Article

Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel

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Abstract

Introduction: The aim of this study was to assess alterations in median nerve biomechanics within the carpal tunnel resulting from ultrasound-guided hydrodissection in a cadaveric model. Methods: Twelve fresh frozen human cadaver hands were used. Median nerve gliding resistance was measured at baseline and post-hydrodissection, by pulling the nerve proximally and then returning it to the origin. Six specimens were treated with hydrodissection, and 6 were used as controls. Results: In the hydrodissection group there was a significant reduction in mean peak gliding resistance of 92.9 ± 34.8 mN between baseline and immediately post-hydrodissection (21.4% ± 10.5%, p= .001). No significant reduction between baseline and the second cycle occurred in the control group: 9.6 ± 29.8 mN (0.4% ± 5.3%, p= .467). Discussion: Hydrodissection can decrease the gliding resistance of the median nerve within the carpal tunnel, at least in wrists unaffected by carpal tunnel syndrome. A clinical trial of hydrodissection seems justified. This article is protected by copyright. All rights reserved.

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... Hydrodissection uses a US-guided injection of sterile saline to establish a perineural fluid plane between the surrounding tissues and the nerve, thereby improving the mobility of the nerve. 9 To the best knowledge of the authors, there were two studies in the literature comparing the effect of US-guided steroid injection with or without hydrodissection, which found no further improvement in the hydrodissected group. 10,11 To fill the gap and consolidate scarce data for CTS, we hypothesized that hydrodissection with corticosteroid injection would yield superior clinical and sonographic results compared to corticosteroid injection alone in the short-term. ...
... 10 Evers et al. demonstrated that US-guided hydrodissection with nor-mal saline could decline gliding resistance of the median nerve within the carpal tunnel in cadaveric wrists. 9 There is no consensus regarding the minimum volume of injected fluid required for a significant effect and the number of sessions of nerve hydrodissection in the literature. 21 We chose the 3 mL volume to avoid the pressure and pain associated with highvolume injections that could potentially have a detrimental effect on the carpal tunnel area. ...
... 24 However, it also stated that the hydrodissection effect does not completely depend on the persistence of the fluid bolus and this effect may be long-lasting. 9 We only examined the short-term effects of hydrodissection and no additional effect of hydrodissection was observed at 4-week after injection. Further studies with longer follow-up periods are needed. ...
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ABS TRACT Objective: Corticosteroid injections are remarkably effective as a treatment for carpal tunnel syndrome (CTS) in the short term. This study aimed to determine the effects of ultrasound (US)-guided corticosteroid injection with or without hydrodissection on symptom severity, functional status , grip strength, quality of life, and the cross-sectional area (CSA) of the median nerve in CTS. Material and Methods: A prospective cohort of patients with CTS was retrospectively evaluated. A total of 28 patients were randomly selected who received US-guided triamcinolone injection with hydrodissection (3 mL) as the hydrodissection group and US-guided triam-cinolone injection (1 mL) as the control group, from the data (case-control ratio 1:1). Outcome measures were the hand grip strength (HGS), CSA of the median nerve, Boston Carpal Tunnel Questionnaire (BCTQ), and Short Form 12. We recorded the assessments at baseline, 1 and 4 weeks after injections. Results: HGS significantly improved, CSA of the median nerve, Symptom Severity Scale, and Functional Status Scale (FSS) scores of BCTQ significantly decreased in both groups throughout the assessment points (p<0.01 for each variable). Percent changes in baseline and 1st-week results between groups showed improvement in the FSS score of BCTQ in the hydrodissection group (-47.46% vs.-13.97%, p=0.016) but this was not available after 4 weeks (-53.25% vs.-33.33%, p=0.053). Conclusion: Cor-ticosteroid injection with hydrodissection did not provide an additional clinical effect except for an improvement in functional scores in 1st week.
... Dynamic median nerve entrapment caused by the flexor tendons within the carpal tunnel was diagnosed. US-guided hydrodissection of the median nerve was performed to improve the gliding of MN within the carpal tunnel [1]. He was prescribed a night splint to keep his V C The Author(s) ...
... The dynamic US was performed with the patient's right forearm pronated and the ventral side of the right wrist facing down the ground, simulating the posture while he was performing surgery. With the wrist extended and fist clenched, the right MN glided freely between the flexor retinaculum and the tendons of the flexor digitorum superficialis [1]. However, when the patient flexed the wrist at about 30 degrees and clenched the fist, just as he was holding a surgical instrument during surgery, the right median nerve was trapped and squeezed by the flexor pollicis longus and flexor digitorum tendons ( Figure 1C and D, and Supplementary Video 1). ...
... Dynamic median nerve entrapment caused by the flexor tendons within the carpal tunnel was diagnosed. US-guided hydrodissection of the median nerve was performed to improve the gliding of MN within the carpal tunnel [1]. He was prescribed a night splint to keep his V C The Author(s) 2021. ...
Article
Dear Editor, A 44-year-old male right-handed maxillofacial oral surgeon visited our clinic for the complaint of a 6-month history of numbness over his right thumb, index and middle fingers, and the radial side of the ringer finger, and weakness of his right thumb while performing surgery. These symptoms would be aggravated when he held the surgical instruments tightly and could be temporarily relieved by shaking his right hand. There was also occasional numbness of those involved fingers during the night, and he would wake up feeling the fingers were stiff and swollen. He denied pain over the neck, right shoulder, and right arm/forearm. The electrodiagnostic study results were within normal limits. The essential blood test results were also normal. Under the clinical diagnosis of carpal tunnel syndrome (CTS), he received oral medication treatment including prednisolone and nonsteroid anti-inflammatory drugs and three courses of physical therapy, but these treatments failed to improve his symptoms.
... 11 The procedure has been demonstrated to reduce gliding resistance of the median nerve within the carpal tunnel. 12 Through the breakage of adhesions within the carpal tunnel that then releases pressure on the nervi nervorum and vasa nervorum, it is hypothesized to break the cycle of nerve injury and promote healing, which is then believed to improve patients' symptoms. ...
... To further build the case for hydrodissection in CTS, we posit that it is necessary to prove that the hydrodissection mechanism works, separate from the effect of the injectates, and above and beyond the previous cadaveric work, which did show a reduction in median nerve gliding resistance. 12 This could possibly be through the use of control injections that avoid the median nerve completely. Other unresolved challenges to the validity of the hydrodissection mechanism in CTS include the reported "hourglass" configuration of the nerve at either end of the carpal tunnel, which may then limit nerve mobility regardless of hydrodissection, 31 and the influence of the placebo effect, 32 both of which also bear addressing. ...
... This is possibly derived from a previous cadaveric study that demonstrated complete median nerve hydrodissection within the carpal tunnel with the same volume. 12 In the trial that used 10 ml of injectate, the rationale behind this choice was not apparent. We note the registration of at least one trial comparing 5 ml with 10 ml of injectate and await their findings with interest. ...
Article
Hydrodissection is an ultrasound-guided technique that has received more attention recently for its role in nerve entrapment syndromes. The purpose of this systematic review was to evaluate the safety and effectiveness of hydrodissection in carpal tunnel syndrome as well as to investigate the ideal parameters for injectate type, dosage, volume, and frequency, injection approach and technique, and operator experience as well as training required. We searched the EMBASE, MEDLINE, and PubMed databases with supplemental searches in the CINAHL, Web of Science, and Google Scholar databases for relevant randomized controlled trials. Primary outcome measures were adverse outcomes and clinical effectiveness. Six randomized controlled trials involving 356 wrists were included. All studies utilized ultrasound guidance in their interventions. No safety-related adverse outcomes were found though not all studies declared this. Only 1 study was placebo-controlled and revealed symptomatic as well as functional improvements at 6 months, whereas the rest investigated hydrodissection with different injectate types. We concluded that nerve hydrodissection for carpal tunnel syndrome can be safely performed under ultrasound guidance. However, it is unclear if the hydrodissection mechanism truly causes improvements in clinical outcomes. We were also unable to draw conclusions regarding the ideal procedure-related parameters. We recommend that future work should investigate not only safety and clinical effectiveness but also attempt to clarify the ideal procedure-related parameters.
... It is indicated for conditions, such as nerve disorders and myofascial pain syndrome (MPS) [1]. For HR for MPS, the solution is injected into the inter-fascia, intra-aponeurotic fascia (APF), or intra-muscle [2] to restore normal gliding between layers [3]. ...
... The efficacy of HR in the layers between the APF and EPI, as well as intramuscularly, has not been thoroughly investigated. The only reported instance involves alterations in post-HR gliding, specifically in the case of HR around the median nerve in the carpal tunnel [3]. Therefore, future research should explore the biomechanical effects of HR to gain a deeper understanding of its impact on gliding. ...
... The nerve's CSA (a cutoff value of 9-10.5 mm 2 ) arises as the most useful parameter for the diagnosis [28], whereas its diameter, gliding resistance [29], stiffness (evaluated by sonoelastography), and intraneural vascularity (assessed by power Doppler imaging) may serve as adjuvant indicators. A bifid median nerve ( Figure 4A), the presence of a per sistent median artery ( Figure 4B) with or without thrombosis, accessory flexor digitorum ...
... superficialis muscle ( Figure 4C), laceration of the palmaris longus tendon ( Figure 4D), and schwannoma ( Figure 5) can be associated findings for carpal tunnel syndrome [9]. Regarding US-guided injections for carpal tunnel syndrome, a network meta-analysis, including ten studies with 497 patients, reported that 5% dextrose (D5W) injection was The nerve's CSA (a cutoff value of 9-10.5 mm 2 ) arises as the most useful parameter for the diagnosis [28], whereas its diameter, gliding resistance [29], stiffness (evaluated by sonoelastography), and intraneural vascularity (assessed by power Doppler imaging) may serve as adjuvant indicators. A bifid median nerve ( Figure 4A), the presence of a persistent median artery ( Figure 4B) with or without thrombosis, accessory flexor digitorum superficialis muscle ( Figure 4C), laceration of the palmaris longus tendon ( Figure 4D), and schwannoma ( Figure 5) can be associated findings for carpal tunnel syndrome [9]. ...
Article
Full-text available
Ultrasound has emerged as a highly valuable tool in imaging peripheral nerve lesions in the wrist region, particularly for common pathologies such as carpal tunnel and Guyon’s canal syndromes. Extensive research has demonstrated nerve swelling proximal to the entrapment site, an unclear border, and flattening as features of nerve entrapments. However, there is a dearth of information regarding small or terminal nerves in the wrist and hand. This article aims to bridge this knowledge gap by providing a comprehensive overview concerning scanning techniques, pathology, and guided-injection methods for those nerve entrapments. The median nerve (main trunk, palmar cutaneous branch, and recurrent motor branch), ulnar nerve (main trunk, superficial branch, deep branch, palmar ulnar cutaneous branch, and dorsal ulnar cutaneous branch), superficial radial nerve, posterior interosseous nerve, palmar common/proper digital nerves, and dorsal common/proper digital nerves are elaborated in this review. A series of ultrasound images are used to illustrate these techniques in detail. Finally, sonographic findings complement electrodiagnostic studies, providing better insight into understanding the whole clinical scenario, while ultrasound-guided interventions are safe and effective for treating relevant nerve pathologies.
... Extrication with an associated restoration of MN kinematics breaks the vicious cycle of compression, inflammation, SSCT fibrosis, and nerve ischemia and could contribute to subsequent nerve regeneration [49,53,92,95]. Evers et al. [96] reported that hydrodissection with normal saline (NS) reduces MN gliding resistance within the carpal tunnel in the cadaveric wrist. The green squares represent the differences between the means of each of the two groups compared, i.e., the mean differences. ...
... Extrication with an associated restoration of MN kinematics breaks the vicious cycle of compression, inflammation, SSCT fibrosis, and nerve ischemia and could contribute to subsequent nerve regeneration [49,53,92,95]. Evers et al. [96] reported that hydrodissection with normal saline (NS) reduces MN gliding resistance within the carpal tunnel in the cadaveric wrist. This effect cannot be explained based on the fluid lubrication effect, as it persists without degradation over 1000 repetitions. ...
Article
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Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.
... This decreased mobility has been hypothesized to exacerbate median neuropathy by making it more susceptible to injury. Hydrodissection is used to liberate the median nerve from surrounding connective tissue adhesions, thereby improving mobility, increasing vascularization, and stimulating axoplasmic transport for improved nerve health [43,44,45,46]. Wu et al. [45] demonstrated the therapeutic value of median nerve hydrodissection as a stand-alone treatment in patients with CTS but it remains unclear if hydrodissection provides additional benefit over injection alone [43]. ...
