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

Abstract

SummaryBackgroundTo our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome.MethodsWe did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452.FindingsBetween April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference −0·32; 95% CI −0·48 to −0·16; p=0·0001). No adverse events were reported.InterpretationA single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.FundingArthritis Research UK.

Regenerative Injections Including 5% Dextrose and Platelet-Rich Plasma for the Treatment of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-Analysis

“…In recalcitrant cases, the physicians should consider surgical management, such as revision neuroplasty, neurolysis, and nerve reconstruction [12].Corticosteroids function as potent anti-inflammatory medications and have been widely used as the main injectate for treating CTS. A recent randomized controlled trial that recruited 234 patients with CTS demonstrated that a single corticosteroid injection was better than night splinting in terms of clinical effectiveness at six weeks post-injection [13]. The aforementioned result is consistent with that of a previous systematic review that revealed the short-term (at one month) benefits of corticosteroid injection in the treatment of CTS [14].…”

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

“…Corticosteroid injections have been found to be useful in both the diagnosis and treatment of CTS, with a benefit that has been supported by multiple systematic reviews and randomized controlled trials. [2][3][4][5] There is existing data showing that patients with less severe stages of CTS, as measured by median nerve cross-sectional area, swelling ratio, and symptom severity scores, are more likely to respond favorably to cortisone injections. 19 In addition to relieving symptoms of CTS in the short term, corticosteroid injections may also reduce the rate of surgery in the long term.…”

Awareness of limited joint mobility in type 2 diabetes in general practice in the Netherlands: an online questionnaire survey

“…For CTS, according to the guidelines for hand and wrist complaints, a corticosteroid injection is recommended as the first treatment step, which can be repeated after two to three weeks if complaints persist [37,39]. However, only 41% of the GPs recommended an injection as a first treatment step, and if complaints persisted, only 34% would repeat an injection.…”