Abstract
This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1 % lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1 % reduction in injection pain (p < 0.01), a 63.3 % reduction in pain scores at outcome (p < 0.014), 93.5 % increase in the responder rate (p < 0.001), 84.6 % reduction in the non-responder rate (p < 0.001), a 71.0 % increase in therapeutic duration (p < 0.001), and a 59.3 % ($150) reduction in cost/responder/year for a hospital outpatient (p < 0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician’s office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.
Similar content being viewed by others
References
Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R (2005) A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology 64:2074–2078
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I (2005) Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum 52:612–619
Gokoglu F, Fndkoglu G, Yorgancoglu ZR, Okumus M, Ceceli E, Kocaoglu S (2005) Evaluation of iontophoresis and local corticosteroid injection in the treatment of carpal tunnel syndrome. Am J Phys Med Rehabil 84:92–96
Sevim S, Dogu O, Camdeviren H, Kaleagasi H, Aral M, Arslan E, Milcan A (2004) Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci 25:48–52
Hui AC, Wong SM, Tang A, Mok V, Hung LK, Wong KS (2004) Long-term outcome of carpal tunnel syndrome after conservative treatment. Int J Clin Pract 58:337–9
Gonzalez MH, Bylak J (2001) Steroid injection and splinting in the treatment of carpal tunnel syndrome. Orthopedics 24:479–481
Hagebeuk EE, de Weerd AW (2004) Clinical and electrophysiological follow-up after local steroid injection in the carpal tunnel syndrome. Clin Neurophysiol 115:1464–1468
Graham RG, Hudson DA, Solomons M, Singer M (2004) A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Plast Reconstr Surg 113:550–556
Ayhan-Ardiá FF, Erdem HR (2000) Long-term clinical and electrophysiological results of local steroid injection in patients with carpal tunnel syndrome. Funct Neurol 15:157–165
O’Gradaigh D, Merry P (2000) Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis 59:918–919
Dammers JW, Veering MM, Vermeulen M (1999) Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ 319:884–886
Ortiz-Corredor F, Enríquez F, Díaz-Ruíz J, Calambas N (2008) Natural evolution of carpal tunnel syndrome in untreated patients. Clin Neurophysiol 119:1373–1378
Silverstein BA, Fan ZJ, Bonauto DK, Bao S, Smith CK, Howard N, Viikari-Juntura E (2010) The natural course of carpal tunnel syndrome in a working population. Scand J Work Environ Health 36:384–393
Pazzaglia C, Caliandro P, Aprile I, Mondelli M, Foschini M, Tonali PA, Padua L (2005) Italian CTS and others entrapment Study Group. Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course. Acta Neurochir Suppl 92:35–39
Resende LA, Tahara A, Fonseca RG, Sardenberg T (2003) The natural history of carpal tunnel syndrome. A study of 20 hands evaluated 4 to 9 years after initial diagnosis. Electromyogr Clin Neurophysiol 43:301–304
Padua L, Padua R, Lo Monaco M, Aprile I, Paciello N, Nazzaro M, Tonali P (1998) Natural history of carpal tunnel syndrome according to the neurophysiological classification. Ital J Neurol Sci 19:357–361
Ouellette EA, Kelly R (1996) Compartment syndromes of the hand. J Bone Joint Surg Am 78:1515–1522
Cherasse A, Kahn MF, Mistrih R, Maillard H, Strauss J, Tavernier C (2003) Nicolau’s syndrome after local glucocorticoid injection. Joint Bone Spine 70:390–392
Park J, Dumanian GA (2009) Shower emboli and digital necrosis after a single corticosteroid injection for trigger thumb: case report. J Hand Surg Am 34:313–316
Payne JM, Brault JS (2008) Digital ischemia after carpal tunnel injection: a case report. Arch Phys Med Rehabil 89:1607–1610
Smith J, Wisniewski SJ, Finnoff JT, Payne JM (2008) Sonographically guided carpal tunnel injections: the ulnar approach. J Ultrasound Med 27:1485–1490
Grassi W, Farina A, Filippucci E, Cervini C (2002) Intralesional therapy in carpal tunnel syndrome: a sonographic-guided approach. Clin Exp Rheumatol 20:73–76
