Re: Median nerve damage following local corticosteroid injection for the symptomatic relief of carpal tunnel syndrome

Swan, Marc C.; Oestreich, Kerstin

doi:10.1177/17531934097318

Cited by 14 publications

(12 citation statements)

References 4 publications

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“…1). After sterilization of the skin, a 27-gauge needle was inserted into the proximal carpal tunnel at the distal wrist crease and ulnar to the area adjacent to the median nerve (19,22). The physician performed the injection by inserting the needle through the flexor retinaculum, avoiding harm to the median nerve, ulnar nerve and artery, and flexor digitorum superficialis tendon.…”

Section: Interventionsmentioning

confidence: 99%

Effectiveness of ultrasound-guided vs direct approach corticosteroid injections for carpal tunnel syndrome: A double-blind randomized controlled trial

Chen¹,

Wang²,

Pong³

et al. 2018

J Rehabil Med

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Both ultrasound-guided and direct approach corticosteroid injection protocols improved clinical symptoms and signs, physical function, and most electrodiagnostic parameters of patients with carpal tunnel syndrome throughout the follow-up period. However, the ultrasound-guided injection group showed greater improvements in the Semmes-Weinstein Monofilament test, sensory nerve conduction velocity, and digit-4 comparison study.

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Section: Interventionsmentioning

confidence: 99%

Effectiveness of ultrasound-guided vs direct approach corticosteroid injections for carpal tunnel syndrome: A double-blind randomized controlled trial

Chen¹,

Wang²,

Pong³

et al. 2018

J Rehabil Med

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“…It is reported to occur due to intraneural injection of the corticosteroid, which leads to immediate nerve pain and residual nerve damage. 4 Our patient did not experience tingling, numbness, or pain during the injection, which clinically rules out intraneural injection. All of the symptoms of acute CTS started 24 hours postinjection.…”

mentioning

confidence: 49%

Iatrogenic Acute Carpal Tunnel Syndrome

2016

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Carpal tunnel syndrome (CTS) is a condition in which there is median nerve entrapment within the carpal tunnel. The carpal tunnel is a small space in which nine tendons and the median nerve pass. Some authors consider it a closed space as it can behave as a closed compartment, and the median nerve may be affected by increased intracompartmental pressure. 1 Chronic CTS is the common form and can be treated conservatively or surgically. Conservative treatment is in the form of splinting, anti-inflammatory medication, and steroid injections (blind or ultrasound guided), while surgical is in the form of decompression (open or endoscopic). 2 On the other hand, acute CTS is rare. It is characterized by rapid progressive symptoms that arise in a matter of hours. It is mainly caused by fractures and/or dislocations around the wrist joint and less commonly caused by nontraumatic causes such as bleeding due to a bleeding disorder or from anticoagulant therapy. Acute CTS is a surgical emergency and requires urgent decompression to prevent undesired complications. 3 We present a case in which a patient suffered from iatrogenic acute CTS following a steroid injection to relief the symptoms of moderate CTS. The patient was a 43 year-old right-handed female dental nurse. She was complaining of tingling and numbness affecting the radial three digits for the last 12 months. Her symptoms progressed over the last 2 months, with increasing nocturnal pain, tingling, and numbness not responding to splints and anti-inflammatory medication. A nerve conduction study was organized and it showed mild-to-moderate CTS. The patient was injected 1 mL of 40-mg methylprednisolone þ 1 mL (0.25%) levobupivacaine into the carpal tunnel. The patient returned 24 hours later with worsening symptoms. She was referred to the accident & emergency department with worsening pain, numbness, and global hand weakness not responding to simple measures such as elevation and splintage. On examination, the patient was in severe pain at rest, paresthesia over the median nerve distribution, and weakness of the abductor pollicis brevis (Medical Research Council grade 3). Passive movement of the thumb, index, and middle fingers resulted in excruciating pain. There were no signs of infection at presentation. The clinical picture was consistent with acute CTS and urgent decompression was performed through an extended approach into the distal forearm. Intraoperatively, the median nerve sheath was swollen with chalky white powder deposits. There were no signs of nerve damage or infection. Serous fluid oozing from the nerve sheath was sent for Gram stain, culture, and sensitivity testing. No organisms were seen or grown from it. The patient had immediate relief of her median nerve symptoms postoperatively. The following day the patient was able to actively move the wrist, thumb, and fingers with minimal pain. The patient was followed up 2 weeks later. She had regained full muscle power strength and had normal sensation at that stage.Steroid injections are frequently us...

