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      • Record: found
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      Comparison of Distal and Proximal Local Steroid Injection for Carpal Tunnel Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials

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          Abstract

          Introduction

          Local steroid injection (LSI) in the carpal tunnel is a mainstay of conservative treatment in patients with carpal tunnel syndrome (CTS). Currently, clinicians generally perform a conventional proximal approach (PA) or novel distal approach (DA) for LSI. Recent systematic reviews comparing the two injection methods are lacking. This systematic review and meta-analysis aimed to assess whether LSI using the DA was superior to PA in treating patients with CTS.

          Methods

          Databases including Pubmed, Embase, and the Cochrane library were searched up to 30 May 2022 to identify relevant randomized controlled trials (RCTs) comparing the DA with the PA steroid injection in patients with CTS. The outcomes mainly included Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQs) and Functional Status Scale (BCTQf), visual analog scores (VAS), electrophysiological outcomes, pain of injection, duration of injection, or adverse events.

          Results

          Five RCTs involving 339 patients were identified. Pooled analysis showed that the DA group took less time [mean difference (MD) −19.91; 95% CI −34.48 to −5.35; P = 0.007] and acquired better sensory nerve action potential amplitude [standardized mean difference (SMD) −0.37; 95% CI −0.62 to −0.11; P = 0.005]. The two groups were not significantly different in terms of BCTQs and BCTQf, VAS, other electrophysiological outcomes, pain of injection, or adverse events ( P > 0.05).

          Conclusion

          Although providing similar improvement in pain relief or function improvement, the distal approach is superior to the proximal approach in terms of timing, without increasing other side effects. Further high-quality randomized studies are required to confirm these results.

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s40122-022-00444-3.

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          Most cited references25

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          The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials

          Julian P. T. Higgins, Douglas G. Altman, Peter C. Gøtzsche … (2013)
          Flaws in the design, conduct, analysis, and reporting of randomised trials can cause the effect of an intervention to be underestimated or overestimated. The Cochrane Collaboration’s tool for assessing risk of bias aims to make the process clearer and more accurate
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            Quantifying heterogeneity in a meta-analysis.

            Julian P T Higgins, Simon G Thompson (2002)
            The extent of heterogeneity in a meta-analysis partly determines the difficulty in drawing overall conclusions. This extent may be measured by estimating a between-study variance, but interpretation is then specific to a particular treatment effect metric. A test for the existence of heterogeneity exists, but depends on the number of studies in the meta-analysis. We develop measures of the impact of heterogeneity on a meta-analysis, from mathematical criteria, that are independent of the number of studies and the treatment effect metric. We derive and propose three suitable statistics: H is the square root of the chi2 heterogeneity statistic divided by its degrees of freedom; R is the ratio of the standard error of the underlying mean from a random effects meta-analysis to the standard error of a fixed effect meta-analytic estimate, and I2 is a transformation of (H) that describes the proportion of total variation in study estimates that is due to heterogeneity. We discuss interpretation, interval estimates and other properties of these measures and examine them in five example data sets showing different amounts of heterogeneity. We conclude that H and I2, which can usually be calculated for published meta-analyses, are particularly useful summaries of the impact of heterogeneity. One or both should be presented in published meta-analyses in preference to the test for heterogeneity. Copyright 2002 John Wiley & Sons, Ltd.
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              A systematic review of conservative treatment of carpal tunnel syndrome.

              R Rabini, P. Ferrara, C Bertolini … (2007)
              To assess the effectiveness of conservative therapy in carpal tunnel syndrome. A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective.
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                Author and article information

                Contributors
                Leiming Hu:
                ORCID: http://orcid.org/0000-0002-9220-1218
                doctor_hulm@126.com
                Journal
                Journal ID (nlm-ta): Pain Ther
                Journal ID (iso-abbrev): Pain Ther
                Title: Pain and Therapy
                Publisher: Springer Healthcare (Cheshire )
                ISSN (Print): 2193-8237
                ISSN (Electronic): 2193-651X
                Publication date (Electronic): 5 October 2022
                Publication date PMC-release: 5 October 2022
                Publication date (Print): December 2022
                Volume: 11
                Issue: 4
                Pages: 1389-1402
                Affiliations
                [1 ]GRID grid.24696.3f, ISNI 0000 0004 0369 153X, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, ; Beijing, China
                [2 ]Section III of Internal Medicine Department, Tongzhou District Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Beijing, China
                [3 ]GRID grid.24695.3c, ISNI 0000 0001 1431 9176, Beijing University of Chinese Medicine, ; Beijing, China
                [4 ]GRID grid.43169.39, ISNI 0000 0001 0599 1243, Department of Spine Surgery, , Honghui Hospital, Xi’an Jiaotong University, ; Xi’an, China
                [5 ]GRID grid.452452.0, ISNI 0000 0004 1757 9282, Department of Hand Surgery, , Honghui Hospital, Xi’an Jiaotong University, ; Xi’an, 710054 Shaanxi China
                Author information
                http://orcid.org/0000-0002-9220-1218
                Article
                Publisher ID: 444
                DOI: 10.1007/s40122-022-00444-3
                PMC ID: 9633920
                PubMed ID: 36197649
                SO-VID: 4004c724-368f-45d0-aa8d-3e03492c7604
                Copyright © © The Author(s) 2022
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 5 August 2022
                Date accepted : 22 September 2022
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100007128, Natural Science Foundation of Shaanxi Province;
                Award ID: 2022JM-546
                Award Recipient :
                Categories
                Subject: Original Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2022

                Keywords: local corticosteroid injection,carpal tunnel syndrome,distal injection,proximal injection,meta-analysis,randomized controlled trial
                Data availability:
                Keywords: local corticosteroid injection, carpal tunnel syndrome, distal injection, proximal injection, meta-analysis, randomized controlled trial

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