... Recent studies have demonstrated the beneficial healing effects of PRP on a variety of human tissues including peripheral neuropathies like CTS [16,30,31,32,39,40,41,42]. However, variation exists with regard to volume of injectate used, injection approach (e.g., palmer vs. ulnar), and whether or not median nerve hydrodissection was performed [31,43,44,45,46]. Blood drawn and PRP prepared. ...
Article
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Introduction: Hydrodissection has been used during injection procedures to liberate median nerve from surrounding adhesions. This investigation examined clinical and neurophysiologic impact of ultrasound-guided injections in patient with bilateral carpal tunnel syndrome (CTS) serving as own control. Novel to this investigation was performance of active tendon and nerve gliding exercises following median nerve hydrodissection and injection. Case report: A 37-year-old male with 6-year history of bilateral CTS presented for treatment. Wrists randomly assigned to receive platelet-rich plasma (PRP) or equal volume saline injection and median nerve hydrodissection. The patient performed active tendon and nerve gliding exercises following injection procedures. Pain ratings, CTS-related disability scores, median nerve function, and median nerve cross-section area measurements for each wrist/hand collected at baseline 2, 4, 6, and 12 months following injection procedures. 6-month follow-up. The right (saline) and left (PRP) wrists showed improvements in disability and nerve function. The left wrist (PRP) also showed improvement in pain. 1-year follow-up. The right (saline followed by PRP at 6 months) and left (PRP) wrists showed improvements in pain, disability, and nerve function. Conclusion: Results suggest innovative treatment approach for CTS, namely, ultrasound-guided PRP injection including median nerve hydrodissection followed by performance of active tendon and nerve gliding exercises in immediate post-injection period. The patient demonstrated improvements in pain, CTS-related disability, and median nerve function comparable to surgical release and generally better than non-surgical interventions. Findings should stimulate further investigation into marrying mechanically based treatments with PRP to produce better long-term outcomes in patients with CTS.
... 37 Saline is widely used either as a single compound in hydrodissection or as a diluting substance for corticosteroids or LAs ( Figure 5A,B,C). [30][31][32][33][34][35]40,41 There are no serious adverse effects of saline; however, pain upon injection has been reported when no LA is added. 22,28,30,40 A promising type of injectate is PRP 25,38 that triggers a neuroregenerative response by releasing several hormones and growth factors, such as platelet-derived growth factor, transforming growth factor, epidermal growth factor, vascular endothelial growth factor, and insulin-like growth factor-1. ...
... 30,43 With hydrodissection, adhesiolysis can be achieved by separating TCL from the MN and enabling normal tendon gliding. 28,41 A prospective randomized control trial on the effects of hydrodissection showed a significant improvement of the intervention group at a 3-month follow-up in comparison to the control group. 37 In the intervention group, a multideposit injection was performed to detach the MN from the TCL and separate the MN from the flexor tendons, whereas in the control group saline was injected subcutaneously. ...
Article
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Background Carpal tunnel syndrome (CTS), one of the most common entrapment neuropathies, can, in fact, be considered as a socio-economic issue that reduces work productivity, increases disability, and requires prolonged rehabilitation. The imaging modality of choice in CTS imaging is the ultrasound (US), as several morphological parameters can be used in CTS diagnosis and follow-up. In recent years, US-guided CTS injection therapy has become an established treatment option for mild to moderate CTS. The authors of this review performed a literature search that revealed several differences in US-guided carpal tunnel injection in an attempt to unify individual stages of CTS injections protocol for future guidance: patient preparation, injection approach, needle positioning, injected medications, and injectate volume. The three approaches to carpal tunnel injections described in the literature, that is, the ulnar, radial, and longitudinal, can be implemented with single or multiple deposits and different injection volumes. Medications used for injections are corticosteroids, local anaesthetics, dextrose, saline, platelet-rich plasma, and progesterone. Conclusions Although no consensus has yet been reached as to which protocol should be used, the ulnar approach with a single deposit injected in large volumes should be considered as the first choice, while dextrose should be the first-line medication option. Furthermore, as terminological differences make it difficult to draw a uniform comparison the presented steps for US-guided carpal tunnel injection might serve as a guideline for future studies.
... A higher volume of PDI yielded better clinical outcomes in our previous work [11]. Moreover, injection therapy with hydrodissection could also improve nerve displacement after decreasing nerve gliding resistance in the carpal tunnel [12]. However, the dynamic ultrasonographic change and elastography of median nerve after a different volume of dextrose injection is still unknown. ...
... Hydrodissection enhanced nerve excursion through mechanical separation of subsynovial connective tissue(SSCT) [19]. In aspect of mechanical concept, cadaveric study assessing the biomechanical change founded the peak gliding resistance reduced after median nerve hydrodissection [12]. The theory based on nerve separation from surrounding connective tissue to release entrapment by perineural injection [20]. ...
Article
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This study aimed to investigate the effect of different injectate volumes on ultrasonographic parameters and the correlation to clinical outcomes under perineural dextrose injection (PDI). In this post hoc analysis of the randomized, double-blinded, three-arm trial, ultrasound-guided PDI with either 1 mL, 2 mL, and 4 mL 5% dextrose water was administered, respectively, in 14, 14, and 17 patients. Ultrasound outcomes included mobility, shear-wave elastography (SWE), and cross-sectional area (CSA) of the median nerve; clinical outcomes were Visual Analog Scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) score. Outcomes were measured before injection, and after injection at the 1st, 4th, 12th, and 24th week. For ultrasound outcomes, CSA decreased significantly from baseline data at all follow-up time-points in the 2 mL group (p = 0.005) and the 4 mL group (p = 0.015). The mean change of mobility from baseline showed a greater improvement on the 4 mL group than the other groups at the 1st week post-injection. For clinical outcomes, negative correlation between the VAS and mobility at the 1st (p = 0.046) and 4th week (p = 0.031) post-injection in the 4 mL group were observed. In conclusion, PDI with higher volume yielded better nerve mobility and decreased CSA of median nerve, but no changes of nerve elasticity.
... In 2018, Evers et al. [20] conducted a cadaveric study aiming to evaluate changes in the biomechanics of median nerves after US-guided hydrodissection. They prepared 12 fresh cadaveric hands (six for hydrodissection and six as controls) by exposing the median nerves proximal to the wrist crease. ...
... In 2018, Wu et al. [21] conducted a randomized controlled trial to investigate the clinical effectiveness of hydrodissection in mild to moderate CTS. A total of 34 patients were randomly assigned to two groups, in other words, the intervention group undergoing US-guided hydrodissection with 5-ml saline as described above [20] versus the placebo group only receiving subcutaneous injection of the same amount of saline. Significant improvement in Boston Carpal Tunnel Syndrome Questionnaire scores was observed in the intervention group (vs the placebo group) at 6 months after the treatment. ...
Article
Full-text available
Ultrasound (US) imaging has become one of the most useful modalities to assess peripheral nerve disorders. Nowadays, it is as important as nerve conduction studies and electromyography for peripheral nerve entrapment. Additionally, US is also helpful in guiding a possible intervention. As peripheral nerves are tiny, palpation-guided injections are really challenging for precisely targeting the nerves. By using US, perineural injections have significantly become safe and effective. Recently, US-guided hydrodissection has emerged as the mainstream for nerve entrapment. Accordingly, this review aims to summarize and update the mechanism and evidence regarding this imperative procedure for neuropathic pain management. Furthermore, the pathogenesis, anatomic features, US findings and histological correlations of nerve entrapment syndromes will also be discussed in this article.
... Most of the included studies chose an injection volume of 5 cc for carpal tunnel injection, likely stemming from previous cadaveric studies that achieved complete intracarpal median nerve hydrodissection with the same volume. 28 Our analysis of these studies showed that 5 cc was the most effective dose for improving symptoms and function. In contrast, higher doses of 10 cc were less effective in improving symptoms and function, suggesting that increased carpal tunnel pressure is a factor in the pathogenesis of CTS and the 10 cc dose may offset the benefits of nerve hydrodissection by increasing intracarpal Five percent DW is an isotonic solution containing 5% DW, specifically D-glucose, at a concentration of 278 mmol/L. ...
... Hydro-dissection releases perineural adhesions by dissecting sub-synovial connective tissue, which may alleviate CTS symptoms. HD of the carpal tunnel has been shown to reduce the gliding resistance of the median nerve in a cadaver investigation [15]. ...
Article
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Background Most cases of entrapment neuropathy are due to median nerve compression, which manifests most commonly as carpal tunnel syndrome (CTS). There are several nonsurgical treatment options available for mild-to-moderate circumstances. Aim To assess the effect of ultrasound-guided percutaneous flexor retinaculum fenestration on the outcome of hydrostatic dissection of the median nerve in cases with CTS. Methods This randomized clinical research included a total of 54 individuals with CTS separated into two groups; group (A) included patients with hydrostatic dissection with adjuvant fenestration of transverse carpal ligament ( n = 27), while group (B) involved patients with hydrostatic dissection alone ( n = 27). Pain and disability through the visual analog scale (VAS), symptom severity (SS) score, modified Boston Carpal Tunnel Questionnaire (BCTQ), and functional disability (FD) score before injection and 3 months post-injection were assessed. Distal motor latency (DML) and sensory conduction velocity (SCV) were measured at baseline and 3 months after the procedure. Results SS and FD scores, were comparable in both groups before the procedure, while after three months of the procedure, the mean of SS and FD scores was significantly higher in group A (24.18 ± 3.62 and 17.52 ± 2.15, respectively) than in group B (16.55 ± 3.17and 11.39 ± 1.81, respectively) ( p < 0.001). Also, there was a significant distinction between before and after the procedure in both groups ( p < 0.001). Regarding electro physiologic outcomes, DML and SCV were comparable in both groups before the procedure, while after three months of the procedure, the mean of DML and SCV scores was significantly higher in group A (4.41 ± 0.41 and 39.27 ± 2.35, correspondingly) than group B (4.23 ± 0.37and 42.55 ± 2.75, respectively) ( p = 0.011 and < 0.001, correspondingly). Also, there was significant variance between before & after the procedure in both groups ( p = 0.010 and < 0.001, correspondingly). Conclusion Ultrasound-guided hydro-dissection and fenestration of the transvers carpal ligament is a simple, non-invasive treatment for CTS that has the potential to reduce symptoms for a long time and delay or perhaps prevent the need for open release.
... 69e71 Extrication of the nerve, with an associated restoration of MN kinematics can break the vicious cycle of compression, neuroinflammation, SSCT fibrosis, and nerve ischemia, and could contribute to subsequent nerve regeneration. 60,69,72,73 Evers et al. 74 reported that HD with normal saline (NS) reduces MN gliding resistance within the carpal tunnel in the cadaveric wrist. Although HD is an interesting technique that may have promise, the evidence for its efficacy and underlying mechanism is still uncertain. ...
Article
Full-text available
Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy but current conservative treatments are unsatisfactory. Recently, clinical trials using ultrasound-guided regener-ative injection with 5 % dextrose water or platelet-rich plasma have reported clinically and statistically significant benefits compared to current conservative treatments for the treatment of CTS. Regenerative injection for CTS is increasingly being utilized, proportional to the worldwide expansion of skills in the use of ultrasound guidance for precise injection and localization, and due to accumulating evidence that it enhances the success rate of conservative treatment, and reduces the rate of surgery. In this narrative review, our goals are to introduce ultrasound-guided regenerative injection and current injection methods, to discuss potential mechanisms, to describe results from recent clinical studies, and to provide perspectives from our clinical experience.
... Hydrodissection refers to a technique of fluidic dissection between tissues using a medicinal solution, and hydrodissection specifically targeting nerves is called nerve hydrodissection [13,14]. Biomechanical studies have shown that performing hydrodissection on nerves improves their gliding resistance [15]. In addition to reducing the gliding resistance of nerves, hydrodissection is believed to be effective in alleviating pain originating from nerves by improving local circulation around the nerve [16]. ...
... Overall, NS is a commonly used fluid in HD procedures and has been demonstrated to be effective in reducing resistance to longitudinal sliding of the median nerve, which can explain the improvement in pain and functional status [71]. ...
Article
Full-text available
Ultrasound-guided perineural hydrodissection (HD) is a novel technique that has been found to be effective in providing mechanical release of perineural adhesions and decompression of the nerve, reducing inflammation and edema and restoring its physiological function. It has a significant impact on chronic neuropathic pain (20 ± 4 weeks with VAS < 5 or VAS diminished by 2 points after the procedure). Carpal tunnel syndrome (CTS) is a common entrapment mononeuropathy, and its distribution is typically innervated by the median nerve. Patients with mild or moderate CTS may benefit from nonsurgical treatments or conservative therapies. This review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Four investigators assessed each title, abstract, and full-text article for eligibility, with disagreements being resolved by consensus with two experienced investigators. The qualitative assessment of the studies was carried out using the modified Oxford quality scoring system, also known as the modified Jadad score. Furthermore, risk of possible biases was assessed using the Cochrane collaboration tool. The results of this review suggest that US-guided HD is an innovative, effective, well-tolerated, and safe technique (11 out of 923 patients had collateral or side effects after the procedure). However, further studies comparing all drugs and with a larger sample population are required to determine the most effective substance.