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“…[6][7][8][9][10][11][12] En 1966, Phalen 8 analiza su experiencia en 654 pacientes con StC, 270 fueron tratados con un corticoide local. Las complicaciones que describe son un caso de neuritis química del nervio mediano en un paciente sometido a 28 infiltraciones previas, y presenta una foto de la inyección intraneural del corticoide, que muestra el depósito de una sustancia blanquecina sobre el nervio, sin describir la clínica del paciente.…”

Section: Discussionunclassified

“…No existe un protocolo estandarizado para el tratamiento y la rehabilitación de esta complicación; todos los autores recomiendan que, ante la sospecha de una inyección intraneural de corticoides, se debería realizar una exploración quirúrgica, liberar el nervio y eliminar el depósito de corticoide de la superficie nerviosa. [6][7][8][9][10][11] Solo un autor presenta a una paciente que fue sometida a inmovilización combinada con ejercicios de relajación nerviosa y terapia analgésica con gabapentina, paracetamol asociado a tramadol, con mejoría de los síntomas a los seis meses. 12 En todos los casos, la recuperación fue parcial, con mejoría sintomática, pero con debilidad y alteración de la sensibilidad, similar a lo que le ocurrió a nuestro paciente.…”

Section: Discussionunclassified

“…12 En todos los casos, la recuperación fue parcial, con mejoría sintomática, pero con debilidad y alteración de la sensibilidad, similar a lo que le ocurrió a nuestro paciente. [6][7][8][9][10][11][12] La infiltración con corticoides para tratar el StC es un procedimiento frecuente y para evitar complicaciones, es imprescindible conocer la anatomía normal del túnel carpiano, 14 las variantes anatómicas y los márgenes de seguridad para aplicar la inyección. Varios autores han descrito la técnica de infiltración, [6][7][8][9][10]15 pero el sitio de la inyección todavía es un tema de discusión, se recomienda que debería realizarse cubital al tendón del músculo palmaris longus, ya que el nervio se encuentra a nivel dorso-radial con respecto a este tendón; por el contrario, algunos autores prefieren colocar la aguja radial al tendón del palmaris longus, entre este y el tendón del músculo flexor carpi radialis.…”

Section: Discussionunclassified

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Neuritis química post-infiltración en síndrome del túnel carpiano.

Olivera

Jabif

Rodríguez

et al. 2017

Rev. Asoc. Arg. Ort. y Traumatol

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65 ResumenLa inyección local de corticoide es una de las opciones de tratamiento conservador para el síndrome del túnel carpiano leve o moderado, son pocos los reportes de lesión del nervio mediano por inyección intraneural. Comunicamos un caso de neuritis química del nervio mediano posterior a la infiltración con corticoide local en un hombre de 42 años con síndrome del túnel carpiano. Se le realizó neurólisis, epineurotomía y desbridamiento del material inyectado. Se han descrito varias técnicas de infiltración a nivel del túnel del carpo. En este reporte, se discuten los límites anatómicos del túnel del carpo, las técnicas de infiltración y las opciones terapéuticas si surge esta complicación. Se recomienda aplicar la inyección cubital al tendón del palmaris longus 1,5 cm proximal al pliegue de flexión de la muñeca. Colocada la aguja se pregunta al paciente si siente parestesias o dolor en el territorio del nervio mediano, si la respuesta es afirmativa, el procedimiento debe detenerse y se debe redireccionar la aguja.Palabras clave: Síndrome del túnel carpiano; nervio mediano; corticoide; inyección; tratamiento conservador. Nivel de Evidencia: IV Chemical neuritis after steroid injection in a patient with carpal tunnel syndrome. Case report AbstractLocal steroid injection is one of the non-operative treatment options in patients with mild or moderate carpal tunnel syndrome; reports of intra-neural median nerve injection injury from this practice are rare. A case of median nerve chemical neuritis after steroid injection in a 42 years old man with carpal tunnel syndrome is presented. He was treated with neurolysis, epineurotomy, and debridement of the injected material. Several carpal tunnel injection techniques have been described in the literature. Carpal tunnel anatomical landmarks, injection techniques and treatment options of this complication are discussed in this report. We recommend administering the injection ulnar to the palmaris longus tendon 1.5 cm proximal to the flexion crease of the wrist. After the needle is placed, the patient is asked for any pain or paresthesia in the distribution of the median nerve, if the answer is affirmative, the injection should be stopped and redirected.Key words: Carpal tunnel syndrome; median nerve; steroid; injection; conservative treatment. Level of Evidence: IV Neuritis química posinfiltración con corticoide en un paciente con síndrome del túnel carpiano

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Re: Median nerve damage following local corticosteroid injection for the symptomatic relief of carpal tunnel syndrome

Cited by 14 publications

References 4 publications

Effectiveness of ultrasound-guided vs direct approach corticosteroid injections for carpal tunnel syndrome: A double-blind randomized controlled trial

Effectiveness of ultrasound-guided vs direct approach corticosteroid injections for carpal tunnel syndrome: A double-blind randomized controlled trial

Iatrogenic Acute Carpal Tunnel Syndrome

Neuritis química post-infiltración en síndrome del túnel carpiano.

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