Procedure

Carpal Tunnel Corticosteroid Injection

search

Carpal Tunnel Corticosteroid Injection, Carpal Tunnel Steroid Injection

  • See Also
  1. Hand Injection
  2. Joint Injection
  3. Injectable Corticosteroid
  • Indications
  1. Carpal Tunnel Syndrome
  • Efficacy
  1. Short-term
    1. Reduced symptoms, and improved function and quality of life in 60-70% cases
    2. Short-term relief for at least 6 months, and reduced need for surgery at 12 months
    3. Ashworth (2023) Cochrane Database Syst Rev (2): CD015148 [PubMed]
  2. Long-term
    1. Clinical outcome at one year for steroid injection is similar to surgery
      1. Ly-Pen (2005) Arthritis Rheum 52:612-9 [PubMed]
  • Precautions
  1. Do not inject into Median Nerve
  2. Risk of tendon rupture
  3. Injection is harmful if improperly done
  • Anatomy
  • Anatomic relationships
  1. Flexor carpi radialis (radial side)
  2. Median Nerve
  3. Palmaris Longus (Ulnar side)
    1. Forms palmar aponeurosis at midline of wrist
    2. Oppose thumb and 5th finger to find palmaris longus
  • Preparation
  1. Needle: 27 gauge 1.25 inch (or 25 gauge 1.5 inch)
  2. Corticosteroid
    1. Methylprednisolone: 20-40 mg (0.5 to 1 ml of 40 mg/ml) or
    2. Triamcinolone 20-40 mg or
    3. Celestone Soluspan: 1 ml
  3. Anesthetic (without Epinephrine)
    1. Lidocaine 1%: 1-2 ml or
    2. Bupivacaine (Marcaine) 0.25%
  • Technique
  • Landmark
  1. Consider Ultrasound guidance of injection (see below)
    1. Non-Ultrasound landmarks offer accurate needle placement in 75% of cases
      1. However landmark-based injection results in Median Nerve penetration in 9% of cases
      2. Green (2020) Hand 15(1): 54-8 [PubMed]
  2. Wrist position
    1. Dorsiflex wrist to 30 degrees resting on towel roll
  3. Injection site
    1. Proximal wrist crease (or 1 cm proximal to most distal wrist crease) AND
    2. RADIAL side of following landmark
      1. Wrist midline (in-line with 4th digit) if palmaris longus absent or
      2. Palmaris longus tendon
        1. Find by opposing thumb with pinky or
        2. Flex middle finger against resistance
    3. References
      1. Brooks (2019) Eplasty 19:e19 +PMID: 31501688 [PubMed]
  4. Needle insertion
    1. Apply antiseptic to skin (e.g. Chlorhexidine or Povidone-Iodine)
    2. Aim 30-45 degrees distally toward middle-ring finger
    3. Insert needle 1-2 cm until no resistance (under the flexor Retinaculum, nerve is very superficial)
    4. Do not inject if Paresthesias (see below)
  5. Warning: Distal Paresthesias with needle before steroid
    1. Indicates needle is at Median Nerve
    2. Do not inject here!
    3. Remove needle and replace further to the ulnar side
  1. Prepare the skin as with landmark approach
  2. High frequency linear Ultrasound probe
    1. Position transverse (horizontally) across the wrist
  3. Needle Insertion
    1. Locate the Median Nerve
    2. Insert the needle from ulnar aspect, parallel to the table and in-line with the Ultrasound probe
    3. First needle direction toward superficial depth within the flexor Retinaculum
      1. Target the space anterior (superficial) and radial to the nerve and hydrodissect it from the overlying Retinaculum
      2. Inject the first half of the steroid-Anesthetic solution
    4. Second needle direction is directed at a deeper plan
      1. Target the space inferior (deep) and ulnar to the Median Nerve
      2. Inject remaining half of the steroid-Anesthetic solution
  4. Efficacy
    1. Ultrasound-guided injection is significantly more effective than landmark-based
      1. Babaei-Ghazani (2018) Arch Phys Med Rehabil 99(4):766-75 +PMID: 28943161 [PubMed]
  • Follow-up
  1. Anticipate at least 2 weeks to see improvement
  2. Continue Wrist Splint use after injection
  3. May be repeated up to 2-3 times
  • References
  1. Pfenninger (1994) Procedures, Mosby, p. 1036-54
  2. Neustadt in Roberts (1998) Procedures, p. 914-5
  3. Boyer (2008) J Hand Surg Am 33(8): 1414-6 [PubMed]
  4. Pujalte (2024) Am Fam Physician 110(4): 402-10 [PubMed]
  5. Tallia (2003) Am Fam Physician 67(4):745-50 [PubMed]