Therapeutics

Methylprednisolone injections reduced carpal tunnel syndrome symptoms at 10 weeks and surgery at 1 year

Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebocontrolled trial. Ann Intern Med. 2013;159:309-17.

Clinical impact rating: F ★★★★★★✩ Question

Main results

In patients with primary idiopathic carpal tunnel syndrome (CTS), what is the efficacy of local methylprednisolone injections?

The main results are in the Table.

Methods

In adults with idiopathic carpal tunnel syndrome, local injections of methylprednisolone, 40 or 80 mg, reduced symptom severity at 10 weeks; methylprednisolone, 80 mg, reduced risk for surgery at 1 year compared with placebo.

Conclusion

Design: Randomized placebo-controlled trial. ClinicalTrials.gov NCT00806871. Allocation: Concealed.* Blinding: Blinded* (patients, surgeons, physical therapists, {data collectors, outcome assessors, data analysts, and safety committee}†).

*See Glossary.

Follow-up period: 1 year.

Sources of funding: Region of Scania Research and Development Foundation and Hässleholm Hospital Organization.

†Information provided by author.

Setting: Regional referral orthopedic department in Sweden.

For correspondence: Dr. I. Atroshi, Hässleholm Hospital, Hässleholm, Sweden. E-mail [email protected]

Patients: 111 patients, 18 to 70 years of age (mean age 46 y, 73% women) who had symptoms of classic or probable CTS (Katz diagnostic criteria; numbness or tingling in ≥ 2 of 4 radial fingers); unsuccessful treatment with wrist splinting for 2 months; referral for surgery; and median neuropathy at the wrist or independent diagnosis by 2 orthopedic surgeons. Exclusion criteria included previous steroid injection or carpal tunnel release, thenar muscle atrophy, sensory loss, diabetes, thyroid disorder, inflammatory disease, polyneuropathy, or surgery on the contralateral hand in the past 2 months.

Commentary The randomized controlled trial by Atroshi and colleagues showed that injections of 40 or 80 mg of methylprednisolone for clinical CTS provided relief of symptoms compared with placebo. This relief lasted to 10 weeks compared with previous RCTs, which reported symptom relief only up to 1 month after steroid injection (1, 2). However, despite this symptom improvement, 75% of the patients in the study had surgery at 1 year. As the definitive treatment for CTS presently remains carpal tunnel release, a prudent clinician has to consider what steroid injections have to offer.

Intervention: Methylprednisolone, 2 mL (80 mg) (n = 37); methylprednisolone, 1 mL (40 mg) plus saline, 1 mL (n = 37); or saline, 2 mL (n = 37); each with lidocaine, 1 mL, injected subfascially in the soft tissues of the carpal tunnel of the most symptomatic hand.

The interpretation of this study is as follows: Steroid injection for CTS should be considered as temporary relief before a definitive carpal tunnel release. When steroid injection for symptomatic relief is reasonable, reasons for postponing definitive carpal tunnel release could include other health issues, inability to take time off work, and caring for an ill spouse.

Outcomes: Primary outcomes were change in CTS symptom severity score (possible score range 1 to 5; 1 = no symptoms, 5 = most severe) at 10 weeks and surgery at 1 year. Patient follow-up: 97% at 10 weeks and 100% at 1 year.

Methylprednisolone (Methyl) 80 mg vs 40 mg vs placebo for the carpel tunnel syndrome‡ Outcomes

Symptom severity§

Mean change at 10 wk Methyl, Methyl, Placebo 80 mg 40 mg −0.90 −1.17 −0.90

−0.30

−0.64 (−1.06 to −0.21)

−0.30

−0.88 (−1.30 to −0.46) 0.24 (−0.20 to 0.69)

−1.17

Event rates at 1 y Surgery

73% 81% 73%

81%

Mean difference

RRR (95% CI)

NNT (CI)

92%

20% (0.4 to 56)

6 (2 to 257)

92%

12% (−3 to 45)

NS

10% (−10 to 42)

NS

Achilleas Thoma, MD McMaster University Hamilton, Ontario, Canada References 1. Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome. Muscle Nerve. 2004;29:82-8. 2. Dammers JW, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ. 1999;319:884-6.

‡NS = not significant; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from control event rates and odds ratios in article. §Measure of severity, frequency, and duration of nighttime and daytime pain and numbness or tingling; possible score range 1 to 5; 1 = no symptoms, 5 = most severe.

21 January 2014 | ACP Journal Club | Volume 160 • Number 2

© 2014 American College of Physicians

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ACP Journal Club. Methylprednisolone injections reduced carpal tunnel syndrome symptoms at 10 weeks and surgery at 1 year.

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