... A biomechanical study has demonstrated that performing hydrodissection on nerves improves their gliding resistance [10]. In addition to reducing the gliding resistance of nerves, hydrodissection is believed to be effective in alleviating pain originating from nerves by improving local circulation around the nerve [5]. ...
Article
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We present a case study of a 61-year-old man who experienced sural neuropathy following calcaneus fracture surgery, which was effectively treated using ultrasound-guided hydrodissection. Postoperatively, while the patient exhibited good bony fusion, he reported pain on the lateral side of the calcaneus. Ultrasound findings did not suggest any nerve discontinuity, but localized tenderness around the sural nerve was observed. After hydrodissection using 0.09% lidocaine, the patient's pain significantly decreased. Although hydrodissection alleviated the pain, complete resolution was achieved only post plate removal and neurolysis. This study represents the first report on the efficacy of hydrodissection for postoperative sural neuropathy, suggesting its potential as an effective treatment option.
... Under ultrasound guidance, it is characterized by anechoic fluid adjacent to a targeted nerve. The volume required for hydrodissection remains a highly contested topic, with most studies using a volume between 1 and 10 ml [9][10][11]. Some argue that the use of increased volume may also result in better distribution for the therapeutic properties of various injectate types [9]. ...
Article
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Purpose of Review The goal of this review was to describe the efficacy of hydrodissection for peripheral nerve entrapments and to explore its utility as a non-surgical treatment modality. Recent Findings Ultrasound guided hydrodissection of nerve entrapments can improve quality of life and prevent the need for surgery in some cases. Summary Hydrodissection proves a useful and efficacious tool in treating peripheral nerve entrapments of both the upper and lower extremity. There is a lack of consensus in injectate type and volume of injectate, but all hydrodissection were performed with ultrasound guidance and many improved primary and secondary outcomes studied.
... Moreover, dextrose 5% has been reported to have similar efficacy as triamcinolone for improving pain intensity and functional limitations in daily life [8]. Its mechanism of action is thought to depend on hydrodissection and adhesiolysis [9]. In these cases, since the diagnosis was not proven by NCS, so 5% dextrose hydrodissection was chosen so as not to take any potential risk of a glucocorticoid injection. ...
Article
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The most common entrapment neuropathy is carpal tunnel syndrome (CTS), which is caused by compression of the median nerve as it travels through the carpal tunnel in the wrist. Nerve conduction studies (NCS) and ultrasound were used to diagnose CTS but neither method is 100% accurate. The benefit of perineural dextrose injection has been supported in the literature. This article presents three cases with bifid median nerve (BMN) in whom median nerve entrapments were not detected with NCS, and symptom relief was provided with hydrodissection with 2 ml 5% dextrose.
... By contrast, a stiffer and thicker SSCT also increases intra-carpal tunnel pressure, followed by nerve ischemia and compression, impairing the motion of the MN [27]. Another cadaver study found that a hydrodissective injection into the MN decreased the gliding resistance in the carpal tunnel, indicating that freeing the nerve from surrounding tissues might restore optimal kinematics via the dissecting method [30]. Our previous clinical trial also demonstrated that the larger volume ultrasound-guided dextrose injection provided better pain relief and nerve mobility in CTS patients [31,32]. ...
Article
Objectives This systematic review and meta-analysis investigated the mobility of the median nerve (MN) in carpal tunnel syndrome (CTS) patients compared to healthy people.Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed and the electronic databases including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to April 2022. All published observational studies comparing the excursion of MN between participants with and without CTS were included. The quality of research was assessed by the Newcastle-Ottawa Scale tool. The primary outcome was the excursion of the MN under dynamic examination, representing nerve mobility quantified by the standardized mean difference (SMD) for random effect meta-analysis.ResultsFourteen studies were included in the qualitative review, and twelve entered the meta-analysis involving a total of 375 CTS patients and 296 healthy controls. The forest plot revealed that the mobility of the MN significantly decreased in the CTS group compared to the non-CTS control (SMD = −1.47, 95% CI: −1.91, −1.03, p < 0.001, heterogeneity 82%). In subgroup analysis, both transverse and longitudinal methods for nerve excursion showed less nerve mobility in CTS than in non-CTS.Conclusions This meta-analysis showed that the patients with CTS exhibited less mobility of the MN than those without CTS, suggesting MN mobility as a potential CTS marker.Key Points • The patients with CTS revealed less mobility of the median nerve than those without CTS. • The mobility of the median nerve could be regarded as a potential CTS marker.
... Because of the ischemia-reperfusion mechanism, noninflammatory thickening and fibrosis of the SSCT may cause adhesion and impair the gliding function of the MN (42). Indeed, studies have revealed that hydro-dissection 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 could decrease the gliding resistance of the MN within the carpal tunnel (43) and improve symptom relief with decreased CSA of the MN in patients with CTS (44). Although the specific action pathway of PRP in the treatment of peripheral neuropathies remains nebulous, it is thought to potentially induce Schwann cell proliferation, migration, myelination, and angiogenesis (6). ...
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Objective Interest in perineural platelet-rich-plasma (PRP) injections for the treatment of carpal tunnel syndrome (CTS) has increased in recent years. However, evidence supporting the long-term effectiveness of PRP is lacking. Therefore, the aim of our cross-sectional cohort study was to investigate the long-term results of PRP injections for CTS. Methods Eighty-one patients diagnosed with CTS of any grade who received a single PRP injection at least 2 years prior were enrolled. Through structured telephone interviews, all patients were asked of their post-injection outcomes compared to their pre-injection condition. Symptom relief ≥50%, compared to the pre-injection condition, was considered an effective outcome. Binary logistic regression was applied to analyze each baseline variable as a regressor for determining the prognostic outcome factors. Results In total, 70% of patients reported positive outcomes ≥2 years post-injection. Shorter duration of symptoms before treatment (odds ratio: 0.991; 95% confidence interval [CI] 0.983–0.999; p = 0.023) and lower electrodiagnostic severity of CTS were the main prognostic factors for an effective outcome (mild grade vs. severe grade, odds ratio: 17.652; 95% CI 1.43–221.1; p = 0.025). Although there was a trend toward positive outcomes at longer follow-up durations (2–3 years vs. 3–4 years vs. 4–5 years), the difference was not statistically significant. Conclusion A single perineural PRP injection has a long-term analgesic effect on CTS, especially in mild-to-moderate cases.
... Because of the ischemia-reperfusion mechanism, noninflammatory thickening and fibrosis of the SSCT may cause adhesion and impair the gliding function of the MN [42]. Indeed, studies have revealed that hydrodissection could decrease the gliding resistance of the MN within the carpal tunnel [43] and improve symptom relief with decreased CSA of the MN in patients with CTS [44]. Although the specific action pathway of PRP in the treatment of peripheral neuropathies remains nebulous, it is thought to potentially induce Schwann cell proliferation, migration, myelination, and angiogenesis [6]. ...
... However, the injectate may infiltrate more into other layers if a higher injection volume was used in group 1 compared with group 2. Moreover, in our clinical experience and cadaver studies, the fluid inside the carpal tunnel after hydrodissection may clear up within 30 min, making the final concentration of the corticosteroid reaching the under-hydrodissected MN even less (6). Assuming that the two groups have the same drug effect, there should be an additional hydrodissection effect in group 1, as was shown in a previous study with 3 months of therapeutic effect for symptom relief of CTS after 5 mL saline hydrodissection (7). ...
Article
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This commentary significantly points out the critical endpoint of the ultrasound-guided hydrodissection of the MN used in CTS. All the tethering fibrotic or scar tissues over both above and below the MN, over both the ulnar and radial sides of the MN, should be hydrodissected, and the final hydrodissected MN should appear rounded/oval for the best results and prevention of recurrence. This letter also further draws attention to the possible contribution of ultrasound-guided hydrodissection of nerves on the treatment of entrapment neuropathy as in CTS.
... By dissecting the subsynovial connective tissue, hydrodissection releases perineural adhesions, which may improve the symptoms of CTS. A cadaver study demonstrated a decrease in gliding resistance of the median nerve in the carpal tunnel after hydrodissection (12). ...
Article
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Background: Despite the wide use of corticosteroid hydrodissection for carpal tunnel syndrome (CTS), there is insufficient evidence to confirm its efficacy. This study aimed to compare the effectiveness of corticosteroid hydrodissection vs. corticosteroid perineural injection alone on clinical and electrophysiological parameters in patients with CTS. Method: This prospective randomized controlled trial (RCT) was conducted in a tertiary care center with a follow-up period of 12 weeks. Subjects were randomly assigned to either ultrasound-guided hydrodissection with a mixture of 1 mL of triamcinolone acetonide (10 mg/mL), 1 mL of 2% lidocaine, and 8 mL normal saline or ultrasound-guided perineural injection with 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of 2% lidocaine. The primary outcome measure was the symptom severity subscale (SSS) of Boston Carpal Tunnel Questionnaire (BCTQ) scores at baseline and at 6 and 12 weeks' post-treatment. The secondary outcomes included the functional status subscale (FSS) of BCTQ and the distal motor latency and sensory nerve conduction velocity of the median nerve. The effect of interventions on the designated outcome was analyzed using a 3 × 2 repeated measures analysis of variance. The within-subject and among-subject factors were differences in time (before the intervention, and 6 and 12 weeks after injection) and intervention types (with or without hydrodissection), respectively. Results: Sixty-four patients diagnosed with CTS were enrolled. Both groups experienced improvement in the SSS and FSS of BCTQ and median nerve distal motor latency and sensory nerve conduction velocity. However, group-by-time interactions were not significant in any outcome measurements. No serious adverse events were reported in either group, except for two patients in the hydrodissection group who reported minor post-injection pain on the first day after the intervention, which resolved spontaneously without the need for additional treatments. Conclusion: Hydrodissection did not provide an additional benefit compared to corticosteroid perineural injection alone. More prospective studies are needed to investigate the long-term effectiveness of corticosteroid hydrodissection, as well as its influence on median nerve mobility.
... Generally, conservative treatment is considered the first option for mild to moderate injuries, while surgical treatment is standard for severe injuries or lesions that do not respond adequately to conservative management [7]. Current literature has focused on the efficacy of surgical and pharmacological treatments [8][9][10][11][12][13][14][15][16][17][18][19][20][21]. Regarding conservative treatments, most research evaluates the effects of electrophysical modalities (EM) in carpal tunnel syndrome (CTS) [22][23][24][25][26][27][28][29][30][31][32]. ...
Article
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Introduction People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them. Methods We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980–2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook. Results Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID). Conclusions We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant. Trial registration PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.
... Some authors believe that hydrodissection, coupled with mechanical disruption of the adhesions around the nerve, may restore normal nerve mobility. 29 Wu et al. 30 conducted a placebo-controlled study where hydrodissection of the median nerve (in contrast to subcutaneous 5 mL saline injection) yielded symptom improvement 6 mos after the procedure. On the other hand, Schrier et al. 31 reported comparable results of US-guided injections applied by either hydrodissection or single delivery medial to the median nerve. ...
Article
Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). While the majority of the anatomical structures are quite superficial and easily evaluated during physical examination; for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis and the radiocarpal joint arthritis. Additionally, the authors also exemplify evidence from the literature supporting the rationale why US guidance is henceforth unconditional in musculoskeletal practice.
... A systematic review documented reduced nerve excursion in CTS people compared to healthy controls (Ellis et al., 2017). One cadaver study showed decreased gliding resistance of the nerve in the carpal tunnel after hydrodissection (Evers et al., 2018). Two clinical RCTs further showed positive effects of hydrodissection on pain, function and CSA (Roghani et al., 2018;Wu et al., 2019). ...
