Introduction
Carpal tunnel syndrome (CTS) is a commonly occurring nerve entrapment disorder with
a reported incidence rate of up to 2.3 cases per 100 person-years.[1] Symptoms mostly consist of tingling, numbness, or burning sensation following the
median nerve path distally from the carpal tunnel. Of all conservative treatments,
splinting and corticosteroid injection (CI) are the most notable ones. For some patients,
the injection of a corticosteroid provides enough relief to CTS symptoms that they
no longer need any further treatment. However, when failure of response to CI and
for that matter other conservative treatments occurs, patients will likely eventually
undergo surgical carpal tunnel release (CTR).[1]
[2]
Even though multiple studies investigated the influence of CIs on CTR, the clear influence
of pre- and postoperative CIs remains unclear.
Therefore, a systematic review was conducted to summarize the benefits and disadvantages
of pre- and intraoperative CIs in patients with CTR.
Methods
The PRISMA guidelines were followed during all stages of this systematic review.[3]
Search Methods
In collaboration with a professional independent librarian, multiple databases, MEDLINE,
Embase, Web of Science, and PubMed, were systematically searched to find eligible
articles on CTR and CIs ([Appendix A]). References lists of included studies were hand searched for relevant studies.
There were no geographic or language restrictions. The last update on the search results
was performed in September 2022. No contact was made with authors for unpublished
data or results. The review of the titles, abstracts, and full-text articles were
done independently by two researchers.
Eligibility Criteria
Studies were included if they contained at least 10 clinically diagnosed patients
with atraumatic CTS who underwent open CTR and underwent a pre- or intraoperative
CI.
Studies were excluded based upon the following criteria: not acquirable in full text,
or no clear description of postoperative results.
Endnote X5 was used during the processing of the search results.[4] Duplicate articles were deleted.
For the first round of reviewing, articles were included based upon their titles and
abstracts. A third individual researcher acted as the third observer, who was consulted
when a consensus was out of reach. Following this, all articles were under full text
review to be checked for inclusion and exclusion criteria by both researchers.
Quality Assessment
Depending on study type, quality assessment and risk-of-bias evaluation were done
by two reviewers. A modified Cochrane risk-of-bias tool (RoB 2) was used for the randomized
trials.[5] After scoring the RoB 2, an overall risk-of-bias judgment of either low, some concerns,
or high was made ([Table 1]). Quality assessment of the cohort studies was done using the Newcastle-Ottawa Scale
(NOS).[6] The finalized result of the NOS is a score ranging from 1 to 9 stars, with 7 to
9 stars being regarded as high quality, 4 to 6 moderate quality, and 1 to 3 low quality
([Table 2]).
Table 1
Characteristics of included intraoperative corticosteroid injection studies and risk-of-bias
assessment
|
Author
|
Title
|
Study type
|
Risk-of-bias assessment
|
Funding or conflict of interest
|
|
Padua et al 2003[8]
|
Intrasurgical use of steroids on carpal tunnel syndrome: a randomized, prospective,
double-blind controlled study
|
Prospective randomized controlled trial
|
Low
|
Nm
|
|
Stepić et al 2008[10]
|
Effects of perineural steroid injections on median nerve conduction during the carpal
tunnel release
|
Prospective randomized controlled trial
|
Some concerns
|
Nm
|
|
Naji 2011[9]
|
Intraoperative steroid irrigation in carpal tunnel
|
Prospective randomized controlled trial
|
High
|
Nm
|
|
Mottaghi et al 2019[7]
|
Carpal tunnel release surgery plus intraoperative CI versus carpal tunnel release
surgery alone: a double blinded clinical trial
|
Prospective randomized controlled trial
|
Low
|
Nm
|
Abbreviation: Nm, not mentioned.
