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Rapid Responses: Rapid Responses published:
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Injection Treatment of Carpal Tunnel Syndrome
- W Angus Wallace (1 October 1999)
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anaesthesia ?
- Jesús García (1 October 1999)
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Study does not demonstrate long-term benefits of steroid injection for Carpal Tunnel Syndrome
- Andrew Hayward (4 October 1999)
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What kind of Methylprednisolon
- DrMarco Brix (5 October 1999)
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Inappropriate outcome measures for assessing the improvement due to methylprednisolone injections.
- Neil Smart, Simon Hill, John Holmes, Elaine Clark, Kevin Little (5 October 1999)
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Do as we say...
- Daniel B Stryer (5 October 1999)
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Steroid injection for CTS: which degree of severity?
- Mario Casmiro (7 October 1999)
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Injections "near the carpal tunnel"
- Tim Davies (12 October 1999)
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Details of neurophysiological findings needed
- Abraham Kurian (4 November 1999)
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Missing the point
- Wong Shiu Man, Hui Che Fai (1 December 1999)
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W Angus Wallace, Professor of Orthopaedic & Accident Surgery Queen''s Medical Centre, Nottingham NG7 2UH
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Dear Editor, Re: Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial by Dammers, Veering and Vermeulen (1999) BMJ; 319: 884-886 I am surprised that the BMJ has published this article without a public health warning. As an orthopaedic surgeon, I occasionally use local steroid injection as temporary treatment for carpal tunnel syndrome in situations when operation cannot be carried out promptly. However to suggest that patients should be offered steroid injection as definitive treatment of carpal tunnel syndrome is both wrong and irresponsible. Pressure on the median nerve medium term can result in permanent damage to the nerve (Bureau et al, 1982). Local steroid injections do not reduce the pressure on the median nerve, all they do is to reduce inflammation temporarily – nerve compression almost always returns with recurrence rates of 80% at one year (Stahl, 1996) and 87% at 11 months (Weiss et al, 1994) reported. The danger with injections is that the patient feels better, believes he is cured and does not return to see the doctor for two or three years. By this time the thenar muscles can be wasted and numbness of the hand in the distribution of the median nerve can have occurred which may not at that stage respond to surgical decompression i.e. is permanent. This is well documented by Katz et al (1998). There is one specific situation in which local steroid injections are justified – in carpal tunnel syndrome associated with pregnancy. These are effective in 85% of the cases, but in some cases with very serious axonal loss, surgical release is justified (Seror P, 1997). Bureau H, Magalon G, Roffe JL (1982) Journal de Chirurgie 1982; 119: 739-47 Katz JN, Keller RB, Simmons BP, Rogers WD, Bessette L, Fossel AH, Mooney NA (1998) Journal of Hand Surgery - American Volume; 23: 697-710 Seror P(1997) Journal de Gynecologie, Obstetrique et Biologie de la Reproduction; 26: 148-53 Stahl S, Yarnitsky D, Volpin G, Fried A(1996) Harefuah ; 130: 241-3; 295 Weiss AP, Sachar K, Gendreau M (1994) Journal of Hand Surgery - American Volume; 19: 410-5 |
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Jesús García INSALUD. Spain
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Wouldn't it be good withdrawing the lignocaine supplementation? I don't think this drug can contribute to relieve the patient's pain, unless you begin to pumo just from the inertion of the needle and, in this case, there's a risk for cutaneous atrophy. I don't think it's a procedure restricted to neurologists or rheumathologists. Probably, the family physician would save much more money if he could solicitate an electrophysiological study |
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Andrew Hayward, Lecturer Public Health University of Nottingham
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The trial by Dammers et al(1) demonstrates that at one month follow- up Carpal Tunnel Syndrome patients who have received steroid injection are considerably more likely to have symptom resolution than those injected with a placebo. However, the study does not provide any evidence to support the suggestion that steroid injection is more effective than placebo after more than three months of follow up. This is because all non-responders were transferred to surgical treatment or steroid injection either at one or three months follow-up, so we do not know whether they would have had symptom resolution after this. A large study from Marshfield USA (2) involving 227 non-surgically treated patients (most of whom were treated with splinting and oral analgesics or NSAID and only six of whom were treated using steroid injection) found that at one year over fifty percent of conservatively managed patients had complete resolution of symptoms. However, for many the response took several months to occur. The fifty percent "response" to steroid injection at one year reported by Dammers et al(1) is therefore probably no different than could be achieved by using non-invasive forms of conservative-management. 1. Dammers JWHH, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel - randomised double blind trial. BMJ 1999;319:884-886 2. DeStefano F, Nordstrom DL, Vierkant RA. Long-term symptom outcomes of Carpal Tunnel Syndrome and its treatment. J Hand Surg (Am) 1997;22A:200-210 |
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DrMarco Brix, general practitioner own studio
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I would like to ask, if the methylprednisolon used by the authors of the study was what we call in German "Kristallsuspension" that means a solution of tiny crystals or if they used the same solution that is also given i.v. Thank You. |
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Neil Smart, Stage 3 Medical Students Department of Epidemiology and Public Health, The Medical School, University of Newcastle, Simon Hill, John Holmes, Elaine Clark, Kevin Little
