Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

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.

Comparing the effectiveness of ultrasound-guided versus blind steroid injection in the treatment of severe carpal tunnel syndrome

“…Therefore, injection under ultrasound (US) guidance may increase precision and therapeutic outcomes and decrease complication rates. There are only a few studies that have investigated US guidance for injections in CTS, and they generally determined that US-guided injections result in better symptom relief and increased and long-lasting therapeutic effects compared to blind injections (11)(12)(13). Since the studies in this area are limited in number, this study was conducted to compare the effectiveness of USguided injection versus blind injection of corticosteroids in the treatment of severe CTS according to symptom severity, hand function, and electrophysiological parameters.…”

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

“…Most studies evaluated injections into a single structure (42/49 (86%)),17 51 54 69 80 84–87 90–95 97–101 103–113 115–125 but seven studies (14%) investigated injections into more than one structure 52 71 88 89 96 102 114. In decreasing frequency, studies evaluated injections into bursae (19/49 (39%)),17 51 52 54 69 87 91–93 95 97 100 101 103 105 110 115 121 123 tendon sheaths (9/49 (18%)),71 89 102 106 108 111–113 116 tendons or fascia (8/49 {(16%)),96 102 107 112 119 120 124 125 perineural regions (6/49 (12%)),85 88 94 104 109 122 muscles (5/49 (10%)),86 97 114 117 118 cysts (2/49 (4%)),84 90 peritendinous regions (2/49 (4%)),71 102 wounds (1/49 (2%))52 and periarticular spaces (1/49 (2%)) 80…”

Comparison of the Clinical Effectiveness of Ultrasound-Guided Corticosteroid Injection with and without Needle Release of the Transverse Carpal Ligament in Carpal Tunnel Syndrome

“…Advancements in ultrasonography allow the visualization of the structures of the carpal tunnel, including the median nerve, flexor tendons, and the TCL as well as the structures at risk, including the ulnar artery and the proximal palmar arch. Recent studies have demonstrated that corticosteroid injection with the use of ultrasound guidance is better than blind administration and reduces the time to symptom resolution [1,8,12,13]. However, ultrasound can clearly delineate the needle and dynamically observe the puncture process; thus, the authors designed the technique of combined use of ultrasound-guided local corticosteroid injections and needle release.…”

“…It provides a real-time anatomic, high-resolution image of the median nerve, the carpal tunnel, and the neighboring structures, and helps physicians to place the needle tip and inject closer to the median nerve accurately. Several previous studies have demonstrated higher effectiveness of ultrasound-guided injections in CTS when compared to blind injections [1,12,13,14,15]. …”