Table 2
Characteristics of included preoperative corticosteroid injection studies and quality
assessment
|
Author
|
Title
|
Study type
|
Quality assessment
|
Funding or conflict of interest
|
|
Hanssen et al 1989[14]
|
Deep postoperative wound infection after carpal tunnel release
|
Retrospective cohort
|
Poor
|
Nm
|
|
Edgell et al 2003[13]
|
Predicting the outcome of carpal tunnel release
|
Retrospective cohort
|
Poor
|
Yes, funded by Jewish Hospital HealthCare Services, the University of Louisville,
and the Christine M. Kleinert Institute for Hand and Microsurgery[13]
|
|
Vahi et al 2013[11]
|
Preoperative CIs are associated with worse long-term outcome of surgical carpal tunnel
release
|
Retrospective cohort
|
Poor
|
None
|
|
Bland and Ashworth 2015[12]
|
Does prior local CI prejudice the outcome of subsequent carpal tunnel decompression?
|
Retrospective cohort
|
Poor
|
None
|
|
Kirby et al 2021[15]
|
Influence of corticosteroid injections on postoperative infections in carpal tunnel
release
|
Retrospective cohort
|
Good
|
Nm
|
Abbreviation: Nm, not mentioned.
Data Extraction
The data of the studies were independently extracted by two researchers. From the
studies, the following data were extracted: patient population, demographics, number
of injections for each patient, duration between injection and surgery, type and dosage
of injection, number of infections, functional outcome report, nerve conduction measurements,
Boston Carpal Tunnel Questionnaire (BCTQ) scores, and eventually other relevant outcomes
([Table 3]).
Table 3
Summary of data of studies included
|
Author
|
Moment of injection
|
No. of patients injected (n)
|
Mean age (y)
|
Male/female (%)
|
No. of injections (n)
|
Duration between injection and surgery (d)
|
Injection
|
Dosage
|
|
Edgell et al[13]
|
Preoperative
|
54 (57)
|
47.8
|
24 (42)/33 (58)
|
1: 29
2: 20
≥3: 5
|
Nm
|
Betamethasone
|
3 mg
|
|
Vahi et al[11]
|
Preoperative
|
127 (174)
|
60.0
|
22 (11)/149 (89)
|
1: 31
2: 34
3: 35
4: 7
5: 7
9: 2
10: 7
|
Nm
|
Nm
|
Nm
|
|
Bland and Ashworth[12]
|
Preoperative
|
278 (942)
|
62.0
|
293 (31)/649 (69)
|
1: 180
2: 79
3: 16
4: 3
|
269 d
|
Triamcinolone
|
40 mg
|
|
Kirby et al[15]
|
Preoperative
|
32 (139)
|
63.4
|
35 (25)/104 (75)
|
1: 135
Multiple: 4
|
105 d
|
Dexamethasone
|
3.6 mg
|
|
Padua et al[8]
|
Intraoperative
|
10 (20)
|
54.3
|
2 (10)/18 (90)
|
1: 10
|
After surgical depression, before skin closure, irrigation of the nerve
|
Methylprednisolone
|
40 mg
|
|
Naji[9]
|
Intraoperative
|
20 (40)
|
38.5
|
2 (5)/38 (95)
|
1: 20
|
One minute before closure of the wound, irrigation of the wound
|
Methylprednisolone acetate (Depo-Medrol)
|
40 mg
|
|
Mottaghi et al[7]
|
Intraoperative
|
20 (42)
|
46.2
|
2 (5)/40 (95)
|
1: 20
|
Before suturing the skin in the flexor tendon sheath and inside the borders of transverse
carpal ligament incision and around the median nerve
|
Dexamethasone
|
1 mg
|
|
Stepić et al[10]
|
Intraoperative
|
20 (40)
|
51.6
|
13 (32.5)/27 (67.5)
|
1: 20
|
During surgery immediately after decompression, a perineural injection
|
Betamethasone
|
1 mL
|
|
Hanssen et al[14]
|
Pre- and intraoperative
|
Preoperative 16 (119)
Intraoperative 59 (119)
|
56.0
|
77 (65)/42 (35)
|
Partly mentioned:
1: 74
2: 1
|
Preoperative timing Nm and intraoperative
|
Nm
|
Nm
|
Abbreviation: Nm, not mentioned.