Article
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Ultrasound-guided perineural dextrose injection (PDI) has been reported effective for carpal tunnel syndrome (CTS). Higher volume of injectate may reduce adhesion of median nerve from other tissues, but volume-dependent effects of PDI in CTS remain unknown. We aimed to investigate whether PDI with different injectate volumes had different effects for CTS participants. In this randomized, double-blinded, three-arm trial, 63 wrists diagnosed with CTS were randomized into three groups that received ultrasound-guided PDI with either 1, 2 or 4 ml of 5% dextrose water. All participants finished this study. Primary outcome as visual analog scale (VAS) and secondary outcomes including Boston Carpal Tunnel Questionnaire (BCTQ), Disability of the Arm, Shoulder and Hand score (QuickDASH), electrophysiological studies and cross-sectional area (CSA) of the median nerve at carpal tunnel inlet were assessed before and after PDI at the 1st, 4th, 12th and 24th weeks. For within-group analysis, all three groups (21 participants, each) revealed significant improvement from baseline in VAS, BCTQ and QuickDASH at the 1st, 4th, 12th and 24th weeks. For between-group analysis, 4 ml-group yielded better VAS reduction at the 4th and 12th weeks as well as improvement of BCTQ and QuickDASH at the 1st, 4th, and 12th weeks, compared to other groups. No significant between-group differences were observed in electrophysiological studies or median nerve CSA at any follow-up time points. There were no severe complications in this trial, and transient minor adverse effects occurred equally in the three groups. In conclusion, ultrasound-guided PDI with 4 ml of 5% dextrose provided better efficacy than with 1 and 2 ml based on symptom relief and functional improvement for CTS at the 1st, 4th, and 12th week post-injection, with no reports of severe adverse effects. There was no significant difference between the three groups at the 24th-week post-injection follow-up. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03598322.
... 5,12 Advantages of the procedure are that injection may be applied using sterile saline solution or physiologically similar fluid and it may be performed in office conditions. 13 Rosales et al. have applied a perisciatic USguided infiltration technique. 14 They used a mixture containing 20 mL saline, 4 mL local anaesthetic and 1 mL corticosteroid and infiltrated in the perisciatic region between the gluteus maximus and pelvitrochanteric muscles. ...
... A cadaveric study done in Mayo clinic showed that HD can decrease the gliding resistance of the median nerve within the carpal tunnel, supporting the concept that HD may result in a beneficial mechanical change in nerve movement. 41 However, the gliding resistance was measured immediately after hydrodissection and does not offer proof of a sustainable benefit. At this time that can be implied only indirectly by sustainable symptomatic benefit, and improvement of neural edema and nerve conduction parameters. ...
Article
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Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.
... Another randomized controlled trial pointed out that precise hydro-dissection of the median nerve using saline under ultrasound guidance yielded better clinical outcomes than subcutaneous saline injection. Therefore, the observed superiority of D5W over PRP (with respect to CTS symptoms) in this meta-analysis may be partly derived from a higher injection volume and the mechanical effect of nerve hydrodissection guided by ultrasound imaging [15,16]. ...
Article
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Background Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Typical symptoms and signs include numbness, tingling, pain, or burning sensation in the digits supplied by the median nerve and/or nocturnal paresthesia. Treatments of CTS range from conservative measures to surgical decompression of the median nerve. Results The PRP group showed a statistically significant reduction in the visual analog scale, Boston Carpal Tunnel Syndrome Questionnaire, for the severity and the functional capacity scores, and cross-sectional area of the median nerve compared to those of control group 3 months post-treatment ( p < 0.05). Conclusions Platelet-rich plasma injection in CTS relieves pain and symptom severity and improves functional status but not significantly improve the electrophysiological parameters.
... 5,6 It has also been used with ultrasound guidance in peripheral nerve entrapment with two goals: (1) to restore function to the nerve and (2) to release soft tissue adhesions causing entrapment. 4,5,7 Methods differ, and saline, anesthetics, steroids, platelet-rich plasma, and dextrose have all been utilized to varying efficacy. 8 While a relative paucity of cases have specifically reported hydrodissection of the peroneal nerve, the procedure has been described as successful in other neuropathies. ...
Article
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A 51-year-old man presented with pain in the region of his left patellar tendon and fibular head. He had previously undergone three L5 epidural steroid injections and physical therapy without relief. Prior magnetic resonance imaging was significant only for fat pad impingement, and electromyography and nerve conduction studies were negative. Ultrasound demonstrated an enlarged peroneal nerve suggestive of peroneal nerve entrapment. Three ultrasound-guided hydrodissection procedures offered symptomatic improvement and identified an area posterior to the fibular head that was unable to be hydrodissected, indicating scar tissue causing peroneal nerve compression. The patient was referred for peroneal nerve decompression at the area of entrapment with complete symptom relief. This case is unique in describing the ability of hydrodissection to identify nerve compression not visualized with other diagnostic tests.
... Additionally, ultrasound guidance was used in the two trials of D5W, but not in all studies using PRP. A cadaveric study has demonstrated that a bolus saline injection could effectively reduce the peak gliding resistance of the median nerve [46]. Another randomized controlled trial pointed out that precise hydro-dissection of the median nerve using saline under ultrasound guidance yielded better clinical outcomes than subcutaneous saline injection [47]. ...
Article
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This network meta-analysis aimed to integrate the available direct and indirect evidence on regenerative injections—including 5% dextrose (D5W) and platelet-rich plasma (PRP)—for the treatment of carpal tunnel syndrome (CTS). Literature reports comparing D5W and PRP injections with non-surgical managements of CTS were systematically reviewed. The main outcome was the standardized mean difference (SMD) of the symptom severity and functional status scales of the Boston Carpal Tunnel Syndrome Questionnaire at three months after injections. Ranking probabilities of the SMD of each treatment were acquired by using simulation. Ten studies with 497 patients and comparing five treatments (D5W, PRP, splinting, corticosteroid, and normal saline) were included. The results of the simulation of rank probabilities showed that D5W injection was likely to be the best treatment, followed by PRP injection, in terms of clinical effectiveness in providing symptom relief. With respect to functional improvement, splinting ranked higher than PRP and D5W injections. Lastly, corticosteroid and saline injections were consistently ranked fourth and fifth in terms of therapeutic effects on symptom severity and functional status. D5W and PRP injections are more effective than splinting and corticosteroid or saline injection for relieving the symptoms of CTS. Compared with splinting, D5W and PRP injections do not provide better functional recovery. More studies investigating the long-term effectiveness of regenerative injections in CTS are needed in the future.
... The term hydrodissection has become common in the descriptions of ultrasound-guided carpal tunnel injections and described recently as being a useful technique for disrupting adhesions, especially when combined with multiple needle fenestration of the transverse carpal ligament in an attempt to weaken it (29). Evers et al (30) demonstrated that infiltration of saline solution only into the carpal tunnel can reduce the resistance to longitudinal sliding of the median nerve, and this can explain the improvement in pain, SS, and functional status we found in the saline solution group. Smith et al (26) described ultrasound-guided HD of the carpal tunnel to be a familiar procedure of CTS corticosteroid injection. ...
Article
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Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, which results from median nerve compression. A lot of nonsurgical modalities are available for the management of mild to moderate situations. Local Hyalase hydrodissection (HD) of the entrapped median nerve could offer a desirable sustained symptom alleviation. Objectives: To evaluate the clinical efficacy of Hyalase/saline solution carpal tunnel HD on pain, functional status, and nerve conduction in patients with CTS. Study design: A randomized, double-blinded trial. Setting: Anesthesia, pain, and rheumatology clinics in a university hospital. Methods: Patients: 60 patients with CTS (> 6 months' duration). Intervention: patients were allocated equally into either group 1 (HD with Hyalase + 10 mL saline solution injection), or group 2 (HD with 10 mL saline solution only). Measurements: assessment of pain using Visual Analog Scale (VAS), functional disability (FD) score, and nerve conduction studies before injection, and over 6 months after injection. Nerve conduction parameters before injection and postinjection by the end of 3 and 6 months were evaluated as well. Results: Statistically significant lower postinjection values of VAS (1 ± 1.8, 2 ± 1.1, 2 ± 1.2, 2 ± 1.1) in group 1 versus (2 ± 1.2, 3 ± 1.7, 4 ± 1.5, 5 ± 2.6) in group 2 by the end of the first week, and the first, third, and sixth months, and significantly lower FD scores (15.3 ± 1.2, 13 ± 1.3, 10.2 ± 1.3, 10.2 ± 1.3) in group 1 versus (17.5 ± 1.8, 16.6 ± 2.8, 19.4 ± 3.2, 21.2 ± 2.5) in group 2 during the same time intervals. Nerve conduction study parameters have shown significantly higher velocity and lower latency in the Hyalase group than in the saline solution group by the 3 and 6 month follow-up. Limitation: We suggest a longer period could be reasonable. Conclusions: Carpal tunnel HD with Hyalase with saline solution is considered as an efficient technique offering a rapid onset of pain relief and functional improvements, and better median nerve conduction in patients with CTS over 6 months follow-up duration. Key words: Carpal tunnel syndrome, Hyalase, median nerve hydrodissection.
... From a clinical perspective, increased attention has been focused on injection treatments targeting the fascia (including the peripheral nerve, myofascia, and surrounding connective tissue), such as US-guided hydrodissection [22,31] and US-guided hydrorelease [25,29]. The underlying mechanism of these procedures for pain relief has undergone debate, with hypotheses including washingout of the algesic substance with solution and improvement in the smoothness of tissue sliding [25,[30][31][32]. The effectiveness of blind injection without US for MPS has been indicated to be as almost equal regardless of the injected substance (physiological saline, local anesthesia, or botulinum toxin) [33]. ...
Article
Objective: An ultrasound-guided interfascial injection, which targets the space between the epimysia, is often performed for myofascial neck and shoulder pain. However, the relationship between the injection volume and clinical effectiveness has been controversial. We conducted an anatomical study with cadavers to measure the distribution of a small amount of pigment solution injected into the interfascial space. Design: An experimental cadaveric study. Setting: An institutional clinical anatomy laboratory. Methods: We performed 20 ultrasound-guided injections with pigment solutions of 1.0 mL each into the space between the trapezius muscle and rhomboid muscle bilaterally on 10 cadaver specimens. Cadavers were then dissected and macroscopically evaluated for pigment distribution on the fascia of the muscular surfaces. The pigment distribution area of each injection site was visually confirmed and calculated using automatic area calculation software. Results: Pigment solution exclusively within the interfascial space was visually confirmed in 95% (19/20) of injection sites. The median pigmented surface area (interquartile range) was 24.50 (16.17-30.76) cm2 on the deep side of the trapezius muscle and 18.82 (13.04-24.79) cm2 on the superficial side of rhomboid muscle; these measurements were statistically significantly different (P = 0.033). Conclusions: A pigment solution comprising as little as 1.0 mL injected under ultrasound guidance separated two adjacent muscles and spread to the wide area within the interfascial space. The difference in the pigment distribution area between the two adjacent muscles can be explained by the path made by the injection needle and several layers of fascia between the epimysium.
... 8 Decreased nerve mobility on ultrasound imaging has been noted in carpal tunnel syndrome; thus, nerve hydrodissection may in part improve the gliding and movement of the nerve in relation to surrounding tissues. 9 Although there remains a paucity of literature describing widespread use of this ultrasound-guided nerve hydrodissection, we have found that it is lower in risk compared to surgical decompression and more effective than nonsurgical measures such as using orthoses to alleviate pain. Even if nerve hydrodissection does not lead to durable relief, it may still provide diagnostic information, especially if the injection volume is not so large that it anesthetizes surrounding tissues. ...
... Hydrodissection (or hydroneurolysis) has been shown to reduce gliding resistance in the carpal tunnel in cadaver models. 14 This technique may be especially helpful in situations where scar tissue contributes to the pathology such as in recurrent carpal tunnel syndrome (CTS) following a surgical release. 15 An example of fluid dissection of the median nerve from the transverse carpal ligament and subsynovium is shown in Supplementary Video 1. ...
Article
The advent of high resolution neuromuscular ultrasound (US) has provided a useful tool for conservative treatment of peripheral entrapment mononeuropathies. US‐guided interventions require careful coordination of transducer and needle movement along with a detailed understanding of sonoanatomy. Preprocedural planning and positioning can be helpful in performing these interventions. Corticosteroid injections, aspiration of ganglia, hydrodissection, and minimally invasive procedures can be useful non‐surgical treatments for mononeuropathies refractory to conservative care. Technical aspects as well as the current understanding of the indications and efficacy of these procedures for common entrapment mononeuropathies will be reviewed. This article is protected by copyright. All rights reserved.
