Optimal Treatment Of Carpal Tunnel Syndrome

Despite the prevalence of CTS and its considerable economic impact – in terms of both worker absenteeism and compensation claims – there is no universally accepted therapy. Mild cases are usually left untreated. Moderate cases may be treated with local injections of corticosteroids, if patients fail to respond to splinting and anti-inflammatory drugs like ibuprofen. In severe cases, with the threat of permanent loss of sensation, the preferred treatment is surgery. Surgery, however, is often recommended to patients before trying less invasive and less expensive treatments. Is surgery always the best course for carpal tunnel syndrome's sufferers? A team of researchers in Madrid recently set out to find the answer. The results of their clinical trial, published in the February 2005 issue of Arthritis & Rheumatism (http://www.interscience.wiley.com/journal/arthritis), suggest that local steroid injection is just as effective as surgery for the long-term symptomatic relief of CTS – for a year, at least – and actually more effective over the short term.

The research effort focused on the results of 163 wrists belonging to 101 patients – 93 women, 8 men – who were referred by their primary care physician to a CTS unit specifically created for this study. All the patients had experienced CTS symptoms – most notably, nightly attacks of extreme tingling and burning in the hand and fingers, which disrupted their sleep – for at least 3 months. Of the total wrists, 80 were randomly assigned to the standard surgical procedure: decompression of the median nerve. The remaining 83 wrists were treated with local steroid injection. Patients in both groups were similar in age – the median was 50 for the surgery group and 53 for the injection group – as well as in the duration and severity of their symptoms.

All wrists were evaluated 14 days after the initial treatment. At that time, 69 of the wrists that had been treated with steroids received a second local injection. Researchers then assessed the symptoms of both groups at 3, 6, and 12 months, using visual analog scale scores to measure improvement. At the 3-month mark, 94 percent of the wrists in the injection group achieved significant improvement – a response of 20 percent or better – for the nocturnal symptoms, compared with 75 percent of wrists in the surgery group. At the 6-month mark, 85.5 percent of wrists in the injection group achieved a 20 percent or better response for the nocturnal symptoms, compared with 76.3 percent in the surgery group. At the 12-month mark, 69.9 percent of the wrists in the injection group achieved a 20 percent or better response for the nocturnal symptoms, compared with 70 percent in the surgery group. Throughout follow-up, results for two other symptoms measured – daily pain in the wrist area and self-perceived functional impairment – were similar.

"This is the first randomized controlled clinical trial comparing the two most common therapies for CTS," notes one of its authors, Dr. Domingo Ly-Pen. "Our findings suggest that both local steroid injections and surgical decompression are highly effective in alleviating the symptoms of primary CTS at 12 months of follow-up. Nevertheless, local injection seems superior to surgery in the short term."

Also notably, more patients whose wrists were randomly assigned to surgery rejected the treatment (11 wrists) than did those whose wrists were assigned to injection (1 wrist). "This finding coincides with our daily clinical practice," Dr. Ly-Pen observes, "in which patients usually prefer conservative therapies." Surgery may still be the best course in severe cases of CTS, for avoiding loss of sensation and improving function. This study, however, has important implications for the effective, affordable, early treatment of carpal tunnel syndrome, an unfortunately common condition of our times.

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Article: "Surgical Decompression Versus Local Steroid Injection in Carpal Tunnel Syndrome: A One-Year, Prospective, Randomized, Open, Controlled Clinical Trial," Domingo Ly-Pen, Jose-Luis Andreu, Gema de Blas, Alberto Sanchez-Olaso, and Isabel Millan, Arthritis & Rheumatism, February 2005; 52:2; pp. 612-619.