Dexamethasone versus hyaluronidase as an adjuvant to local anesthetics in the ultrasound-guided hydrodissection of the median nerve for the treatment of carpal tunnel syndrome patients

Abstract

Background:Carpal tunnel syndrome (CTS) is one of the most common focal entrapment neuropathies. Although the exact etiology remains unclear, high-pressure-related intracarpal tunnel compression of the median nerve (MN), progressing ischemia, and mechanical strangulation are common mechanisms. The therapeutic managements for CTS depend on the disease severity, varying from a conservative treatment to surgical interventions. Conservative treatment is helpful for most of the patients with mild-to-moderate CTS. Hydrodissection is a minimally invasive procedure of injecting solutions into some anatomical spaces to facilitate dissection and adhesiolysis. Steroids as an anti-inflammatory drugs are used to treat chronic pain conditions. Hyaluronidase as an adhesolysis agent can also be used for epidural injections with local anesthetics (LAs) and steroids for control of chronic back pain.Aim of the Study:This study was carried out to compare the efficacy of hyaluronidase versus dexamethasone as adjuvants to the mixture of LAs in ultrasound (US)-guided hydrodissection of the median nerve in mild to moderate cases of carpal tunnel syndrome.Settings and Design:This study was a prospective randomized controlled double-blinded clinical study.Methods:40 patients aged from 20 to 60 years old with clinical, electrophysiologic, and ultrasonographic evidence of mild to moderate CTS were included in this study. Each patient was assessed at the baseline (prior to injection) and at 1 week, 1 month, 3 months, and 6 months intervals after injection: (1) The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) which is a frequently used patient-based questionnaire for measurement of CTS. primary outcome. (2) Median motor and sensory nerve conduction studies (NCS) secondary outcome. (3) Median nerve ultrasonography. The ultrasound examination included measurement of the median nerve cross-sectional area (CSA) at the distal wrist crease (DWC). Also, the median nerve echogenicity, mobility, and vascularity at the DWC were assessed by US. Secondary outcome. All outcome assessments were assessed by single investigator who was blinded to the study details. All patients received US guided hydrodissection of the median nerve at the distal wrist crease. The selected patients were randomly allocated into 2 groups containing 20 patients each according to the study drugs; Group (D) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL (8 mg) dexamethasone), and Group (H) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL normal saline containing 300 international units (IU) hyaluronidase. Ultrasound-guided intracarpal injection using ultrasonography (Sono Scape A5; Shinzhen, China) with a 10-18-MHZ linear array transducer was performed by the same physician who was not aware of study groups, the MN was observed at the inlet of the carpal tunnel, 3 ml of solution was injected via the in-plane ulnar approach, to detach the MN from the transverse carpal ligament and an additional 2 ml was injected to separate the MN from underlying flexor tendons. All pa...

Change to movement and morphology of the median nerve resulting from steroid injection in patients with mild carpal tunnel syndrome

“…Last, the present study was not the first study to evaluate the CSA and mobility of the median nerve after steroid injection 22,23 . However, the two studies reported previously followed a different protocol to evaluate the same outcomes.…”

Volume Matters in Ultrasound-Guided Perineural Dextrose Injection for Carpal Tunnel Syndrome: A Randomized, Double-Blinded, Three-Arm Trial

“…Although the effect of dextrose, conducted by a previous RCT, lasted for up to 6 months (Wu et al, 2017b), the effect of perineural saline injection showed an improved BCTQ only until the 3rd month post-injection which deteriorated by the 6th month of follow-up (Wu et al, 2019). Similarly, another RCT reported the improvement of BCTQ did not last until the 6th month after hydrodissection (with either steroid or hyaluronidase) (Alsaeid, 2019). In this study, via post-hoc Bonferroni analysis, pain and functional outcomes were not significant between the 3rd and 6th months follow-up in the 1, 2 and 4-ml groups (VAS: p 1.000, 0.895, 0.750, respectively; BCTQ: p 1.000, 1.000, 0.295, respectively).…”

The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review

“…The flow chart in Figure 1 presents the results describing the exclusions at different stages during the review process. Ten studies were included in this systematic review ( van Veen et al, 2015 ; Wu et al, 2017a ; Wu et al, 2017b ; Malahias et al, 2018 ; Roghani et al, 2018 ; Wu et al, 2018 ; Alsaeid, 2019 ; Güven et al, 2019 ; Senna et al, 2019 ; Shen et al, 2019 ).…”

“…When comparing one injectate to another, D5W, PRP, and hyaluronidase gave greater improvement than their steroids counterparts (Wu et al, 2018;Alsaeid, 2019;Senna et al, 2019). Regarding main electrodiagnostic parameters (SNCV and DML) findings, D5W and hyaluronidase resulted in superior outcomes comparing to NSS and dexamethasone, respectively (Wu et al, 2017b;Alsaeid, 2019). PRP plus splinting also significantly improved main electrodiagnostic parameters (Güven et al, 2019).…”

“…In the same way of another research by Wu et al, 2017a compared PRP with splinting as a control group, there was a significant improvement BCTQs (55) at 3 and 6 months (mean differences: −10.41, 95% CI −7.99 to −12.83, p < 0.001 and −12.03, 95% CI −9.65 to −14.41, p < 0.001) with the observed difference between groups after three months as well (Wu et al, 2018). For BCTQs (1-5) outcomes, two studies (Alsaeid and Senna et al) used corticosteroid medications (dexamethasone and methylprednisolone) as a comparison group (Alsaeid, 2019; Delta CSA: Cross-sectional area difference of the median nerve's surface at the tunnel's inlet minus the median nerve's surface proximal to the tunnel and overpronator quadrant. Q-DASH success: Presented as the number of patients with either a. higher than 25% improvement in Q-DASH score at final follow-up or b. positive Q-DASH difference bigger than 8.0 points at final follow-up; divided by the number of patients in the belonging group.…”