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. 2023 Feb 1;2(2):CD015148.
doi: 10.1002/14651858.CD015148.

Local corticosteroid injection versus placebo for carpal tunnel syndrome

Nigel L Ashworth  1 , Jeremy D P Bland  2 , Kristine M Chapman  3 , Gaetan Tardif  4 , Loai Albarqouni  5 , Arjuna Nagendran  6   7
Affiliations

Local corticosteroid injection versus placebo for carpal tunnel syndrome

Nigel L Ashworth et al. Cochrane Database Syst Rev. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

NA: none.

JB: none known. Dr Bland gives an annual lecture to students on a neuroscience MSc course, for which he is paid as an external lecturer. This activity has no relevance to this review.

KC: none.

GT: none.

LA: none.

AN: I received no money or sponsorship for my participation in this review. I am employed full‐time as a Clinical Neurophysiologist and thus have an academic interest in carpal tunnel syndrome. I am a member of the British Society of Clinical Neurophysiologists who have published guidelines and recommendations with respect to carpal tunnel syndrome.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 1: Symptoms ≤ 3 months
1.2
1.2. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 2: Symptoms > 3 months
1.3
1.3. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 3: Symptoms ≤ 3 months by local anaesthetic (LA) use
1.4
1.4. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 4: Symptoms > 3 months by LA use
1.5
1.5. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 5: Symptoms ≤ 3 months by corticosteroid dose
1.6
1.6. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 6: Symptoms > 3 months by corticosteroid dose
1.7
1.7. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 7: Symptoms ≤ 3 months by duration of action of corticosteroid
1.8
1.8. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 8: Symptoms ≤ 3 months by type corticosteroid
1.9
1.9. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 9: Boston Carpal Tunnel Questionnaire (Symptom Severity Scale) ≤ 3 months
1.10
1.10. Analysis
Comparison 1: Local corticosteroid injection (LCI) versus control: improvement in symptoms, Outcome 10: Boston Carpal Tunnel Questionnaire (Symptom Severity Scale) > 3 months
2.1
2.1. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 1: Function ≤ 3 months
2.2
2.2. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 2: Function > 3 months
2.3
2.3. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 3: Function ≤ 3 months by local anaesthetic (LA) use
2.4
2.4. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 4: Function > 3 months by LA use
2.5
2.5. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 5: Function ≤ 3 months by dose of corticosteroid
2.6
2.6. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 6: Function > 3 months by dose of corticosteroid
2.7
2.7. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 7: Function ≤ 3 months by duration of action of corticosteroid
2.8
2.8. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 8: Function ≤ 3 months by type of corticosteroid
2.9
2.9. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 9: Boston Carpal Tunnel Questionnaire (Functional Status Scale) ≤ 3 months
2.10
2.10. Analysis
Comparison 2: Local corticosteroid injection (LCI) versus control: improvement in function, Outcome 10: Boston Carpal Tunnel Questionnaire (Functional Status Scale) > 3 months
3.1
3.1. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 1: Median nerve distal motor latency (DML) ≤ 3 months
3.2
3.2. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 2: Median nerve DML > 3 months
3.3
3.3. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 3: Median nerve DML ≤ 3 months by local anaesthetic (LA) use
3.4
3.4. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 4: Median nerve DML ≤ 3 months by dose of corticosteroid
3.5
3.5. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 5: Median nerve DML > 3 months by dose of corticosteroid
3.6
3.6. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 6: Median nerve DML ≤ 3 months by duration of action of corticosteroid
3.7
3.7. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 7: Median nerve DML ≤ 3 months by type of corticosteroid
3.8
3.8. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 8: Median nerve sensory nerve conduction velocity (SNCV) ≤ 3 months
3.9
3.9. Analysis
Comparison 3: Local corticosteroid injection (LCI) versus control: improvement in neurophysiological parameters, Outcome 9: Median nerve SNCV > 3 months
4.1
4.1. Analysis
Comparison 4: Local corticosteroid injection (LCI) versus control: other outcomes, Outcome 1: Requirement for surgery
4.2
4.2. Analysis
Comparison 4: Local corticosteroid injection (LCI) versus control: other outcomes, Outcome 2: Change in quality of life (Short‐Form Six‐Dimension Instrument)
See this image and copyright information in PMC

Comment in

References

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References to other published versions of this review

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