Outcomes
The primary outcomes of this study are infection and nerve conduction rates for patients
receiving either pre- or intraoperative CI and for control patients. Secondary outcomes
are any patient-reported outcomes with well-described outcomes before and after treatment
and other CTS-related complaints.
Results
The database search identified 2,470 papers, and 1 other paper was added through scanning
the reference lists of included articles.[7] A total of 1,372 papers were left after removing duplicates and these papers were
screened for eligibility on title and abstract. For the full text screening, 51 papers
were assessed, leaving 9 relevant studies: 5 papers with intraoperative CIs and 5
papers with preoperative CIs.[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15] One study used both intraoperative and preoperative CIs.[14] The reviewing process is shown in [Fig. 1].
Fig. 1 Flow chart of reviewing process.
Four of five studies using intraoperative CIs were randomized controlled trials, and
one study was a retrospective cohort study. This study also included a preoperative
CI cohort.[14] A summary of a risk of bias is given in [Table 1]. All five studies using preoperative CIs were retrospective cohort studies. A summary
of the quality assessment of these articles is given in [Table 2].
Intraoperative Corticosteroid Injections
The five studies included in the intraoperative CI consisted of four randomized controlled
trials and one retrospective trial, in which a total of 245 patients were included.
Intraoperative CI was performed on 129 patients, and 116 patients received no injection.
The CIs that were used and patient characteristics are shown in [Table 3].
Infections
Four of the included studies quantified the rate of wound infections after CTR.[7]
[8]
[9]
[14] In three of these studies, none of the 50 patients with an intraoperative CI developed
a postoperative wound infection.[7]
[8]
[9] Hanssen et al reported 13 (22%) postoperative infections in the intraoperative CI
group and 2 (4.5%) in the control group ([Table 4]).[14] The intraoperative CI group had a significant (p < 0.002) higher risk of having an infection. There was a difference between incidence
of infections in male (0.87%) and female (0.25%) patients, which was also significant
(p < 0.02). In addition, a total of 19 patients received prophylactic antibiotics, which
did not change the statistical analysis; the difference in postoperative wound infections
between the intraoperative CI and control group was still significant.
Table 4
Infections after intraoperative corticosteroid use in Hanssen et al[14]
|
Group
|
Patients
|
Number of infections (%)
|
Revisions (n)
|
Clinical presentation intraoperative CI (n)
|
|
Intraoperative injection group
|
59
|
13 (22)
|
Surgical debridement (14), debridement of infected tendon sheaths (6)
|
● Carpal canal pain (8)
● Small finger pain (3)
● Spontaneous drainage (2)
● Thumb (flexor) pain (2)
|
|
Control group
|
44
|
2 (4.5)
|
|
Total
|
103
|
15 (14.6)
|
Abbreviation: CI, corticosteroid injection.
Postoperative Pain
Only one of the included studies reported on postoperative pain after CTR.[9] Naji evaluated postoperative pain after CTR in 40 patients. In total, 20 patients
received an intraoperative CI and none of them (0%) reported postoperative pain complaints.
In the control group of 20 patients, 11 patients (55%) had persisting agonizing pain
postoperatively at the ulnar side of the wrist (incision site), which was not responding
to analgesic treatment. The other nine patients (45%) did not have any postoperative
pain complaints. This difference was found to be significant (p < 0.05).
Symptom Relief
One study described postoperative symptom relief of CTS.[10] Stepić et al registered the disappearance of symptoms in 40 patients after CTR,
of which 20 patients received an intraoperative CI. After 3 months, only one patient
(5%) receiving intraoperative CI still experienced symptoms, compared with two patients
(10%) in the control group. Intraoperative CI did not lead to an increased proportion
of patients without symptoms when compared with patients receiving no CI ([Fig. 2]).
Fig. 2 Postoperative recovery of symptoms in patients (%) after carpal tunnel release in
Stepić et al.
Median Nerve Conduction Speed
Two studies performed electrophysiological measurements in a total of 82 patients
before and after CTR, comparing 40 patients receiving an intraoperative CI with 42
patients in a control group without CI.[7]
[10] The median (sensitive) nerve conduction speed and the distal motor and sensory latencies
were measured. In 20 patients receiving intraoperative CI, a faster and bigger recovery
in electrophysiological measurements was established, compared with the control group.
