Diagnostic Value of a Carpal Tunnel Corticosteroid Injection in Patients with Negative Electrodiagnostic Studies

Abstract

Introduction There is a known false negative rate when using electrodiagnostic studies (EDS) to diagnose carpal tunnel syndrome (CTS). This can pose a management dilemma for patients with signs and symptoms that correlate with CTS but normal EDS. While corticosteroid injection into the carpal tunnel has been used in this setting for diagnostic purposes, there is little data in the literature supporting this practice. The purpose of this study is to evaluate the prognostic value of a carpal tunnel corticosteroid injection in patients with a normal electrodiagnostic study but exhibiting signs and symptoms suggestive of carpal tunnel, who proceed with a carpal tunnel release.

Materials and Methods The group included 34 patients presenting to an academic orthopedic practice over the years 2010 to 2019 who had negative EDS, a carpal tunnel corticosteroid injection, and a carpal tunnel release. One patient (2.9%), where the response to the corticosteroid injection was not documented, was excluded from the study, yielding a study cohort of 33 patients. Three patients had bilateral disease, yielding 36 hands for evaluation. Statistical analysis was performed using Chi-square analysis for nonparametric data.

Results Thirty-two hands (88.9%) demonstrated complete or partial relief of neuropathic symptoms after the corticosteroid injection, while four (11.1%) did not experience any improvement. Thirty-one hands (86.1%) had symptom improvement following surgery, compared with five (13.9%) which did not. Of the 32 hands that demonstrated relief following the injection, 29 hands (90.6%) improved after surgery. Of the four hands that did not demonstrate relief after the injection, two (50%) improved after surgery. This difference was statistically significant (p = 0.03).

Conclusion Patients diagnosed with a high index of suspicion for CTS do well with operative intervention despite a normal electrodiagnostic test if they have had a positive response to a preoperative injection. The injection can provide reassurance to both the patient and surgeon before proceeding to surgery. Although patients with a normal electrodiagnostic test and no response to cortisone can still do well with surgical intervention, the surgeon should carefully review both the history and physical examination as surgical success may decrease when both diagnostic tests are negative. Performing a corticosteroid injection is an additional diagnostic tool to consider in the management of patients with CTS and normal electrodiagnostic testing.

Keywords

carpal tunnel syndrome - electrodiagnostic - cortisone injection - nerve conduction studies - electromyography

Publication History

Article published online:
22 September 2020

• References

• 1 Jablecki CK, Andary MT, Floeter MK. et al. American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation. Practice parameter: electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2002; 58 (11) 1589-1592
• 2 Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2007; (02) CD001554
• 3 Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med 2013; 159 (05) 309-317
• 4 Chesterton LS, Blagojevic-Bucknall M, Burton C. et al. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial. Lancet 2018; 392 (10156) 1423-1433
• 5 Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell TD. Predicting the outcome of carpal tunnel release. J Hand Surg Am 2003; 28 (02) 255-261
• 6 Green DP. Diagnostic and therapeutic value of carpal tunnel injection. J Hand Surg Am 1984; 9 (06) 850-854
• 7 Grundberg AB. Carpal tunnel decompression in spite of normal electromyography. J Hand Surg Am 1983; 8 (03) 348-349
• 8 Levine DW, Simmons BP, Koris MJ. et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993; 75 (11) 1585-1592
• 9 Wang L. Electrodiagnosis of carpal tunnel syndrome. Phys Med Rehabil Clin N Am 2013; 24 (01) 67-77
• 10 American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. Published February 29, 2016. Accessed February 2, 2020 at: https://www.aaos.org/ctsguideline
• 11 Keith MW, Masear V, Chung KC. et al. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2009; 91 (10) 2478-2479
• 12 Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2008; 90 (12) 2587-2593
• 13 Graham B, Regehr G, Naglie G, Wright JG. Development and validation of diagnostic criteria for carpal tunnel syndrome. J Hand Surg Am 2006; 31 (06) 919-924
• 14 Sonoo M, Menkes DL, Bland JDP, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: do they add value?. Clin Neurophysiol Pract 2018; 3: 78-88
• 15 Fowler JR. Nerve conduction studies for carpal tunnel syndrome: gold standard or unnecessary evil?. Orthopedics 2017; 40 (03) 141-142
• 16 American Association of Neuromuscular & Electrdiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve 2006; 33 (03) 436-439
• 17 Hara Y, Nishiura Y, Ochiai N, Murai S, Yamazaki M. The relationship between preoperative needle electromyography findings and muscle power restoration after surgery in severe carpal tunnel syndrome patients. J Orthop Sci 2017; 22 (03) 430-433
• 18 Callaghan BC, Burke JF, Skolarus LE, Jacobson RD, De Lott LB, Kerber KA. Medicare's reimbursement reduction for nerve conduction studies: effect on use and payments. JAMA Intern Med 2016; 176 (05) 697-699
• 19 Meys V, Thissen S, Rozeman S, Beekman R. Prognostic factors in carpal tunnel syndrome treated with a corticosteroid injection. Muscle Nerve 2011; 44 (05) 763-768
• 20 Evers S, Bryan AJ, Sanders TL, Gunderson T, Gelfman R, Amadio PC. Corticosteroid Injections for Carpal Tunnel Syndrome: Long-Term Follow-Up in a Population-Based Cohort. Plast Reconstr Surg 2017; 140 (02) 338-347
• 21 Jenkins PJ, Duckworth AD, Watts AC, McEachan JE. Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis. Hand (N Y) 2012; 7 (02) 151-156
• 22 de Miranda GV, Fernandes CH, Raduan Jr J, Meirelles LM, Dos Santos JB, Faloppa F. Corticoid injection as a predictive factor of results of carpal tunnel release. Acta Ortop Bras 2015; 23 (02) 76-80
• 23 Beck JD, Brothers JG, Maloney PJ, Deegan JH, Tang X, Klena JC. Predicting the outcome of revision carpal tunnel release. J Hand Surg Am 2012; 37 (02) 282-287