McNally E (2005) Musculoskeletal interventional ultrasound. In: McNally E (ed) Practical musculoskeletal ultrasound. Elsevier, New York, NY, pp 293–294
Balint PV, Kane D, Hunter J, McInnes IB, Field M, Sturrock RD (2002) Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. J Rheumatol 29:2209–2213
Qvistgaard E, Kristoffersen H, Terslev L, Danneskiold-Samsøe B, Torp-Pedersen S, Bliddal H (2001) Guidance by ultrasound of intraarticular injections in the knee and hip joints. Osteoarthritis Cartilage 9:512–517
Pendleton A, Millar A, O’Kane D, Wright GD, Taggart AJ (2008) Can sonography be used to predict the response to intraarticular corticosteroid injection in primary osteoarthritis of the knee? Scand J Rheumatol 37:395–397
Raza K, Lee CY, Pilling D, Heaton S, Situnayake RD, Carruthers DM et al (2003) Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology (Oxford) 42:976–979
Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O (1997) Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 56:59–63
Naredo E, Cabero F, Beneyto P, Cruz A, Mondejar B, Uson J et al (2004) A randomized comparative study of short term response to injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 31:308–314
Sibbitt WL Jr, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA, Bankhurst AD (2009) Does sonographic guidance influence the outcome of intraarticular injections? J Rheumatol 36:1892–1902
Hall S, Buchbinder R (2004) Do imaging methods that guide needle placement improve outcome? Ann Rheum Dis 63:1007–1008
del Cura JL (2008) Ultrasound guided procedures in the musculoskeletal system. Curr Probl Diagn Radiol 37:203–218
Parker L, Nazarian LN, Carrino JA, Morrison WB, Grimaldi G, Frangos AJ, Levin DC, Rao VM (2008) Musculoskeletal imaging: Medicare use, cost, and potential for cost substitution. J Am Coll Radiol 5:182–188
El Miedany Y, Ashour S, Youssef S, Mehanna A, Meky FA (2008) Clinical diagnosis of carpal tunnel syndrome: old tests-new concepts. Joint Bone Spine 75:451–457
Wilder-Smith EP, Seet RC, Lim EC (2006) Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests. Nat Clin Pract Neurol 2:366–374
Graham B, Regehr G, Naglie G, Wright JG (2006) Development and validation of diagnostic criteria for carpal tunnel syndrome. J Hand Surg [Am] 31:919–924
Miller MD, Ferris DG (1993) Measurement of subjective phenomena in primary care research: the Visual Analogue Scale. Fam Pract Res J 13:15–24
Katz J, Melzack R (1999) Measurement of pain. Surg Clin North Am 79:231–252
Derendorf H, Möllmann H, Grüner A, Haack D, Gyselby G (1986) Pharmacokinetics and pharmacodynamics of glucocorticoid suspensions after intra-articular administration. Clin Pharmacol Ther 39:313–317
Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G (2006) Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2, CD005328
Firestein GS, Paine MM, Littman BH (1991) Gene expression (collagenase, tissue inhibitor of metalloproteinases, complement, and HLA-DR) in rheumatoid arthritis and osteoarthritis synovium. Quantitative analysis and effect of intraarticular corticosteroids. Arthritis Rheum 34:1094–1105
U.S. Department of Health & Human Services. Centers for Medicare & Medicaide Services. Physician fee schedule look-up. http://www.cms.hhs.gov/PFSlookup/. Accessed 1 June 2010
Sibbitt RR, Sibbitt WL Jr, Nunez SE, Kettwich LG, Kettwich SC, Bankhurst AD (2006) Control and performance characteristics of eight different suction biopsy devices. J Vasc Interv Radiol 17:1657–1669
Nunez SE, Draeger HT, Rivero DP, Kettwich LG, Sibbitt WL Jr, Bankhurst AD (2007) Reduced pain of intraarticularhyaluronate injection with the reciprocating procedure device. J ClinRheumatol 13:16–19
Bankhurst AD, Nunez SE, Draeger HT, Kettwich SC, Kettwich LG, Sibbitt WL Jr (2007) A randomized controlled trial of the reciprocating procedure device for intraarticular injection of corticosteroid. J Rheum 34:187–192
Sibbitt WL Jr, Sibbitt RR, Michael AA, Fu DI, Draeger HT, Twining JM, Bankhurst AD (2006) Physician control of needle and syringe during traditional aspiration-injection procedures with the new reciprocating syringe. J Rheumatol 33:771–778