In Stepić et al, values of the median nerve conduction speed and sensitive conduction
speed were measured both preoperatively and postoperatively after 7, 30, and 90 days.[10] Twenty patients receiving intraoperative CI were compared with 20 patients in the
control group ([Fig. 3a, b]). The median nerve conduction speed measurements 7 days postoperatively were not
significantly different between these groups. After 30 days, the median nerve conduction
speed improved in both groups, but this improvement was significantly greater in the
CI group (p = 0.025). After 90 days, both groups showed improvement of the median nerve conduction
speed in comparison to the preoperative situation, which was significantly greater
in the CI group (p = 0.043).
Fig. 3 (A, B) Median nerve (sensitive) conduction speed (ms) pre- and postoperatively in Stepić
et al.
In Mottaghi et al, the median sensitive conduction speed after 30 days also improved
significantly in the CI group compared with the control group (p = 0.018).[7] The measurements after 90 days did not show any significant difference between the
CI group and the control group.
Furthermore, the nerve conduction speed in the distal motor and sensory nerves showed
a greater improvement in the intraoperative CI group compared with the control group
([Fig. 4]).[7] The distal motor latency improved by 30.0% in the steroid group and by 25.3% in
the control group, compared with the preoperative situation. The distal sensor latency
improved by 37.7% in the steroid group and by 26.3% in the control group. However,
the data were not significantly different (preoperative p = 0.671, postoperative 7 days p = 0.404, postoperative 30 days p = 0.16, postoperative 90 days p = 0.977).
Fig. 4 Motor and sensory latency values (m/s) in Mottaghi et al.
Boston Carpal Tunnel Questionnaire
In two studies, pre- and postoperative BCTQ scores were compared in a total of 62
patients: 30 intraoperative CI patients and 32 control patients.[7]
[8] The improvement in the BCTQ scores of the CI groups was shown in both studies. The
mean BCTQ score improved by 63.3% in 30 patients with intraoperative CI and by 48.7%
in 32 patients without CI.
The first study, Mottaghi et al, used the sum of the symptom and functional scales
to determine a BCTQ index ([Fig. 5]).[7] Both groups showed improvement of symptoms (p < 0.001) after CTR, but the CI group showed greater improvement (the mean BTCQ improved
with 55.8%) compared with the control group (mean BTCQ improvement of 49.2%). However,
the postoperative values were not significantly different from one another (p = 0.131).
Fig. 5 Preoperative and postoperative BCTQ scores in Mottaghi et al. BCTQ, Boston Carpal
Tunnel Questionnaire.
Padua et al also used the BCTQ index but showed the values in scales: the Symptom
Severity Scale (SSS) and Functional Status Scale (FSS) of the BCTQ ([Fig. 6]).[8] In 2 months, the SSS improved by 73.4% in the CI group and by 53.6% in the control
group, compared with the preoperative scores. The FSS improved by 68.1% in the CI
group and by 42.8% in the control group. The changes from baseline to 15 and 60 days
showed a significant difference in the SSS in both groups (p = 0.0035 and 0.005, respectively) compared with the preoperative scores. The postoperative
FSS differences were not significant between the study groups.
Fig. 6 BCTQ symptom and functional scales in Padua et al. BCTQ, Boston Carpal Tunnel Questionnaire;
FSS: Functional Status Scale; SSS, Symptom Severity Scale.
Preoperative Corticosteroid Injections
The five studies included in the preoperative CI group were all retrospective cohort
studies, in which a total of 1,413 patients were included.[11]
[12]
[13]
[14]
[15] From these patients, 504 patients underwent a preoperative CI, and 909 patients
did not receive a CI. Study characteristics are shown in [Table 3].
