Abstract
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.
Highlights
Carpal tunnel syndrome (CTS), the most common compressive mononeuropathy caused by entrapment of the median nerve, leads to functional impairment of the hand (Atroshi et al, 1999)
There was no significant difference between the three groups at the 24th-week post-injection follow-up
No significant difference was observed between the three groups in all variables, including age, gender, hypertension, diabetes, symptom duration, Phalen or Tinel test positive rate, lesion side, visual analog scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), QuickDASH, parameters of electrodiagnosis or cross-sectional area (CSA) (Table 1)
Summary
Carpal tunnel syndrome (CTS), the most common compressive mononeuropathy caused by entrapment of the median nerve, leads to functional impairment of the hand (Atroshi et al, 1999). Possible etiologies include increased pressure in the intracarpal canal, which compromise the circulation of median nerve (Bland, 2005) and tissue adhesion around median nerve (LaBan et al, 1986; Smith et al, 2008). As for treatment, wrist resting splint and steroid injection have long been the mainstream of conservative treatments, while surgical intervention was reserved for severe or refractory cases (Huisstede et al, 2014). Perineural dextrose injection (PDI) has been reported to be beneficial or even better than steroid injection (Wu et al, 2017b; Wu et al, 2018). To explain the therapeutic response of PDI with the hypoosmolar 5% dextrose for neuropathy-related pain, sensorineural mechanism was postulated that analgesic effect of dextrose on tender peripheral nerves as well as central nerve system via caudal epidural injection (ManiquisSmigel et al, 2016). Potential down-regulation to molecular pathway on the ion channel capsaicin receptor of sensory neurons may attenuate nociceptive and neuropathic pain (Watabiki et al, 2011; Bertrand et al, 2015)
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