Article
Entrapment neuropathy is mainly diagnosed on the basis of clinical symptoms. Often electrodiagnostic studies help in detecting the abnormalities in conduction velocity, latency, and amplitude and aid in diagnosis. There is a lack of guidelines on the management of entrapment neuropathies. However, in recent times, ultrasound-guided injections, hydrodissection, and pulsed radiofrequency ablation are being increasingly done. We present a case of a 40-year-old female presented with severe burning pain, tingling, and occasional numbness over the anterolateral aspect of the left leg radiating to the thigh and dorsum and the lateral aspect of the left foot for more than 1 and 1/2 years. Pain was gradual in onset, associated with occasional pins and needle sensation, followed by numbness over the dorsum of the foot. She took multiple medical opinions, consulted many doctors, and was advised for magnetic resonance imaging of the lumbosacral spine, which showed mild annular and posterior disc bulge at the L4-L5 level without significant nerve root compression, and was initially treated conservatively with nonsteroidal anti-inflammatory agents, gabapentinoids, muscle relaxants, and then underwent transforaminal epidural steroid injection and physical therapy. Since symptoms did not subside, she sought an opinion at our center for further management. On examination, she had tenderness over the left fibular head region with mild sensory loss over the lateral aspect of the left leg up to the dorsum of the foot and no associated motor weakness. With this clinical history, a provisional diagnosis of common peroneal neuropathy was made, and for confirming that, we ordered for an electromyography/nerve conduction velocity study, which was suggestive of left fascicular division common peroneal axonal neuropathy. We proceeded with ultrasound-guided hydrodissection of the common peroneal nerve with local anesthetic and steroid, which completely relieved her symptoms. This case is unique in describing the ability of ultrasonography as a diagnostic as well as a therapeutic modality in the treatment of common peroneal entrapment, which was misdiagnosed as lumbar radiculopathy. First-line treatments include removing anything that may be causing external compression and reducing inflammation. Accurate and timely diagnosis of any peroneal neuropathy is important to avoid the progression of nerve injury and permanent nerve damage.
Article
Background: Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS for many years, but its effectiveness is still debated. Objectives: To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome (CTS) compared to surgery. Search methods: We used standard, extensive Cochrane search methods. We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and WHO ICTRP. The latest search was 26 May 2022. Selection criteria: We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local corticosteroid injection (LCI) into the wrist and one group of any surgical intervention. Data collection and analysis: We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. improvement in quality of life and 7. Adverse events: We used GRADE to assess the certainty of evidence for each outcome. Main results: We included seven studies involving 569 'hands' (although two studies had unusable data for quantitative analyses). All studies used a one-time LCI as a comparator, using several different types and doses of corticosteroids. In every study, for both surgery and LCI groups, all our primary and secondary outcomes showed improvement from pre- to post-treatment. However, evidence from the combined analysis was too uncertain for us to draw reliable conclusions for the comparison of surgical treatment versus LCI with respect to our primary outcome of symptom relief at up to three months' follow-up (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) -0.61 to 1.88; I2 = 95%; 5 trials, 305 participants; very low-certainty evidence). Findings with respect to secondary outcome measures of symptom relief at greater than three months' follow-up (SMD 0.94, 95% CI -0.31 to 2.19; I2 = 93%; 4 trials, 235 participants), functional improvement at up to three months' follow-up (SMD -0.11, 95% CI -0.94 to 0.72; I2 = 84%; 3 trials, 215 participants) and functional improvement at greater than three months' follow-up (SMD 0.19, 95% CI -1.22 to 1.59; I2 = 93%; 3 trials, 185 participants) were also uncertain (very low-certainty evidence) and showed no clear advantage for surgery or LCI. Surgery may improve neurophysiology (median nerve distal motor latency) more than LCI (mean difference (MD) 0.87 ms, 95% CI 0.32 to 1.42; I2 = 72%; 3 trials, 162 participants; low-certainty evidence). Evidence for quality of life and adverse events was also uncertain; quality of life (EuroQol-5D-3L) may be slightly improved after LCI than after surgery (the difference may not be clinically important) (MD 0.07, 95% CI 0.02 to 0.12; 1 trial, 38 participants; very low-certainty evidence) and there may be fewer adverse events with LCI than with surgery (risk ratio (RR) 0.34, 95% CI 0.04 to 3.26; 3 trials, 112 participants; very low-certainty evidence). Authors' conclusions: The evidence comparing LCI to surgery for CTS, either in the short term or up to 12 months' follow-up, is too uncertain for any reliable conclusions to be drawn.
Article
Carpal tunnel syndrome (CTS) is one of the most common entrapment neuropathies leading to median nerve compression, with a high prevalence in the adult population. The term hydrodissection (HD) conveys a process of nerve fiber separation from adjacent structures, thus alleviating the underlying nerve compression, helping in pain relief, and improving nerve functions subsequently. Several methods with different techniques and different injectates have been studied with variable results. This review aims at highlighting the efficacy and safety of CTS ultrasound-guided HD, discussing and evaluating different techniques and modalities, and covering the most practical points of this technique with evidence-based recommendations for its use.
Article
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Objective: Clinical research has shown that local injections for carpal tunnel syndrome reduce the symptoms of patients and enhance their quality of life considerably. However, there are several therapy options, and the optimal choice of regimen remains uncertain. Therefore, we comprehensively evaluated the variations in clinical efficacy and safety of several medications for treating carpal tunnel syndrome. Methods: Computer searches of Embase, PubMed, Cochrane Library, and Web of Science databases were used to collect articles of randomized controlled trials on local injections for treating carpal tunnel syndrome from database creation till 10 June 2023. Two researchers independently screened the literature, extracted information, evaluated the risk of bias in the included studies, and performed network Meta-analysis using Stata 17.0 software. Drug efficacy was assessed using symptom severity/function and pain intensity. Surface under the cumulative ranking curve (SUCRA) ranking was used to determine the advantage of each therapy. Results: We included 26 randomized controlled trials with 1896 wrists involving 12 interventions, such as local injections of corticosteroids, platelet-rich plasma, 5% dextrose, progesterone, and hyaluronidase. The results of the network meta-analysis showed the following: (i) symptom severity: at the 3-month follow-up, D5W combined with splinting (SUCRA = 95%) ranked first, and hyaluronidase (SUCRA = 89.6%) at 6 months; (ii) functional severity: either at the 3-month follow-up (SUCRA = 89.5%) or 6 months (SUCRA = 83.6%), iii) pain intensity: 5% dextrose in water combined with splinting was the most effective at the 3-month (SUCRA = 85%) and 6-month (SUCRA = 87.6%) follow-up. Conclusion: Considering the combination of symptoms/function and pain intensity, combining 5% dextrose in water with splinting is probably the treatment of choice for patients with carpal tunnel syndrome. It is more effective than glucocorticoids and no adverse effects have been observed. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022370525.
Article
Radicular pain due to sciatica is a common occurrence with a lifetime incidence of up to 40%. Typical approaches to treatment vary and may include topical and oral analgesics, such as opioids, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs); however, these medications may be contraindicated in some or result in untoward effects in others. The use of ultrasound-guided regional anesthesia is an important component of multimodal analgesia in the emergency department. Transgluteal sciatic nerve block has been described as an effective method to treat patients with sciatica but carries risk of injury and falls due to its resultant loss of motor function and potential for systemic toxicity when higher volumes are used. Ultrasound-guided peripheral nerve hydrodissection with D5W has been shown to be an effective treatment of various compressive neuropathies in the outpatient setting. Here we present 4 cases of patients who presented to the emergency department with severe acute sciatica and were treated successfully using an ultrasound guided transgluteal sciatic nerve hydrodissection (TSNH). This technique may offer a safe and effective approach to treating patients with sciatica, but more studies are needed to assess its utility on a larger scale.
Article
Background: Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated. Objectives: To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection. Search methods: We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022. Selection criteria: We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment. Data collection and analysis: We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8. Adverse events: We used GRADE to assess the certainty of evidence for each outcome. Main results: We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events. Authors' conclusions: Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.
Article
Background: Direct and quantitative measurement of median nerve strain within the carpal tunnel has been difficult because of the technical limitations associated with conventional devices. We used capacitive sensors (C-stretch), which are thin and flexible, to measure the median nerve strain within the carpal tunnel. Methods: We used 12 fresh frozen upper extremity specimens. The transverse carpal ligament was left in situ, and we attached the sensor to the palmar surface of the median nerve to measure the nerve strain at 60 degrees of wrist extension. The sensor measured the median nerve strain at both the carpal tunnel site and the proximal to the carpal tunnel site before and after the carpal tunnel release. The amount of nerve excursion during wrist extension was also measured with the length change of the attached suture by a digital caliper. Findings: The mean median nerve strain within the carpal tunnel [8.07% (95 %CI:7.17-8.97)] was significantly higher than that proximal to the carpal tunnel [5.21% (95 %CI:4.46-5.97)] at the wrist extension. There was no significant difference of the mean nerve excursion within and proximal to the carpal tunnel. The mean nerve strain and excursion were unaffected by carpal tunnel release. Interpretation: These results indicated that wrist extension position might lead to increased strain on the median nerve within the carpal tunnel compared with at the proximal to the carpal tunnel. We believe that the current study might provide new information and help us understand the pathogenesis of carpal tunnel syndrome.
Article
Background: The objective was to determine which of midazolam or hyalase could improve the pain score and functional disability in median nerve hydrodissection. Methods: In a double-blind study with two groups, both received bupivacaine 15 mg with either 300 IU hyalase in 2 ml of saline (group HA) or 2 mg of midazolam in 2 ml of sterile saline (group MZ). Results: Statistically significantly lower post-injection Visual Analog Scale scores in group MZ compared with group HA at all follow-ups. Group MZ had significantly lower functional disability scores than group HA. Conclusion: Both drugs yielded favorable results. Midazolam was more impactful in alleviating pain and reducing functional disability up to 6 months.
Article
Background: Carpal arch space augmentation can help decompress the median nerve. The augmentation can be achieved by mechanical manipulations utilizing the biomechanics of the tunnel structure. The purpose of this study was to expand the carpal arch in vitro by applying volar forces on the surface of the wrist. Methods: The mechanism was implemented in eight cadaver hands by attaching a volar force transmitter to the palmar surface of the wrist and pulling the transmitter volarly at six force levels (0, 3, 6, 9, 12, and 15 N). Ultrasound images of the cross section at the distal carpal tunnel were collected for morphological analysis. Findings: The carpal arch height, width, and area were significantly altered by the volarly applied force (P < 0.001). The arch height and area were increased but the arch width was decreased by the force. Pearson's correlation coefficient showed that there was a positive correlation between the arch height and force magnitude; and between the arch area and force magnitude. A negative correlation existed between the arch width and force magnitude (P < 0.001). The magnitude of change of the arch height, width, and area was increased as the force magnitude increased. Interpretation: This study demonstrated that applying external forces on the wrist skin to increase the carpal arch space was feasible. The magnitude of the force influenced its effect on altering the carpal arch. Study limitations include small sample size and inclusion of male specimens. Future in vivo work is needed for clinical translation feasibility.
Article
This study analyzes the effectiveness of ultrasound-guided hydrodissection (HD) perineural as a treatment for radial tunnel syndrome (RTS). A literature search was performed along with retrospective analysis of local cases to assess outcomes and safety of this procedure. In the case series, surgical candidates, defined as cases with over 80% but temporary relief after diagnostic injection, were treated with ultrasound-guided HD. Of 22 patients who received ultrasound-guided diagnostic injections, 11 proceeded to HD. All HD patients experienced complete and lasting symptom resolution for a minimum of 2 years, and none required surgery. Thorough literature review provided seven studies, which fulfilled inclusion criteria. Sixty-one patients are represented in the literature. All studies reported significant benefit to pain symptoms with HD of radial nerve, with five specifying over 90% improvement. No adverse effects from HD were noted in any study. Ultrasound-guided HD of the radial tunnel has potential to be a surgery sparing treatment for RTS.
Article
Objectives Corticosteroid injections can provide (temporary) relief in patients with mild to moderate carpal tunnel syndrome (CTS). Hydrodissection as part of an injection has been associated with positive clinical outcomes but data for CTS so far has been scarce. This study is designed to assess patient tolerance and secondarily provide pilot data on the added effect of hydrodissection. Methods Twenty CTS patients were randomized to an ultrasound‐guided betamethasone injection with hydrodissection (5 mL) or without (2 mL). Patient tolerance was assessed directly after intervention and patient‐reported outcome after 4 and 24 weeks. Intra‐group data were compared using Wilcoxon Signed Rank and inter‐group with Wilcoxon rank‐sum tests. Results Tolerance and pain scores did not differ between the two groups. Symptom scores decreased in both groups, but to a lesser extent in the hydrodissection group with a mean difference of −0.8 versus −1.5 in the control group at 4 weeks (P = .02). At 6 months, this difference was no longer present (P = .81). No statistically significant differences were found between the hydrodissection and control groups in the function or pain scores at follow‐up at either time point. Conclusion After injection, both symptomatic and functional scores improved, but the hydrodissected group did not show additional improvement. Data presented can be used to support larger studies to assess the value of hydrodissection in CTS management.