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Dear Sir, Dammers et al.1 reported that injection of methylprednisolone proximal to the carpal tunnel may result in long term improvement in patients with carpal tunnel syndrome. The primary outcome measure was subjective symptomatic improvement as assessed by the patient at interview with one of the authors. However, we feel that this is an inadequate technique for measuring outcome. A suitable quantitative technique should have been used for assessing improvement, e.g. visual analogue scales. To be included in the study, patients were assessed electrophysiologically prior to injection. Had the patients been tested again after treatment, the initial test would have provided a useful reference point for measuring functional improvement, quantitatively. Why was this study carried out? We wonder why there was an absence of detailed comparisons with studies of intracarpal tunnel steroid injections and feel that the study could have compared extra- to intracarpal tunnel steroid injections rather than to placebo. This study merely served to put their clinical practice of 20 years (which was known to be effective from their own observations) on an evidence based footing. We believe that this overall well-designed trial would have benefited from more appropriate outcome measures. If the authors' aim was to provide evidence for their clinical practice, we do not agree that this article has achieved this. Yours faithfully Competing interests: none 1. Dammers JWHH, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ 1999;319:884-6. |
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Daniel B Stryer, Medical Officer Agency for Health Care Policy and Research
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The picture which depicts the injection site discussed in "Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial" shows the injector without gloves. Although the likelihood of significant bleeding during the procedure is small, universal precautions, including use of gloves by the injector, should be required for the protection of both patient and provider. While the picture may have been just a simulation, it is important to show the use of gloves to avoid even the suggestion that they may be unnecessary. |
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Mario Casmiro, Head, Neurophysiology Service Department of Neurology, Faenza Hospital Italy
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The article by Dammers et al. has a major drawback in the complete lack of neurophysiologic data about patients and controls. The article simply states that the diagnosis of CTS was confirmed by means of electrophysiologic tests (not otherwise specified). Therefore the reader is not allowed to know the distribution of disease severity (e.g mild vs. severe)among cases and controls: could a different "severity profile" have influenced the outcome? |
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Tim Davies
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Editor - Dammers et al report that injection of methylprednisolone near the carpal tunnel relieves compression symptoms. Every UK general practitioner knows that carpal tunnel syndrome is at best a miserable condition which affects many people, and can at worst be disabling, so it is a subject well worth study. Although they mention possible danger from injections into the carpal tunnel itself, the authors present no evidence that such difficulties are widespread or significant or that such injections are any less effective. This was a placebo-controlled experiment rather than a trial of different treatments. Taught from a book, I have been injecting the carpal tunnel to the ulnar
side of the palmaris longus tendon at the most distal wrist crease with
lignocaine and tramcinolone hexacetonide for over a decade, without
difficulty. I have never knowingly caused ill effects, but have had
apparent long term success in many cases. Our local orthopaedic surgeon
seems to use a technique involving an (anecdotally more painful yet no
more effective) injection into the hand. Perhaps there are yet other
techniques than these three. I do not know whether my injections or those
of my orthopaedic colleague do actually go into the carpal tunnel or
whether they only go near it.
Practically speaking, those who manage carpal tunnel syndrome need to
know:
The "best" site and preparation would have to be decided by reference to
Disappointingly, Dammers et al do not really help us on any of these points and perhaps one day someone will organise a systematic study to elucidate the management of this, perhaps neglected, problem. Tim Davies BMJ 1999; 319:884-6 |
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Abraham Kurian, consultant , Department of Clinical Neurophysiology Southampton General Hospital, Southampton,United Kingdom
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EDITOR - In their double blind trial of Methyl prednisolone injection for carpal tunnel syndrome authors Damners et al mentions that electrophysiological studies were done prior to the treatment. Were they also done during follow up as an objective measure of improvement? If so was there a significant change? Another point of interst would be whether there was any significant difference in the quality of symptoms between responders and non responders. Did troublesome painful paresthesia respond better than symptoms such as numbness,dropping of objects,loss of dexterity and muscle weakness? The latter generally tends to be associated with secondary axonal degeneration and one would expect such cases to respond less well to conservative treatment. There is even a possible risk that these may not recover well even with surgical treatment if it is only used as a last resort after a long delay which can occur if repeated attempts at injecting are made unlike in this study were patients were offered surgical decompression after a single failed injection. Thirdly, table 1 in the article gives the 'number of participants with absence of sensory action potential of Median nerve' as 25 out of 30 in the intervention group and 23 out of 30 in the control group. One assumes it refers to Median digit sensory nerve action potentials(SNAPs).This is an unusually high proportion. SNAPs are usually absent only in very severe cases and it seems rather strange that a study of this nature was done on such severe cases. |
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Wong Shiu Man, Medical Officer and Senior Medical Officer Prince of Wales Hospital,Hong Kong, Hui Che Fai
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Dear Sir Dammers et al has added no new insight to the treatment of carpal tunnel syndrome (CTS). The technique he described has been previously shown to be an effective means of introducing medication into the carpal tunnel in cadaveric forearms(1). Injection of steroids has been reported to be an effective treatment for CTS for relief of symptoms. Unfortunately, the improvemnet is rarely permanent;the figure for relapse given by Dammers et al (50%at one year) is within the expected range quoted by Kulick et al (mean of 27 weeks ranging from 0 to 330 weeks).(2) In the absence of neurophysiological data there is no way of knowing if the control group is comparable to the treatment group. What is needed is a direct comparision between steroid injection against surgical decompression or other mode of treatment. 1.Minamikawa Y,Peimer CA, Kambe K et al Tenosynovial injection for carpal tunnel syndrome. J Hand Surg 1992;17a:178-81 2.Kulick MI, Gordillo G, Jarvidi T et al (1986) Long term analysis of patients having surgical treatment for carpal tunnel syndrome. J Hand Surg [Am]11:59-65 |
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