INTRODUCTION:

Carpal tunnel syndrome, this is the best known of all the entrapment syndromes. In the normal carpal tunnel, there is barely room for all the tendons and the median nerve; consequently, any swelling is likely to result in compression and ischemia of the nerve. Usually the cause elude detection; the syndrome is, however, common at the menopause, in rheumatoid arthritis, pregnancy and myxoedema.

The carpal tunnel syndrome, caused by compression of the median nerve at the wrist, is considered the most common entrapment neuropathy. Patients complain of paraesthesia (with or without numbness or pain) involving the fingers innervated by the median nerve and weakness of thumb abduction. Symptoms are worst at night and often wake the patient. Standard treatments include splints, local injection of corticosteroid, and surgical decompression. Benefit from non-surgical treatments, however, seems to be limited and not all patients respond to surgery. (1, 2, 9)

Evidence for the efficacy of most conservative treatment options is limited. A recent systematic review has shown that among the various available surgical techniques, open carpal tunnel release is preferred method. However, only few randomized controlled trial has compared conservative treatment (splinting) with surgery but provided no information on comparability of the groups at baseline.

Due to limited evidence, there is no consenus on the preferred method of treatment for CTS. Advocates of surgery refer to its safety and effectiveness for electrophysiologically confirmed cases with no underlying reversible disorder and point out that conservative treatment options generally offer only temporary symptoms relief. Advocates of conservative options refer to the potential benefits and safety of these treatments and the potential complications of surgery. (3, 4, 12)

Aim of study:

To compare one of the most efficient and safe conservative methods in the treatment of CTS with most popular known method by surgical release of the median nerve at the carpal tunnel.

MATERIALS AND METHODS:

All patients with clinically suspected CTS were examined for eligibility to participate in the study. Inclusion criteria were (1) pain, paresthesia and or hypoesthesia in the hand in the area innervated by the median nerve (2) electrophysiological confirmation of the diagnosis (3) age of 18 years or older. Exclusion criteria were(1) previous treatment with surgery, (2) a history of wrist trauma (e.g, fracture) or surgery, (3) a history suggesting underlying causes of CTS (e.g diabetes mellitus, pregnancy) (4) clinical signs or symptoms or electrophysiological finding suggesting conditions that could mimic CTS or interfere with its validation (eg: cervical radiculopathy, polyneuropathy) and (5) severe thenar muscle atrophy.

The whole number of patients who were involved in the study was 86 patients (38 patients were excluded from the study and 48 were included) (see table 1)

Table (1): number of excluded patients and cause of exclusion

Cause of exclusion	Number of of patients
History of DM	10
Pregnancy	13
History of previous CTS surgery	6
History of cervical radiculopathy	7
Thenar muscle atrophy	2
Sum of patients	38

48 patients were randomly allocated to receive either local injection or surgery. If bilateral symptoms were present, the hand with more severe symptoms (according to the patient) was treated. All patients who met the eligibility criteria were randomly allocated into two groups (24 patients were treated with local injection) and other (24 patients were treated by surgery).

Participants in the local injection group received one or two intracarpal injections with 1 ml triamciloneacetonide 10mg/ml which was injected to the ulnar side of Palmaris longus tendon, proximal 6to the wrist crease; the needle was aimed toward the carpal tunnel at 10-20 degree angle of entry, if there was no parasthesia during insertion of the needle the corticosteroid was injected.

All surgical procedures were performed using a limited palmar incision technique. We chose this approach because it is the usual surgical procedure for CTS decompression performed at our unit. The limited palmar incision technique is used in attempt to minimize postsurgical pain and to achieve an earlier recovery. Results of a recent randomized controlled trail suggest that the efficacy of limited palmar incision is similar to that of wide incision decompression and that the limited palmar incision procedure is better tolerated.

All patients were diagnosed both clinically and by neurophysiologically by nerve conduction study. The main clinical signs and symptoms that the patients was complaining of are (pain, tingling, burning, numbness, or some combinations of these symptoms on the fingers in the distribution of the median nerve that may radiate to the forearm).

Electrodiagnostic study was done for both median nerve and ulnar nerves for the affected hand(which has been involved in this study), all patients were informed to have follow up at 3 months, 6 months, 12 months intervals, but after the initial treatment the patients were instructed to be seen after 14 days interval for surgical group for follow up of this scar and for the injection group patients may receive another CS injection if nocturnal parasthesia has not completely disappeared.