Article
In amputees, the majority of residual limb pain ensues due to neuroma(s). Recently, high‐resolution ultrasound (US) has substantially facilitated the morphological evaluation of nerves and the surrounding soft tissues/scars contributory in entrapment syndromes. We reported a 57‐year‐old male, who had received below‐knee amputation due to osteomyelitis three years ago, was seen for continuous stabbing and burning sensation at the left residual limb. US examination showed that the terminal end of the deep peroneal nerve was enlarged and encircled by hypoechoic scars. US‐guided hydro‐dissection was conducted besides the epineurium of the neuroma. After the injection, the numerical rating scale score decreased from 8 to 3, and the numbness was also relieved when putting on the prosthesis. It is noteworthy that one of the superiorities of dextrose (over corticosteroid) is the possibility to use higher volumes for adhesiolysis of the twisting scars. Herein, treatment success lies in introducing the needle at the upper and lower borders of the neuroma to ensure complete relief of the adhesions.
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Objective: The aim of this study was to describe time trends of incidence/prevalence of carpal tunnel syndrome (CTS), one of the most common musculoskeletal disorders, in a French region over an 8-year period. Methods: Three independent data sources were analyzed for the population of the Pays de la Loire region aged 20-59 between 2004 and 2011: hospital discharge records for "surgically treated CTS" (SURG-CTS), the social insurance data on "CTS compensated for as an occupational disease" (OD-CTS), and the regional surveillance program of "work-related diseases" (WRD-CTS). Case counts were analyzed using negative binomial regression models and cubic spline curves with year as the main covariate. Results: The annual incidence rates of SURG-CTS decreased from 3.35 to 2.98 per 1000 person-years over the 8-year period, with an overall declining trend [-2.00%, 95% confidence interval (95% CI) -3.07- -0.91%), P<0.001]. The annual incidence rate of OD-CTS per 1000 person-years decreased (from 1.52 to 1.01) between 2004 and 2007 and increased after 2007 (from 1.45 to 2.34), with an overall gain of 54% during the study period. The prevalence rate of WRD-CTS decreased from 5.04 (95% CI 3.90-6.13) to 3.08 (95% CI 2.11-4.06) per 1000 employed person-years, with a non-significant trend between 2004 and 2011. Conclusion The study showed declining rates of SURG-CTS and WRD-CTS in the population of working age between 2004 and 2011, contrasting with increasing rate of OD-CTS after 2007. More research and surveillance data are needed to assess whether and to what extent the declining rates of CTS are actually attributable to improvement in working conditions and/or to non-occupational factors.
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[Purpose] The purpose of this study was to assess the quality of evidence for the efficacy of tendon and nerve gliding exercises in the management of carpal tunnel syndrome. [Subjects and Methods] Four electronic databases were searched to identify randomized controlled trials on the efficacy of tendon and nerve gliding exercises for carpal tunnel syndrome. Quality assessment was conducted using the Cochrane risk of bias tool. [Results] Four trials were identified and included in the review. The results of critical appraisal of quality ranged between low and moderate risk of bias. The available data could only be included as a narrative description. Symptom severity decreased and functional status improved with combined treatment, involving a tendon or nerve gliding exercise group plus conventional treatments, compared with the use of conventional treatments alone. [Conclusion] Evidence from 4 randomized controlled trials suggests that tendon and nerve gliding exercises, when combined with conventional treatments, may have a favorable effect in patients with carpal tunnel syndrome. However, further randomized controlled trials designed to assess the effect of tendon and nerve gliding exercises alone are required to investigate the hypothesis that such exercises alleviate carpal tunnel syndrome, and to confirm and further elucidate the efficacy of standardized physical exercise programs in patients with carpal tunnel syndrome.
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The objective of this study is to evaluate the degree of symptom improvement and the change of electrophysiological and ultrasonographic findings after sonographically guided local steroid injection using an in-plane ulnar approach in carpal tunnel syndrome (CTS). Seventy-five cases of 44 patients diagnosed with CTS were included and evaluated at baseline and at 4 and 12 weeks after injection. All patients received injection with 40 mg of triamcinolone mixed with 1 mL of 1% lidocaine into the carpal tunnel using an in-plane Ultrasound (US)-guided ulnar approach, out-plane US-guided approach, and blind injection. For clinical evaluation, we used the Boston Carpal Tunnel Questionnaire (BCTQ) and electrophysiological tests. The ultrasonographic findings were also evaluated with regard to cross-sectional area and the flattening ratio of the median nerve. Subjective symptoms measured by BCTQ and median nerve conduction parameters showed significant improvement at 4 weeks in the in-plane ulnar approach group compared with the out-plane ulnar approach and blind injection. This improvement was still observed at 12 weeks. The flattening ratio and cross-sectional area of the median nerve showed a more significant decrease with the in-plane ulnar approach than with the out-plane ulnar approach and blind injection (P < 0.05). US-guided local steroid injection using an in-plane ulnar approach in the CTS may be more effective than out-plane or blind injection.
Article
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The median nerve and flexor tendons are known to translate transversely in the carpal tunnel. The purpose of this study was to investigate these motions in differential finger motion using ultrasound, and to compare them in healthy people and carpal tunnel syndrome patients. Transverse ultrasounds clips were taken during fist, index finger, middle finger and thumb flexion in 29 healthy normal subjects and 29 CTS patients. Displacement in palmar-dorsal and radial-ulnar direction was calculated using Analyze software. Additionally, the distance between the median nerve and the tendons was calculated. We found a changed motion pattern of the median nerve in middle finger, index finger and thumb motion between normal subjects and CTS patients (p<0.05). Also, we found a changed motion direction in CTS patients of the FDS III tendon in fist and middle finger motion, and of the FDS II and flexor pollicis longus tendon in index finger and thumb motion, respectively (p<0.05). The distance between the median nerve and the FDS II or FPL tendon is significantly greater in patients than in healthy volunteers for index finger and thumb motion, respectively (p<0.05). Our results suggest a changed motion pattern of the median nerve and several tendons in carpal tunnel syndrome patients compared to normal subjects. Such motion patterns may be useful in distinguishing affected from unaffected individuals, and in studies of the pathomechanics of carpal tunnel syndrome.
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Objective: To study the demographic characteristics of patients with carpal tunnel syndrome and changes in incidence over time. Methods: Prospective collection of neurophysiological and clinical data on all patients presenting to the subregional department of clinical neurophysiology in Canterbury, UK, from 1992 to 2001 and to the electromyography clinic in St Luke’s Hospital, Huddersfield, UK, from 1991 to 1993. Results: 6245 new cases of neurophysiologically confirmed carpal tunnel syndrome were identified in Canterbury and 590 in Huddersfield. The average annual incidences (per 100 000) were 139.4 for women and 67.2 for men in East Kent, and 83.2 for women and 48.0 for men in Huddersfield. Corrected to the WHO European standard population these rates were 120.5 for women and 60.0 for men in East Kent, and 61.5 for women and 35.0 for men in Huddersfield. Between 1992 and 2001 there was an increase in the number of confirmed cases in East Kent but a decrease in their average severity. The age distributions were bimodal with a peak in the 50–54 age group and a second peak between 75 and 84 years. Over half the cases were bilateral. The disorder was consistently worse in the elderly, and more severe in men than in women in all age groups. Conclusions: The age distributions of unselected cases of carpal tunnel syndrome in both clinics differ markedly from that usually portrayed in surgical series. There was a significant increase in cases diagnosed between 1992 and 2001 in Canterbury, probably the result of increased ascertainment of milder cases. Median nerve impairment is more severe in the elderly and in men at all ages.
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Scleroderma is associated with intractable hand pain from vasospasm, digital ischemia, tenosynovitis, and nerve entrapment. This study investigated the effect of hydrodissection of the carpal tunnel followed by corticosteroid injection for the painful scleroderma hand. Twenty-six consecutive subjects [12 with painful scleroderma hand and 14 with rheumatoid arthritis and carpal tunnel syndrome (RA/CTS)] underwent sonographically observed carpal tunnel hydrodissection with 3 ml of 1% lidocaine administered with a 25-gauge 1-in. needle on a 3-ml RPD mechanical syringe (reciprocating procedure device). After hydrodissection, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected. Baseline pain, procedural pain, pain at outcome, responders, therapeutic duration, and reinjection interval were determined. Hydrodissection and injection with corticosteroid significantly reduced pain scores by 67% in scleroderma (p < 0.001) and by 47% in RA/CT (p < 0.001). Scleroderma and RA/CTS were similar in outcome measures: injection pain (p = 0.47), pain scores at outcome (p = 0.13), responders (scleroderma, 83.3%; RA/CTS, 57.1%, p = 0.15), pain at 6 months (p = 0.15), and therapeutic duration (p = 0.07). Scleroderma patients responded better in time to next injection (scleroderma, 8.5 ± 3.0 months; RA/CTS, 5.2 ± 3.1 months, p = 0.03). Reduced Raynaud's attacks and healing of digital ulcers occurred in 83% of subjects. There were no complications. Hydrodissection with lidocaine followed by injection of triamcinolone reduces pain and vasomotor changes in the scleroderma hand. The mechanism may be a combination of hydrodissection-mediated mechanical freeing of entrapped arteries, nerves, and tendinous structures and corticosteroid-induced reduction of inflammatory vasospasm.
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To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS). The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). Two reviewers independently applied the inclusion criteria to select potential studies. Two reviewers independently extracted the data and assessed the methodologic quality. A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found. The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.
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Median nerve compression is a well-known cause of carpal tunnel syndrome (CTS). Yet, reasons why the most common idiopathic form of CTS develops in certain individuals are not well understood. To further understand the compressive mechanisms at work in CTS development, the authors used ultrasonographic imaging of the median nerve to evaluate 2 patients with CTS. Findings were compared to those of 2 control subjects who did not have CTS. In the patients who had CTS, the transverse carpal ligament was pulled taut by thenar muscle contraction as the flexor tendons tightened, compressing the median nerve between the ligament and tendons. No such compression was observed with the control subjects. Thus, a pathologic mechanism of median nerve compression was confirmed in the patients with CTS. Demonstration of such pathologic mechanisms during prehensile hand movement may improve understanding of how to treat patients with CTS and prevent nerve injury.
Article
Background: The best treatment for mild to moderate carpal tunnel syndrome (CTS) is still controversial. The main aim of our study was to determine whether corticosteroid injection would result in a better outcome. Methods: In this randomized clinical trial, 88 individuals with mild to moderate CTS were selected from patients who referred to Kashani Hospital in Isfahan, Iran. The patients were randomly assigned into two groups. Splinting in neutral position of wrist was the only therapeutic method utilized in first group. However, splinting accompanied with corticosteroid injection was performed in the second group. Then the patients were evaluated in terms of pain intensity, and the relative prevalence of Phalen’s and Tinel tests. Findings: Pain intensity and prevalence of Phalen’s and Tinel tests were significantly lower in patients treated with splinting accompanied with corticosteroid injection. Conclusion: It seemed that splinting accompanied with corticosteroid injection is a more effective method in treatment of mild to moderate CTS. © 2012, Isfahan University of Medical Sciences(IUMS). All rights reserved.
Article
Background: Forceful, high-velocity, and repetitive manual hand tasks contribute to the onset of carpal tunnel syndrome. This study aimed to isolate and identify mechanisms that contribute to tendon gliding resistance in the carpal tunnel. Methods: Eight human cadaver hands (four pairs) were used. Tendon gliding resistance (force, energy, and stiffness) was measured under different conditions: with intact and with divided subsynovial connective tissue, at 2mm/s and 60mm/s tendon excursion velocity, and with and without relaxation time before tendon excursion. Results: Subsynovial connective tissue stretching substantially contributed to increased gliding resistance force and energy during higher tendon excursion velocities, and subsynovial connective tissue stiffening was observed. Poroelastic properties of the tendon (and possibly the subsynovial connective tissue) also appear to be involved because relaxation time significantly increased gliding resistance force and energy (P<0.01), and the difference in energy and force between high- and low-velocity tendon excursions increased with relaxation time (P=0.01 and P<0.01). Lastly, without relaxation time, no difference in force and energy was observed (P=0.06 and P=0.60), suggesting contact friction. Interpretation: These findings are consistent with the hypothesis that the mechanics of tendon motion within the carpal tunnel are affected by the integrity of the subsynovial connective tissue. While not tested here, in carpal tunnel syndrome this tissue is known to be the fibrotic, thickened, and less-fluid-permeable. An extrapolation of our findings suggests that these changes in the subsynovial connective tissue of carpal tunnel syndrome patients could increase contact friction and carpal tunnel pressure.