Infection
Two studies mentioned if any infection occurred. Hanssen et al reported two (12.5%)
infections in the preoperative CI group and two (4.5%) in the control group ([Table 5]).[14] There was no statistically significant correlation between preoperative CI and infection
in this study. There was a difference between incidence of infections in male (0.87%)
and female (0.25%) patients, which was significant (p < 0.02). In total, 19 patients received prophylactic antibiotics, which did not change
the statistical analysis; the difference was still not significant.
Table 5
Overview of results of intraoperative corticosteroid injections
|
Article
|
Patients with infection (% of total patients)
|
Boston Carpal Tunnel Questionnaire
|
Patient-reported outcomes
|
|
Symptom score
|
Functional score
|
|
CI
|
Control
|
CI
|
Control
|
CI
|
Control
|
CI
|
Control
|
|
Hanssen et al[14]
|
2 (12.5%)
|
2 (4.5%)
|
–
|
–
|
–
|
–
|
–
|
–
|
|
Kirby et al[15]
|
16 (41%)
|
16 (16%)
|
–
|
–
|
–
|
–
|
–
|
–
|
|
Bland and Ashworth[12]
|
Nm
|
Nm
|
1.42
|
1.47
|
1.45
|
1.45
|
Success rate (in %):
|
|
84
|
85
|
|
Failure rate (in %):
|
|
3.9
|
3.3
|
|
Vahi et al[11]
|
Nm
|
Nm
|
–
|
–
|
–
|
–
|
NRS (in points):
|
|
88
|
84
|
Abbreviations: CI, corticosteroid injection; Nm, not mentioned; NRS, Numeric Rating
Scale.
Kirby et al analyzed patients with postoperative infection retrospectively and compared
these to control patients ([Table 5]).[15] Patients in the infection group had a significantly shorter period between CI and
surgery (77 ± 52 days) than in the control group (133 ± 89 days) (p = 0.05). Thirty-six patients (92%) had a superficial postoperative infection, and
three patients (8%) had a deep postoperative infection ([Table 6]).
Table 6
Infections after preoperative corticosteroid use in Hanssen et al[14] and Kirby et al[15]
|
Group
|
Patients without infection (%)
|
Number of infections (%)
|
Revisions in Hanssen et al[14] (n)
|
Clinical presentation in Hanssen et al[14] (n)
|
|
Preoperative injection
|
30 (19.2)
|
18 (41.9)
|
Surgical debridement (14), debridement of infected tendon sheaths (6)
|
● Carpal canal pain (10)
● Small finger pain (5)
● Spontaneous drainage (2)
● Thumb (flexor) pain (2)
|
|
Controls
|
126 (80.8)
|
25 (58.1)
|
|
Total
|
156 (100)
|
43 (100)
|
Only one study reported on BCTQ scores in patients receiving preoperative CIs. Bland
and Ashworth used the BCTQ to measure the symptom severity and functional status in
942 patients: 278 patients underwent a preoperative CI and 664 patients did not ([Fig. 7]).[12] The postoperative SSS and FSS scores showed more improvement in the control group
when compared with the preoperative corticosteroid group but the improvements were
not significant (SSS p = 0.37 and FSS p = 0.40).
Fig. 7 BCTQ SSS and FSS scores preoperatively and postoperatively in Bland and Ashworth.
BCTQ, Boston Carpal Tunnel Questionnaire; SSS, Symptom Severity Scale.
Patient-Reported Outcomes
Two studies used patient-reported outcomes of 1,170 patients to evaluate the success
of preoperative CI.[11]
[12] A total of 182 patients (39.7%) receiving a preoperative CI were free of symptoms
postoperatively, compared with 268 patients (37.7%) in the control group. Also, 277
patients (60.3%) receiving a preoperative CI still experienced symptoms such as pain
and paraesthesia postoperatively, compared with 443 patients (62.3%) in the control
group. Bland and Ashworth found no significant difference in patient-reported outcomes
after CTR in the injection group compared with the control group (p = 0.82).[12]
Vahi et al found that patients who received a preoperative CI had a higher occurrence
of complaints (pain [p = 0.04], paraesthesia [p = 0.007], and nocturnal awakenings [p = 0.003]) when compared with the control group.[11] Within the injection group, there was an association between patients receiving
more injections and the reporting of the specific complaints. However, this difference
was not significant (p = 0.09). Other studies did not mention if there were any pain complaints postoperatively.
