamcinolone acetonide vs procaine hydrochloride injection in the management of carpal tunnel syndrome: randomized placebo-controlled study. J Rehabil Med. 2012 Jun 7. 44(7):601-4. [Medline].
Sebastin SJ, Puhaindran ME, Lim AY, Lim IJ, Bee WH. The prevalence of absence of the palmaris longus–a study in a Chinese population and a review of the literature. J Hand Surg [Br]. 2005 Oct. 30(5):525-7. [Medline].
Kose O, Adanir O, Cirpar M, Kurklu M, Komurcu M. The prevalence of absence of the palmaris longus: a study in Turkish population. Arch Orthop Trauma Surg. May 2009. 129 (5):609-11. [Medline].
Linskey ME, Segal R. Median nerve injury from local steroid injection in carpal tunnel syndrome. Neurosurgery. 1990 Mar. 26(3):512-5. [Medline].
Hennink S, van der Horst CM, Breugem CC. Complications following steroid treatment for carpal tunnel syndrome. J Hand Surg Eur Vol. 2007 Jun. 32(3):362-3. [Medline].
Gottlieb NL; Riskin WG. Complications of local corticosteroid injections. JAMA. April 18 1980. 243:1547-8. [Medline].
Kasten SJ, Louis DS. Carpal tunnel syndrome: a case of median nerve injection injury and a safe and effective method for injecting the carpal tunnel. J Fam Pract. Jul 1996. 43 (1):79-82. [Medline].
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005 Feb. 52(2):612-9. [Medline].
Nonsurgical treatment is effective for carpal tunnel syndrome. J Fam Pract. 2004 Sep. 53(9):685. [Medline].
Samir Shah, MD Resident Physician, Department of Anesthesiology, Stony Brook University Hospital
Disclosure: Nothing to disclose.
Eugene Deo Kim, MD Resident Physician, Department of Anesthesiology, Stony Brook University Hospital
Eugene Deo Kim, MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, New York State Society of Anesthesiologists, New York Society of Interventional Pain Physicians
Disclosure: Nothing to disclose.
Bassem Abraham, MD Chief of Pain Services, John Cochran Veterans Affairs Medical Center; Adjunct Associate Professor of Anesthesiology, St Louis University School of Medicine
Bassem Abraham, MD is a member of the following medical societies: International Spine Intervention Society
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center
Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Arie Gluzman, MD Staff Physician, Department of Physical Medicine and Rehabilitation, UCLA/Greater Los Angeles Veterans Administration
Disclosure: Nothing to disclose.
Zita Konik, MD Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Zita Konik, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.
Jeffrey S Peterson, MD Clinical Assistant Professor of Surgery/Emergency Medicine, Stanford University School of Medicine, Stanford University Hospital; Founder and Sports Medicine Physician, Innovative Sports Medicine
Jeffrey S Peterson, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Sports Medicine, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Carpal Tunnel Steroid Injection
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