Nunez SE, Bedrick EJ, Kettwich SC, Kettwich LG, Bankhurst AD, Sibbitt WL Jr (2008) A randomized, controlled trial of the reciprocating procedure device for local anesthesia. J Emerg Med 35:119–125
Sander O (2007) Intra-articular corticosteroid injections with the reciprocating procedure device reduced procedural pain and duration more than the conventional syringe. Evid Based Med 12:106
Wroblicka JT, Kuligowska E (1998) One-step needle aspiration and lavage for the treatment of abdominal and pelvic abscesses. AJR Am J Roentgenol 170(5):1197–1203
Luyet C, Eichenberger U, Greif R, Vogt A, SzücsFarkas Z, Moriggl B (2009) Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth 102:534–539
Gimbel HV (1994) Hydrodissection and hydrodelineation. Int Ophthalmol Clin 34:73–90
Demirci S, Kutluhan S, Koyuncuoglu HR, Kerman M, Heybeli N, Akkuş S, Akhan G (2002) Comparison of open carpal tunnel release and local steroid treatment outcomes in idiopathic carpal tunnel syndrome. Rheumatol Int 22:33–37
Keith MA (1957) Acroparaesthesiae in sclerodactyly and carpal tunnel syndrome treated with prednisolone. Scott Med J 2:435–438
Campagna R, Pessis E, Feydy A, Guerini H, Le Viet D, Corlobé P, Drapé JL (2009) MRI assessment of recurrent carpal tunnel syndrome after open surgical release of the median nerve. AJR Am J Roentgenol 193:644–650
Lee WP, Schipper BM, Goitz RJ (2008) 13-year experience of carpal tunnel release using the Indiana Tome technique. J Hand Surg Am 33:1052–1056
Luria S, Waitayawinyu T, Trumble TE (2008) Endoscopic revision of carpal tunnel release. Plast Reconstr Surg 121:2029–2034
Stütz N, Gohritz A, van Schoonhoven J, Lanz U (2006) Revision surgery after carpal tunnel release—analysis of the pathology in 200 cases during a 2 year period. J Hand Surg Br 31:68–71
Prick JJ, Blaauw G, Vredeveld JW, Oosterloo SJ (2003) Results of carpal tunnel release. Eur J Neurol 10:733–736
Steyers CM (2002) Recurrent carpal tunnel syndrome. Hand Clin 18:339–345
Pomerance J, Zurakowski D, Fine I (2009) The cost-effectiveness of nonsurgical versus surgical treatment for carpal tunnel syndrome. J Hand Surg Am 34:1193–1200
Lorgelly PK, Dias JJ, Bradley MJ, Burke FD (2005) Carpal tunnel syndrome, the search for a cost-effective surgical intervention: a randomised controlled trial. Ann R Coll Surg Engl 87:36–40
Osterman AL, Whitman M, Porta LD (2002) Nonoperative carpal tunnel syndrome treatment. Hand Clin 18:279–289
Monacelli G, Rizzo MI, Spagnoli AM, Pardi M, Irace S (2008) The pillar pain in the carpal tunnel’s surgery. Neurogenic inflammation? A new therapeutic approach with local anaesthetic. J Neurosurg Sci 52:11–15
Moghtaderi AR, Jazayeri SM, Azizi S (2009) EMLA cream for carpal tunnel syndrome: how it compares with steroid injection. Electromyogr Clin Neurophysiol 49:287–289
Nalamachu S, Crockett RS, Mathur D (2006) Lidocaine patch 5 for carpal tunnel syndrome: how it compares with injections: a pilot study. J FamPract 55:209–214
Pietruck C, Grond S, Xie GX, Palmer PP (2003) Local anesthetics differentially inhibit sympathetic neuron-mediated and C fiber-mediated synovial neurogenic plasma extravasation. Anesth Analg 96:1397–1402
Im SH, Lee SC, Park YB, Cho SR, Kim JC (2009) Feasibility of sonography for intraarticular injections in the knee through a medial patellar portal. J Ultrasound Med 28:1465–1470
Grosse SD, Teutsch SM, Haddix AC (2007) Lessons from cost-effectiveness research for the United States public health policy. Annu Rev Public Health 28:365–391
Melfi CA (2001) Using databases for studying and comparing health care costs and resource use. Pharmacoepidemiol Drug Saf 10:399–402
Barnett PG (1999) Review of methods to determine VA health care costs. Med Care 37(4 SupplVa):AS9–17
Nazarian LN (2010 Aug) Denying payments for musculoskeletal ultrasound: how did we get here? J Am CollRadiol 7(8):553–556. doi:10.1016/j.jacr.2010.03.009
Disclosures
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Makhlouf, T., Emil, N.S., Sibbitt, W.L. et al. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Clin Rheumatol 33, 849–858 (2014). https://doi.org/10.1007/s10067-013-2438-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10067-013-2438-5