The study aimed to compare Ultrasound-Guided Normal saline plus steroid hydrodissection group and Ultrasound-Guided normal saline alone hydrodissection group in patients with carpal tunnel syndrome (CTS), and to determine their clinical relevance in relation to treatment outcomes. We performed 60 US-guided hydrodissections Normal saline with and without corticosteroid injections in 51 patients with CTS, and evaluated their pre- and post-injection US findings. We categorized these injections into two groups based on the normal saline plus corticosteroid (steroid group). normal saline (control group) and we also recorded clinical data including gender, age, side of injection, BW, and the duration of pre-injection CTS related discomfort. The outcomes were measured using the visual analog scale was assigned to assess the primary outcome. The secondary outcomes were assessed using the Boston Carpal Tunnel Syndrome Questionnaire, cross-sectional area of the median nerve, and electrophysiological studies. The assessment was performed prior to injection, and 1, 3, and 6 months’ post-injection, and the symptom relief for the patients receiving normal saline and steroid injection were compared. We compared hydrodissections with normal saline and corticosteroid injections. The clinical data, pre injection CSA-MN at the inlet of the carpal tunnel, and pre-injection BCTQ scores showed no significant intergroup differences (p > 0.05). All patients (data from 30 wrists in each group) completed the study. Compared both the control group, at all post-injection time points, both groups had a significant reduction in pain and disability, improvement on electrophysiological response measures, and decreased cross-sectional area of the median nerve. Our study reveals that ultrasound-guided Normal saline with and without corticosteroid hydrodissection has therapeutic effect in patients CTS. Nerve hydrodissection was shown to be potentially beneficial for CTS patients pre-surgery. Hydrodissection is a simple, minimally invasive procedure that can be performed using only NS. In addition, compared to blind injection, hydrodissection under ultrasound guidance can lower the chances of nerve injury.
Carpal Tunnel Syndrome, Hydrodissection, Corticosteroid, Normal Saline Injection, Ultrasound Guidance
Carpal tunnel syndrome (CTS), involving compression of the median nerve (MN) deep to the flexor retinaculum, is one of the most common nerve entrapment syndromes encountered in musculoskeletal practice [1,2]. The age distribution is bimodal with first peak in early 50s and second peak at age 75-84 years, and women, especially during pregnancy, are more commonly affected than men . There are many causes and risk factors for carpal tunnel syndrome, such as trauma, vascular lesions, inflammation, obesity, occupational exposure, older age, osteoarthritis, pregnancy, hypothyroidism, or autoimmune diseases [4-8].
Pathophysiology of CTS is due to multifactorial causes, including nerve compression and traction disorders of the intraneural microcirculation, direct lesioning of the myelin sheath and axon, and alteration in the supporting connective tissue. Increased carpal tunnel pressure is thought to cause ischemic compression of the median nerve . The severity of carpal tunnel syndrome can be divided into 5 levels, from very mild symptoms (pins and needles sensation, pain, or sensibility loss in the fingers and/ or hand, mostly only during nighttime) to continuously very severe symptoms (pins and needles sensation, pain, significant then atrophy, and/or significant sensibility loss in the fingers and/or hand, most time) .
Although ultrasound of the carpal tunnel can depict similar MRI criteria used in CTS, the most commonly evaluated parameter has been the median nerve cross-sectional area. Using the circumferential trace mode on the ultrasound screen, the cross-sectional area of the median nerve can be measured. A widely accepted cutoff cross-sectional surface area for CTS with the highest sensitivity and specificity is 10 mm2, measured at the carpal tunnel inlet or pisiform. This sensitivity and specificity are high [11-14]. Although to avoid blind injection complications and for providing safer, reliable, and more efficient needle tip placement during CTS injections, ultrasound (US) guidance can play a beneficial role. Currently, musculoskeletal US has gained popularity based on its dynamic real-time property and low-cost availability . Ultrasound provides high-resolution scanning view of median nerve and surrounding vessels and tendons and assists in diagnosis as well as needle placement guidance. Hence, there is a need for new intervention during the pre-surgical stages of CTS. Hydrodissection is a minimally invasive procedure of injecting fluid into anatomic spaces to facilitate dissection and adhesiolysis during surgery. injecting the material between the MN and transverse carpal ligament and underlying tendons which may interrupt the adhesions of MN and reduce the symptoms [16,17].