Article
Biomechanical evaluation of the subsynovial connective tissue (SSCT) provides insight into the causes of carpal tunnel syndrome. Studies of carpal tunnel mechanics have been performed using fresh-frozen cadaver tissue. Freezing can affect mechanical properties of some tissues, but its effect on SSCT is unknown. A total of 16 rabbit paws were harvested from eight New Zealand rabbits and subjected to mechanical testing consisting of three repeated tendon excursions in sets of three different excursion magnitudes. One paw from each animal was unfrozen. The contralateral paw was frozen and thawed before testing. Force, energy and stiffness of the first cycle of each set were evaluated, as were ratios of the second to first cycle for each parameter. Two-factor ANOVA with repeated measures over both factors was performed. No significant interactions between factors were found. There were no significant differences between fresh and frozen paws for any parameters, though there were significant differences between excursion amplitudes. The damage threshold was not different between fresh and frozen paws. This study demonstrated that freezing rabbit subsynovial connective tissue does not significantly change its mechanical properties. The same may be true for human cadaver tissues. Results of cadaver mechanical testing may not be influenced by this preservation technique.
Article
Objective: Carpal tunnel syndrome, caused by compression of the median nerve deep to the flexor retinaculum, is the most common entrapment neuropathy. Most patients are initially treated with conservative measures such as splinting. When conservative measures fail, interventional techniques are considered the next step. Many studies have appeared comparing open surgical flexor retinaculum release to blind injections of corticosteroids into the carpal tunnel, but neither technique has proven superior to the other. Advantages of injection are: lower level of invasiveness, faster recovery, and ease of the technique. Occasional failures and complications occur with all techniques. Method: We have been using an ultrasoundguided procedure of percutaneous hydrodissection of the median nerve away from the deep surface of the flexor retinaculum, followed by fenestration of the flexor retinaculum along a path parallel to the long axis of the arm, starting from the level of the distal part of the capitate bone and progressing proximally to the level of the radio-lunate joint, the intent being to lower the pressure exerted by the flexor retinaculum on the nerve. We have treated a series of 44 wrists in 34 patients who had electrically-proven carpal tunnel syndrome, using this technique of hydrodissection and fenestration, performed using standard injection equipment and an ultrasound system. All patients had typical carpal tunnel syndrome symptoms, and presented to us for interventional treatment after conservative measures had failed. No patient had had previous surgery, and two had had blind carpal tunnel steroid injections, without hydrodissection or fenestration. Outcomes were defined as: Excellent-all symptoms resolved, Fair-some residual symptoms, or return of symptoms, but improved compared to prior to procedure, Failure-required open surgical release. First follow-up periods after procedure ranged from 3-60 weeks, averaging 32 weeks. Second follow up periods varied from 25-96 weeks, averaging 63 weeks. Patients were contacted by telephone, or seen in follow-up in clinic, to determine outcomes. Results: Excellent at first followup, lost to second followup--two wrists, too little time to judge second followup---0ne wrist Excellent at first followup and second followup-19 wrists Excellent at first followup, fair at second followup--9 wrists Fair at first followup and second followup- five wrists Fair at first followup, lost to second followup--one wrist Fair at first followup, to little time to judge second followup--2 wrists Failure-5 wrists No complications were encountered. Conclusion: Ultrasound-guided hydrodissection and fenestration is a viable, easy, relatively non-invasive therapy for carpal tunnel syndrome that can result in prolonged symptom relief, and may be a way to postpone, or even obviate the need for, open release.
Article
Dynamics of structures within the carpal tunnel may alter in carpal tunnel syndrome (CTS) due to fibrotic changes and increased carpal tunnel pressure. Ultrasound can visualize these potential changes, making ultrasound potentially an accurate diagnostic tool. To study this, we imaged the carpal tunnel of 113 patients and 42 controls. CTS severity was classified according to validated clinical and nerve conduction study (NCS) classifications. Transversal and longitudinal displacement and shape (changes) were calculated for the median nerve, tendons and surrounding tissue. To predict diagnostic value binary logistic regression modeling was applied. Reduced longitudinal nerve displacement (p≤0.019), increased nerve cross-sectional area (p≤0.006) and perimeter (p≤0.007), and a trend of relatively changed tendon displacements were seen in patients. Changes were more convincing when CTS was classified as more severe. Binary logistic modeling to diagnose CTS using ultrasound showed a sensitivity of 70-71% and specificity of 80-84%. In conclusion, CTS patients have altered dynamics of structures within the carpal tunnel. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Article
Rationale and Objectives Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. Strong pinch or grip with wrist flexion has been considered a risk factor for CTS. Studying median nerve displacement during wrist movements may provide useful information about median nerve kinematic changes in patients with CTS. The purpose of this study was to evaluate the deformability and mobility of the median nerve in patients with CTS compared to healthy subjects. Materials and Methods Dynamic ultrasound images were obtained in 20 affected wrists of 13 patients with CTS. Results were compared to complementary data obtained from both wrists of 10 healthy subjects reported in a previous study. Shape and position of initial and final median nerve were measured and analyzed for six defined wrist movements. The deformation ratios for each movement were defined as the median nerve area, perimeter, and circularity of the final position normalized by respective values assessed in the initial position. The median nerve displacement vector and magnitude were also calculated. Results The deformation ratio for circularity was significantly less in patients with CTS compared to healthy subjects during wrist flexion (P < .05). The mean vector of median nerve displacement during wrist flexion was significantly different between patients with CTS and healthy subjects (P < .05). The displacement magnitude of the median nerve was found to be less in patients with CTS compared to healthy subjects during most movements, with the exception of wrist extension with fingers extended. Conclusions Patients with CTS differ from normal subjects with regard to mobility and deformability of the median nerve.
Article
Fibrosis of the subsynovial connective tissue (SSCT) in the carpal tunnel is the most common histological finding in carpal tunnel syndrome (CTS). Fibrosis may result from damaged SSCT. Previous studies found that with low-velocity (2 mm/s), tendon excursions can irreversibly damage the SSCT. We investigated the effect of tendon excursion velocity in the generation of SSCT damage. Nine human cadaver wrists were used. Three repeated cycles of ramp-stretch testing were performed simulating 40%, 60%, 90%, and 120% of the middle finger flexor tendon superficialis physiological excursion with an excursion velocity of 60 mm/s. Energy and force were calculated and normalized by values obtained in the first cycle for each excursion level. Data were compared with low-velocity excursion data. For high-velocity excursions, a significant drop in the excursion energy ratio was first observed at an excursion level of 60% physiological excursion (p < 0.024) and that for low-velocity excursions was first observed at 90% physiological excursion (p < 0.038). Furthermore, the energy ratio was lower at 60% for high velocities (p ≤ 0.039). Increasing velocity lowers the SSCT damage threshold. This finding may be relevant for understanding the pathogenesis of SSCT fibrosis, such as that accompanying CTS, and a relationship with occupational factors. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
Article
Non-surgical treatment, including exercises and mobilisation, has been offered to people experiencing mild to moderate symptoms arising from carpal tunnel syndrome (CTS). However, the effectiveness and duration of benefit from exercises and mobilisation for this condition remain unknown. To review the efficacy and safety of exercise and mobilisation interventions compared with no treatment, a placebo or another non-surgical intervention in people with CTS. We searched the Cochrane Neuromuscular Disease Group Specialised Register (10 January 2012), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to December 2011), EMBASE (January 1980 to January 2012), CINAHL Plus (January 1937 to January 2012), and AMED (January 1985 to January 2012). Randomised or quasi-randomised controlled trials comparing exercise or mobilisation interventions with no treatment, placebo or another non-surgical intervention in people with CTS. Two review authors independently assessed searches and selected trials for inclusion, extracted data and assessed risk of bias of the included studies. We calculated risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes of the review. We collected data on adverse events from included studies. Sixteen studies randomising 741 participants with CTS were included in the review. Two compared a mobilisation regimen to a no treatment control, three compared one mobilisation intervention (for example carpal bone mobilisation) to another (for example soft tissue mobilisation), nine compared nerve mobilisation delivered as part of a multi-component intervention to another non-surgical intervention (for example splint or therapeutic ultrasound), and three compared a mobilisation intervention other than nerve mobilisation (for example yoga or chiropractic treatment) to another non-surgical intervention. The risk of bias of the included studies was low in some studies and unclear or high in other studies, with only three explicitly reporting that the allocation sequence was concealed, and four reporting blinding of participants. The studies were heterogeneous in terms of the interventions delivered, outcomes measured and timing of outcome assessment, therefore, we were unable to pool results across studies. Only four studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared to baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). However, of these, only three fully reported outcome data sufficient for inclusion in the review. One very low quality trial with 14 participants found that all participants receiving either neurodynamic mobilisation or carpal bone mobilisation and none in the no treatment group reported overall improvement (RR 15.00, 95% CI 1.02 to 220.92), though the precision of this effect estimate is very low. One low quality trial with 22 participants found that the chance of being 'satisfied' or 'very satisfied' with treatment was 24% higher for participants receiving instrument-assisted soft tissue mobilisation compared to standard soft tissue mobilisation (RR 1.24, 95% CI 0.89 to 1.75), though participants were not blinded and it was unclear if the allocation sequence was concealed. Another very low-quality trial with 26 participants found that more CTS-affected wrists receiving nerve gliding exercises plus splint plus activity modification had no pathologic finding on median and ulnar nerve distal sensory latency assessment at the end of treatment than wrists receiving splint plus activity modification alone (RR 1.26, 95% CI 0.69 to 2.30). However, a unit of analysis error occurred in this trial, as the correlation between wrists in participants with bilateral CTS was not accounted for. Only two studies measured adverse effects, so more data are required before any firm conclusions on the safety of exercise and mobilisation interventions can be made. In general, the results of secondary outcomes of the review (short- and long-term improvement in CTS symptoms, functional ability, health-related quality of life, neurophysiologic parameters, and the need for surgery) for most comparisons had 95% CIs which incorporated effects in either direction. There is limited and very low quality evidence of benefit for all of a diverse collection of exercise and mobilisation interventions for CTS. People with CTS who indicate a preference for exercise or mobilisation interventions should be informed of the limited evidence of effectiveness and safety of this intervention by their treatment provider. Until more high quality randomised controlled trials assessing the effectiveness and safety of various exercise and mobilisation interventions compared to other non-surgical interventions are undertaken, the decision to provide this type of non-surgical intervention to people with CTS should be based on the clinician's expertise in being able to deliver these treatments and patient's preferences.
Article
The subsynovial connective tissue (SSCT) in the carpal tunnel may participate in the origin of carpal tunnel syndrome (CTS), yet material properties of the SSCT have not been well-characterized. We investigated the response of the SSCT to repeated ramp stretch tests. Eight human cadaver wrists were used. The physiological excursion of the flexor digitorum superficialis of the third digit (FDS 3) was measured, starting from a neutral position to maximal flexion of the metacarpophalangeal and proximal interphalangeal joints. The FDS 3 tendon was pulled to 40%, 60%, 90%, and 120% of the physiological excursion. Two "ramp stretch" cycles were performed at every excursion level, except for 120% of excursion, where three cycles were performed. The ratio of energy absorbed between the second (E2) and first (E1) ramp stretch was 0.94 (SD = 0.07) for 60%, 0.84 (SD = 0.11) for 90%, and 0.68 (SD = 0.11) for 120% of the physiological excursion. A significant decrease occurred in energy absorbed after the first ramp stretch cycle at 90% and 120% of the physiological excursion, which was not seen at 60%. Our data are consistent with a stepwise damage occurring in the SSCT. Furthermore, the damage seems to initiate within the physiological range of tendon excursion. This finding may be important in understanding the pathophysiology of conditions that are associated with SSCT pathology, such as carpal tunnel syndrome. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1732-1737, 2012.
Article
The normal gliding environment in the carpal tunnel is complex. The median nerve and flexor tendons are surrounded by a multilayered subsynovial tissue. To date, observations of the relative motions of the flexor tendon, median nerve and multilayered subsynovial tissue have been through a surgically released open carpal tunnel. The purpose of this study was to compare the motions of these tissues in an intact and open carpal tunnel. We measured the relative motion of the middle finger flexor digitorum superficialis tendon, its surrounding subsynovial connective tissue (SSCT) and the median nerve in 8 human cadavers. The flexor retinaculum was used as a fixed reference point. The motions were compared for simulated isolated middle finger and simulated fist motion as measured fluoroscopically in the closed carpal tunnel and directly in the open carpal tunnel. While the simulated isolated finger motion produced significantly less SSCT and median nerve motion (p<.05), there was no difference in flexor digitorum superficialis, SSCT, or nerve motion when comparing the fluoroscopic measurements in the closed carpal tunnel with the direct visual measurements in the open carpal tunnel. Relative motion of the flexor tendons, SSCT, and median nerve within the carpal tunnel follows a certain pattern, which may indicate the physiological state of the SSCT. This relative motion pattern was not affected by flexor retinaculum release.
