Steroid shots allow some patients to avoid surgery
Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. Evidence has suggested that around three percent of women and two percent of men will be diagnosed with carpal tunnel syndrome in their lifetime.
The most common initial treatment is wrist splinting. When splinting is ineffective, steroid injections are often given and provide relief. However, it is difficult to know whether steroids are really the reason for improvement because the condition sometimes gets better on its own. When symptoms persist, surgery is performed. Although such surgery usually resolves the condition, it is associated with short-term pain and limitation of use of the operated hand as well as increased medical costs, according to a new study by Dr. Isam Atroshi, MD, PhD, Lund University, Department of Clinical Sciences, Hässleholm Hospital, Hässleholm, Sweden, and colleagues.
For this new study researchers examined how often patients who received steroids decided to have surgery compared with those who received placebo.
The study consisted of 111 patients aged 18 to 70 years with the carpal tunnel syndrome who had no previous steroid injections. Patients were randomized into three groups to receive injections of either of the two doses of methylprednisolone (a corticosteroid) or placebo.
All the participants had symptoms of classic or probable carpal tunnel (numbness or tingling in at least two of the four radial fingers) and all had been treated unsuccessfully with wrist splinting for two months. Patient’s symptoms were severe enough to warrant a referral for surgical consult. The researchers followed patients for 1 year after injection to assess whether injecting steroids helped some patients feel better and avoid surgery.
The primary endpoints were change in carpal tunnel symptom severity score at 10 weeks and the rate of surgery at 1 year. Secondary endpoints included time to surgery, change in carpal tunnel symptom severity score at 1 year, and treatment satisfaction at 10 weeks and 1 year.
The results showed patients who received 80 mg methylprednisolone injections were less likely to report pain, numbness, tingling, and other symptoms when evaluated 10 weeks later compared with patients who received placebo. They were also less likely to have surgery but no significant difference was seen between the 40-mg steroid and placebo groups.
At 24 weeks and 1 year, there were no differences between the three groups in pain scores and treatment satisfaction.
One year after injection, somewhat fewer patients who received steroids had surgery compared with those who received placebo. However, the benefit was not large because 3 out of 4 patients who received steroids still had surgery within 1 year.
In their study the team writes “In patients with the carpal tunnel syndrome who have been treated unsuccessfully with wrist splinting, a steroid injection into the carpal tunnel space often provides relief in the short term and enables some patients to avoid surgery. However, most patients who respond to steroid treatment will still decide to have surgery within 1 year because of persistent symptoms and limitations in hand function.”
In an email to MedPageToday , Dr. Atroshi writes "The probability of a long-term benefit is relatively small, which should be taken into consideration by doctors who currently use this treatment on most of their patients," he wrote. "On the other hand, for doctors who rarely use it, our study shows that the treatment has a proven short-term benefit and therefore, in certain situations, could be an appropriate alternative to surgery."
He also notes that the findings should help physicians counsel their carpal tunnel patients about what they can and cannot expect from steroid treatments.
These findings are reported in the Annals of Internal Medicine.