RESULTS:

The whole number of patients who were involved in this study was 86 patients (38 patients were excluded from the study and 48 were included). 48 patients were randomly allocated to receive either local injection or surgery. If bilateral symptoms were present, the hand with the more symptoms (according to patient) was treated. All patients who met the eligibility criteria were randomly allocated into two groups (24 patients were treated with local injection) and other (24 patients were treated by surgery). Table (2)

Table (2): Number of improved cases per visit

Number of improved cases per visit
Group	3 months	6 months	12 months
Local injection group	19/24=79%	10/24=42%	3/24=13%
Open surgery group	16/24=66%	22/24=92%	21/24=88%

Most of our patients were cooperative and excellent follow up was done at 3 months, 6 moths, and 12 months interval. Chart (1)

DISCUSSION:

An increase in the pressure in the carpal tunnel is usually caused by non-specific flexor tenosynovitis. Chronic focal compression of a nerve trunk can cause focal demyelination by mechanical stress deforming the myelin lamellae. Ischemia also plays a pathogenic role in the carpal tunnel syndrome. It could account for intermittent paraesthesia that occurs at night or with wrist flexion. The carpal tunnel syndrome is often observed bilaterally. Symptoms are usually markedly worse on one (mostly the dominant) side. (5, 6)

Conservative treatment approaches seem to offer clear advantages over surgical treatment of the carpal tunnel syndrome. Recent studies have confirmed short term effects of steroid injections into the carpal tunnel, with modest or complete pain relief in up to 92% of the patients, although long term recurrence rates seem variable.Potential adverse effects to nerves and tendons with repeated injections have limited the value of this treatment. Palmar wrist splints worn at night seem suitable only when symptoms are mainly nocturnal and ergonomic strategies have not yet been evaluated. (6)

The American Academy of Neurology recommends treatment of CTS with conservative treatment approaches first and open carpal tunnel release only if noninvasive treatment proves to be ineffective. This study showed that treatment of CTS with surgery results in better outcomes. Conservative treatment approaches might be used while a patient waits for surgery because the waiting period for open carpal tunnel release in practice is often longer than in this study, as efforts were made to make an appointment for the patients after randomization. Patients not willing to undergo surgery could also be offered conservative treatment approach. Another recently conducted study found that patients wearing a wrist splint showed more relief from symptoms than patients not receiving any treatment.

(1,7,8)

Our results show that, although both local steroid injection and surgical decompression are very effective therapies in alleviating symptoms in primary CTS; surgery is superior to injection at 12-month follow up.

There is generally a lack of rigorous scientific support for non- surgical treatment in CTS. Whereas most studies evaluating local injection have been retrospective or uncontrolled, local CS injection provides greater clinical improvement at 3 months compared to surgical release, at 6month period surgical method had shown that long term relief is best achieved by surgery. Our study has some limitations. An injection in one wrist could theoretically result in improvement in the opposite, surgically decompressed wrist because of the systemic absorption of the CS. An overweighting effect cannot be excluded in the surgically decompressed wrist when other wrist has been injected. If this is the case, an apparent superiority of surgical decompression could be a bias of the study design. However, statistical analysis of data from operated wrists with or without an injected opposite wrist did not show any relevant difference (data not shown). (10,11,15)

CONCLUSION:

In a summery steroid injection is feasible, non expensive and quite effective therapy in CTS, but it is only for short term relief and the best long term solution is by surgical release.

We think that there are some questions which should be answered: what is the degree of improvement after treatment? Do all patients need treatment, some patients may resolve spontaneously without any treatment. We recommend further study to extend the follow up period and to record number of relapsed cases after surgical decompression.

REFERENCES:

1. American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guideline on the treatment of carpal tunnel syndrome. National Guideline Clearinghouse. http://www.guidelines.gov/content.aspx?id=13304.(25Feb2012, date last accessed).

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8. Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgiucal versus non surgical treatment for carpal tunnel syndrome: Cochrane Database Syst Rev 2003; 3:CD001552.

9. Ly-Pen D, Andreu JL, De Blas G, Sa nchez-Olaso A, Milla n I.Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one year, prospective, randomized, open, controlled trail. Arthritis Rheum 2005; 52:612-9.

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12. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles andpractice, third ed. Oxford University press, 2001.

13. Serra JM, Benito JR, Monner J. Carpal tunnel release with short incision. PlastReconstrSurg 1997; 99:129-35.

14. Lee WP, Strickland JW. Safe carpal tunnel release via a limited palmar incision. PlastReconstrSurg 1998; 101:418-24.

15. Jugovac I, Burgic N, Micovic V et al. Carpal tunnel release by limited palmar incision vs traditional open technique: randomized controlled trail. Croat Med J 2002; 43:33-6

Received on 08.12.2018 Modified on 17.01.2019

Research J. Pharm. and Tech. 2019; 12(5):2490-2492.

DOI: 10.5958/0974-360X.2019.00418.9