Article
Author Contributions: Dr Atroshi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Atroshi, Englund, and Petersson. Acquisition of data: Atroshi, Englund, and Petersson. Analysis and interpretation of data: Atroshi, Englund, Turkiewicz, Tägil, and Petersson. Drafting of the manuscript: Atroshi and Petersson. Critical revision of the manuscript for important intellectual content: Atroshi, Englund, Turkiewicz, Tägil, and Petersson. Statistical analysis: Atroshi, Englund, and Turkiewicz. Obtained funding: Atroshi and Petersson. Administrative, technical, and material support: Petersson. Study supervision: Englund and Petersson.
Article
Carpal tunnel syndrome is a commonly encountered entrapment disorder resulting from mechanical insult to the median nerve. Magnetic resonance imaging (MRI)-based investigations have documented typical locations of the median nerve within the carpal tunnel; however, it is unclear whether those locations are consistent within an individual on different days. To determine the day-to-day variability of nerve location, 3.0T MRI scans were acquired from six normal volunteers over multiple sessions on three different days. Half of the scans were acquired with the wrist in neutral flexion and the fingers extended, and the other half were acquired with the wrist in 35 degrees of flexion and the fingers flexed. Prior to half of the scans (in both poses), subjects performed a preconditioning routine consisting of specified hand activities and several repetitions of wrist flexion/extension. The shape, orientation, location, and location radius of variability of the median nerve and three selected flexor tendons were determined for each subject and compared between days. Two of the six subjects had substantial variability in nerve location when the wrist was in neutral, and four of the subjects had high variability in nerve position when the wrist was flexed. Nerve variability was typically larger than tendon variability. The preconditioning routine did not decrease nerve or tendon location variability in either the neutral or the flexed wrist positions. The high mobility and potential for large variability in median nerve location within the carpal tunnel needs to be borne in mind when interpreting MR images of nerve location.
Article
Various tendinopathies occur about the ankle, but there are few publications investigating their etiology or pathoanatomy. The purpose of this investigation was to determine the gliding resistance of the tendons about the posteromedial ankle: the posterior tibial (PT), flexor digitorum longus (FDL), and flexor hallucis longus (FHL) tendons. The gliding abilities of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons at the ankle-hindfoot level were compared, in terms of gliding resistance, with use of a system that was developed in this laboratory. Six cadaveric specimens were used and tested in a dorsiflexed position, then in simulated flatfoot in a dorsiflexed position. The gliding resistance was found to be significantly greater in the simulated flatfoot in dorsiflexion compared to the dorsiflexed position with an intact arch for the PT, FDL, and FHL tendons. The gliding resistance was significantly higher in the PT tendon than FDL or FHL tendons in the flatfoot/dorsiflexion condition. There was no significant difference between the FDL and FHL tendons in resistance in either condition. We concluded that the gliding ability of the PT tendon was inferior to that of the FDL and FHL tendons in a simulated flatfoot model. The findings of the present study are consistent with the clinical observations that tendinitis and rupture of the PT tendon commonly occurs at the malleolar level, whereas FDL and FHL ruptures do not. A pre-existing flexible flatfoot deformity may be associated with PT tendon dysfunction in the adult due to poor gliding ability of the PT tendon.
Article
A previous randomised controlled trial reported greater efficacy of surgery than of splinting for patients with carpal tunnel syndrome. Our aim was to compare surgical versus multi-modality, non-surgical treatment for patients with carpal tunnel syndrome without denervation. We hypothesised that surgery would result in improved functional and symptom outcomes. In this parallel-group randomised controlled trial, we randomly assigned 116 patients from eight academic and private practice centres, using computer-generated random allocation stratified by site, to carpal tunnel surgery (n=57) or to a well-defined, non-surgical treatment (including hand therapy and ultrasound; n=59). The primary outcome was hand function measured by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) at 12 months assessed by research personnel unaware of group assignment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00032227. 44 (77%) patients assigned to surgery underwent surgery. At 12 months, 101 (87%) completed follow-up and were analysed (49 of 57 assigned to surgery and 52 of 59 assigned to non-surgical treatment). Analyses showed a significant 12-month adjusted advantage for surgery in function (CTSAQ function score: Delta -0.40, 95% CI 0.11-0.70, p=0.0081) and symptoms (CTSAQ symptom score: 0.34, 0.02-0.65, p=0.0357). There were no clinically important adverse events and no surgical complications. Symptoms in both groups improved, but surgical treatment led to better outcome than did non-surgical treatment. However, the clinical relevance of this difference was modest. Overall, our study confirms that surgery is useful for patients with carpal tunnel syndrome without denervation. NIH/NIAMS 5P60AR048093 and the Intramural Research Program of the NIH Clinical Center.
Article
To assess temporal trends in carpal tunnel syndrome (CTS) incidence, surgical treatment, and work-related lost time. Incident CTS and first-time carpal tunnel release among Olmsted County, Minnesota, residents were identified using the medical records linkage system of the Rochester Epidemiology Project; 80% of a sample were confirmed by medical record review. Work-related CTS was identified from the Minnesota Department of Labor and Industry. Altogether, 10,069 Olmsted County residents were initially diagnosed with CTS in 1981-2005. Overall incidence (adjusted to the 2000 US population) was 491 and 258 per 100,000 person-years for women vs men (p < 0.0001) and 376 per 100,000 for both sexes combined. Adjusted annual rates increased from 258 per 100,000 in 1981-1985 to 424 in 2000-2005 (p < 0.0001). The average annual incidence of carpal tunnel release surgery was 109 per 100,000, while that for work-related CTS was 11 per 100,000. An increase in young, working-age individuals seeking medical attention for symptoms of less severe CTS in the early to mid-1980s was followed in the 1990s by an increasing incidence in elderly people. The incidence of medically diagnosed carpal tunnel syndrome (CTS) accelerated in the 1980s. The cause of the increase is unclear, but it corresponds to an epidemic of CTS cases resulting in lost work days that began in the mid-1980s and lasted through the mid-1990s. The elderly present with more severe disease and are more likely to have carpal tunnel surgery, which may have significant health policy implications given the aging population.
Article
The purpose of this report is to describe a new sonographically guided technique for carpal tunnel injections using an ulnar approach. Previously published sonographically guided techniques for carpal tunnel injections were reviewed. Described approaches were noted to be technically challenging because of the need to perform long-axis imaging of the carpal tunnel, short-axis (out-of-plane) imaging of the needle, or both. We developed and herein describe the ulnar approach for sonographically guided carpal tunnel injections. Advantages of this approach include transverse imaging of the carpal tunnel, long-axis (in-plane) imaging of the needle, and versatility in targeting structures within the carpal tunnel. Clinicians should consider the ulnar-sided approach when performing sonographically guided carpal tunnel injections.
Article
To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome. Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations. The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively). This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.
Article
This article has reviewed recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy of the median nerve. The problems surrounding the diagnosis and treatment of recurrent CTS have been discussed at length. The percent of failures from traditional open ligament surgery is observed to be high, and will become more prevalent as more casual treatments are carried out. This article makes a positive statement with reference to mobilization of the median nerve and anatomic restoration of the transverse carpal ligament. Fibrous fixation of the median nerve is a product of life and function. All cases are different, reflecting the strength, abilities, and personalities of the patients. A bottom line is drawn on these patients, where the summation of the problems of life become symptomatic and disabling. Epineural fibrous fixations induce median nerve traction, governed by hand, wrist, and forearm movements. Traction and tension suggest the intermittent disturbance of nerve nutrition and nerve conduction as the elastic limits of the nerve are approached. These factors accumulate and, in time, cause traction neuropathies with pain. This is followed by a reduced work capability. This impairment can be reversed by surgical nerve mobilization followed by functional nerve gliding therapy. A background history injury to the hand and wrist may be significant, as well as factors such as overuse and misuse of the hand and extremity. Prior to surgery, the careful application of diagnostic stress tests are essential, for the differential diagnosis of fixation traction and positional peripheral neuropathies. Nerve mobilization supported by magnification and the techniques of hand surgery has been successful by the methods discussed and has permitted, importantly, the restoration of the anatomic retinaculum for the flexor tendon system. This can be restored in carpal tunnel surgery and reconstructed with basic ligament material in recurrent carpal tunnel surgery.
Article
The most common histological finding in carpal tunnel syndrome is noninflammatory synovial fibrosis. The accumulated effect of minor injuries is believed to be an important etiologic factor in some cases of carpal tunnel syndrome. We sought evidence of such injuries in the synovial tissue of patients with carpal tunnel syndrome and in cadaver controls. We compared synovial specimens from thirty patients who had idiopathic carpal tunnel syndrome with specimens from a control group of ten fresh-frozen cadavers of individuals who had not had an antemortem diagnosis of carpal tunnel syndrome and who met the same exclusion criteria. Analysis included histological and immunohistochemical examination for the distribution of collagen types I, II, III, and VI and transforming growth factor-beta (TGF-beta) RI, RII, and RIII. Histological examination showed a marked increase in fibroblast density, collagen fiber size, and vascular proliferation in the specimens from the patients compared with the control specimens (p < 0.001). Collagen types I and II were not found in the synovium of either the patients or the controls, but collagen type VI was a major component of both. Collagen type-III fibers were more abundant in the patients than in the controls (p < 0.001). Expression of TGF-beta RI was found in the endothelial cells and fibroblasts in the patient and control specimens, with a marked increase in expression in the fibroblasts of the patients compared with that in the control tissue (p < 0.001). These findings are similar to those after injury to skin, tendon, and ligament and suggest that patients with idiopathic carpal tunnel syndrome may have sustained an injury to the subsynovial connective tissue.
Article
The characteristic pathological finding in carpal tunnel syndrome (CTS) is noninflammatory fibrosis of the synovium. How this fibrosis might affect tendon function, if at all, is unknown. The subsynovial connective tissue (SSCT) lies between the flexor tendons and the visceral synovium (VS) of the ulnar tenosynovial bursa. Fibrosis of the SSCT may well affect its gliding characteristics. To investigate this possibility, the relative motion of the flexor tendon and VS was observed during finger flexion in patients undergoing carpal tunnel surgery, and for comparison in hands without CTS, in an in vitro cadaver model. We used a camera to document the gliding motion of the middle finger flexor digitorum superficialis (FDS III) tendon and SSCT in three patients with CTS during carpal tunnel release and compared this with simulated active flexion in three cadavers with no antemortem history of CTS. The data were digitized with the use of Analyze Software (Biomedical Imaging Resource, Mayo Clinic, Rochester, MN). In the CTS patients, the SSCT moved en bloc with the tendon, whereas, in the controls the SSCT moved smoothly and separately from the tendon. The ratio of VS to tendon motion was higher for the patients than in the cadaver controls. These findings suggest that in patients with CTS the synovial fibrosis has altered the gliding characteristics of the SSCT. The alterations in the gliding characteristics of the SSCT may affect the ability of the tendons in the carpal tunnel to glide independently from each other, or from the nearby median nerve. These abnormal tendon mechanics may play a role in the etiology of CTS.
Article
Abnormal gliding of the posterior tibial tendon may lead to mechanical trauma, degeneration, and eventually posterior tibial tendon dysfunction. Our study analyzed the gliding resistance of the posterior tibial tendon in intact feet and in feet with simulated flatfoot deformity. An experimental system was developed that allowed direct measurement of gliding resistance at the tendon-sheath interface. Seven normal fresh-frozen cadaver foot specimens were studied, and gliding resistance between the posterior tibial tendon and sheath was measured. The effects of ankle and hindfoot position and the effect of flatfoot deformity on gliding resistance were analyzed. Gliding resistance was measured for 4.9 N applied load to the tendon. Mean gliding resistance for the neutral position was 77 +/- 13.1 (x10(-2) N). Compared to neutral position, dorsiflexion increased gliding resistance and averaged 130 +/- 38.9 (x10(-2) N), and plantarflexion decreased gliding resistance and averaged 35 +/- 12.6 (x10(-2) N). Flatfoot deformity increased gliding resistance compared to normal feet, averaging 104 +/- 17.0 (x10(-2) N) for neutral, 205 +/- 55.0 (x10(-2) N) for dorsiflexion, and 58 +/- 21.3 (x10(-2) N) for plantarflexion. The findings indicate that patients with a preexisting flatfoot deformity may be predisposed to develop posterior tibial tendon dysfunction because of increased gliding resistance and trauma to the tendon surface.