In Edgell et al, patients were considered cured if they did not have any complaints
after 6 months postoperatively.[13] In total, 13 patients (87%) with some relief after CI underwent surgery, while 21
patients (54%) without relief after CI underwent surgery.
In Vahi et al, the patients were also asked to fill in the Numeric Rating Scale (NRS)
from 0 to 100: 100 points meaning total regression of symptoms and 0 meaning no effect.[11] In total, 120 patients had regression of symptoms, meaning they scored 90 or more
points in the NRS. In the control group, 33 patients (70%) had a score of 90 or more
points, while in the steroid group 86 patients (68%) scored 90 points or more. The
pain was still present in 14 patients (30%) in the control group and in 41 patients
(32%) in the steroid group. The difference in NRS scores between patients receiving
preoperative injections and the control group was not significant.
Nerve Conduction Studies
Edgell et al measured median sensory values of 31 patients with preoperative CI, in
which 24 (77%) patients had diminished values, 16 (67%) patients were symptom-free
after surgery, and 7 (23%) patients had a normal median sensory value; 3 (43%) of
these patients showed complete relieve by CTR.[13] The number of patients who were symptom-free after CTR did not differ significantly
between the group with retarded and normal median sensory values preoperatively (p = 0.255). The median motor measurement was performed on 37 patients: 24 (65%) patients
had a diminished value, of whom 15 (63%) recovered after CTR, and 13 (35%) patients
had a normal value, of whom 6 (46%) recovered after CTR (p = 0.338). The number of patients who were symptom-free after CTR was not significantly
different between the groups with retarded or normal median motor measurements preoperatively
([Table 7]).
Table 7
Overview of results of preoperative corticosteroid injections
|
Article
|
Infection
|
Postoperative pain
|
Symptom relief (in %)
|
Electrodiagnostic measurement
|
Boston Carpal Tunnel Questionnaire
|
|
CI
|
Control
|
CI
|
Control
|
CI
|
Control
|
CI
|
Control
|
CI
|
Control
|
|
Hanssen et al[14]
|
13 (22%)
|
2 (4.5%)
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
|
Naji[9]
|
0 patients with infection in both groups
|
0 (100%)
|
11 (55%)
|
–
|
–
|
–
|
–
|
–
|
–
|
|
Stepić et al[10]
|
Nm
|
Nm
|
Nm
|
Nm
|
7 d postoperative:
|
Sensitive conduction speed preoperative:
|
–
|
–
|
|
77.5
|
75
|
31.493
|
25.287
|
|
|
|
30 d postoperative:
|
Sensitive conduction speed 90 d postoperative:
|
|
|
|
90
|
90
|
47.673
|
50.147
|
|
|
|
|
90 d postoperative:
|
Conduction speed preoperative:
|
|
|
|
97.5
|
95
|
32.2
|
25.487
|
|
|
|
Conduction speed 90 d postoperative:
|
|
|
|
45.347
|
47.027
|
|
|
|
Mottaghi et al[7]
|
0
|
Nm
|
|
|
|
Predistal sensory latency:
|
Questionnaire sum preoperative:
|
|
54.83
|
47.6
|
35.83
|
37.7
|
|
Postdistal sensory latency:
|
Questionnaire sum postoperative:
|
|
34.11
|
35.1
|
15.83
|
19.15
|
|
Predistal motor latency:
|
|
|
63.22
|
62.35
|
|
|
Postdistal motor latency:
|
|
|
44.56
|
46.55
|
|
|
Padua et al[8]
|
0 patients with infection in both groups
|
–
|
–
|
–
|
–
|
–
|
–
|
Symptoms score at baseline:
|
|
44.8
|
41.8
|
|
Symptoms score after 60 d:
|
|
11.8
|
19.4
|
|
Functional score at baseline:
|
|
28.2
|
26.9
|
|
Functional score after 60 d:
|
|
9
|
15.4
|
Abbreviations: CI, corticosteroid injection; Nm, not mentioned.
Discussion
In this systematic review, nine studies were evaluated for the outcome of CTR after
either preoperative or intraoperative CIs.[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15] A meta-analysis could not be performed on any of the outcome measures due to the
lack of data and heterogeneity of the data in the included studies.
Administering intraoperative CI might be beneficial for reduced postoperative pain
after CTR and lead to earlier recovery of the hand function.[9]
[10] However, no benefit is seen in using intraoperative CI for the final outcomes in
terms of symptoms, function, and electrophysiology.[7]
[8]
[10]
Hanssen et al found that an intraoperative CI increases the risk of having a postoperative
infection compared with the control group.[14] This study, however, associates the infection rates with extended operative techniques,
such as flexor tenosynovectomy and the insertion of a surgical drain, and not with
the steroid usage. Other studies using intraoperative CIs did not find any infection
in their cohorts after CTR, leading to believe the usage of this injection does not
predispose patients to postoperative infections.[7]
[8]
[9]
[10] In Mottaghi et al, all patients received postoperative prophylactic cefazolin 500
every 6 hours for 3 days, which can cause unnecessary antibiotic resistance due to
the fact that intraoperative CI does not significantly induce infections.[7]
Kirby et al showed that the usage of preoperative CI increases the risk of having
a postoperative infection significantly.[15] However, the number of infections seems to be underrated, due to limited reporting
or diagnosis of postoperative wound infections in different clinics. They recommend
informing patients about the risk of infection after CTR when CIs are given in the
prior 2 to 3 months.[15] Other studies using preoperative CIs did not mention infection rates.[11]
[12]
[13]
There is no evidence for improved recovery after CTR when using preoperative CIs.
Specifically, Bland and Ashworth found no difference in postoperative complaints after
CTR between patients receiving a preoperative CI and the control group.[12] A possible advantage of preoperative CI could be a holdup for a CTR. Disadvantages
of this study were the small sample size, a big loss in follow-up, and heterogeneity
between the study groups due to the direct offer to undergo CTR to patients with serious
complaints. Vahi et al found that preoperative CIs lead to more postoperative complaints,
such as pain, paresthesia, and numbness.[11] However, the outcome of BCTQ scores, symptom relief, and NRS scores was not significantly
better in the group of patients with preoperative CI, compared with the control group.[11]
[12]
[13] In conclusion, there is no evidence for improved recovery after CTR when using preoperative
CIs. Additionally, the adverse effects of CIs such as skin depigmentation and subcutaneous
atrophy should not be forgotten.[16]
A limitation of this systematic review is the heterogeneity of the included studies,
especially in the preoperative CI studies. The time between injection and surgery
are different in all the studies, such as the number of CI per patient. Furthermore,
the quality of four of the included studies addressing preoperative CIs is poor. A
prospective randomized trial with large cohort of patients and a longer follow-up
in the future could increase our knowledge of CI usage in patients after CTR.
Appendix A
Search strategy
|
No.
|
Search
|
MEDLINE hits
|
|
#1
|
(exp Carpal Tunnel Syndrome/OR carpal tunnel.ti,ab,kf. OR CTR.ti,ab,kf. OR CTS.ti,ab,kf.
OR (Median nerve*.ti,ab,kf. AND (compress*.ti,ab,kf. OR entrap*.ti,ab,kf. OR neuropath*.ti,ab,kf.))
OR median neuropath*.ti,ab,kf. OR median neurit*.ti,ab,kf. OR (carpal.ti,ab,kf. AND
(nerve entrapment.ti,ab,kf. or nerve compression.ti,ab,kf. or entrapment neuropath*.ti,ab,kf.)))
|
23,810
|
|
#2
|
(exp Steroids/OR exp Glucocorticoids/OR steroid*.ti,ab,kf. OR corticosteroid*.ti,ab,kw.
OR glucocorticoid*.ti,ab,kf. OR exp Injections/OR inject*.ti,ab,kf.)
|
1,930,958
|
|
#3
|
(exp Postoperative Complications/OR exp Treatment Outcome/OR outcome*.ti,ab,kf. OR
postoperat*.ti,ab,kf. OR post-operat*.ti,ab,kf. OR postsurg*.ti,ab,kf. OR post-surg*.ti,ab,kf.
OR exp infections/OR infect*.ti,ab,kf.)
|
6,155,074
|
|
#4
|
#1 AND #2 AND #3
|
561
|
|
Embase search
|
|
No.
|
Search
|
Embase hits
|
|
#1
|
(exp Carpal Tunnel Syndrome/OR carpal tunnel.ti,ab,kw. OR CTR.ti,ab,kw. OR CTS.ti,ab,kw.
OR (Median nerve*.ti,ab,kw. AND (compress*.ti,ab,kw. OR entrap*.ti,ab,kw. OR neuropath*.ti,ab,kw.))
OR median neuropath*.ti,ab,kw. OR median neurit*.ti,ab,kw. OR (carpal.ti,ab,kw. AND
(nerve entrapment.ti,ab,kw. or nerve compression.ti,ab,kw. or entrapment neuropath*.ti,ab,kw.)))
|
36,999
|
|
#2
|
(exp Steroids/OR exp Glucocorticoids/OR steroid*.ti,ab,kw. OR corticosteroid*.ti,ab,kw.
OR glucocorticoid*.ti,ab,kw. OR exp Injections/OR inject*.ti,ab,kw.)
|
2,575,275
|
|
#3
|
(exp Postoperative Complications/OR exp Treatment Outcome/OR outcome*.ti,ab,kw. OR
postoperat*.ti,ab,kw. OR post-operat*.ti,ab,kw. OR postsurg*.ti,ab,kw. OR post-surg*.ti,ab,kw.
|
4,400,647
|
|
#4
|
#1 AND #2 AND #3
|
1,041
|
|
Web of Science search
|
|
No.
|
Search
|
Web of Science hits
|
|
#1
|
TS = (carpal tunnel* OR CTR OR CTS OR (Median nerve* AND (compress*OR entrap* OR neuropath*))
OR median neuropath* OR median neurit* OR (carpal AND (nerve entrapment OR nerve compression
OR entrapment neuropath*)))
|
36,515
|
|
#2
|
TS = (Steroid* OR corticosteroid* OR glucocorticoid* OR inject*)
|
1,348,295
|
|
#3
|
TS = (*outcome* OR postoperat* OR post-operat* OR postsurg* OR post-surg* OR infect*)
|
4,472,112
|
|
#4
|
#1 AND #2 AND #3
|
564
|
|
PubMed search
|
|
No.
|
Search
|
PubMed hits
|
|
#1
|
Search: ((“Carpal Tunnel Syndrome”[Mesh]) OR (“Carpal Tunnel Syndrome/surgery”[Mesh]))
OR (“Carpal Tunnel Syndrome/drug therapy”[MAJR])
|
8,713
|
|
#2
|
Search: ((((((carpal tunnel[tiab]) OR (Carpal tunnel syndrome[tiab])) OR (CTS[tiab]))
OR (Median nerve compression[tiab])) OR (Carpal tunnel release[tiab])) OR (open carpal
tunnel release[tiab])) OR (carpal tunnel surgery[tiab])
|
17,211
|
|
#3
|
#1 or #2
|
18,554
|
|
#4
|
Search: ((“Steroids/administration and dosage”[MeSH]) OR (“Injections”[Mesh])) OR
(“Injections, Intra-Articular”[MeSH])
|
378,459
|
|
#5
|
Search: (Steroid injection[tiab]) OR (Corticosteroids[tiab])
|
72,977
|
|
#6
|
#4 or #5
|
442,419
|
|
#7
|
Search: (“Treatment Outcome”[MeSH]) OR (“Postoperative Complications”[Mesh])
|
1,534,116
|
|
#8
|
Search: (infection[tiab]) OR (post-operative outcomes[tiab])
|
1,148,374
|
|
#9
|
#7 or #8
|
2,572,503
|
|
#10
|
#3 and #6 and #9
|
162
|
