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ARTICLES: A.C.F. Hui, S. Wong, C. H. Leung, P. Tong, V. Mok, D. Poon, C. W. Li-Tsang, L. K. Wong, and R. Boet A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome Neurology 2005; 64: 2074-2078 [Abstract] [Full text] [PDF]

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Reply to Andreu et al

Andrew C-F Hui, FRCP, S. Wong, MRCP   (20 September 2005)

A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome

José Luis Andreu, Domingo Ly-Pen   (20 September 2005)

Reply to Andreu et al 20 September 2005
Andrew C-F Hui, FRCP, Chinese University of Hong Kong Prince of Wales Hospital, Hong Kong, S. Wong, MRCP Send Correspondence to journal: Re: Reply to Andreu et al cfhui{at}cuhk.edu.hk Andrew C-F Hui, FRCP, et al.	We thank Dr. Andreu et al for their comments. Although our trial only focused on the role of a single steroid injection versus decompressive surgery in the treatment of idiopathic carpal tunnel syndrome, the use of two injections is an attractive suggestion. However, there is indirect evidence that multiple injections may not be more effective. In one trial, patients were given two weeks versus four weeks of oral steroid (i.e., double the dose), no significant difference was found at the conclusion of the study. [3] In another trial, high dose steroid injection conferred no advantage over low dose. [4] We have just completed a trial in which half the patients were given two injections of methylprednisolone over an eight-week period and the other half were given a single injection of methyl-prednisolone and one of normal saline eight weeks later. No differences were found at long-term follow up. [5] Some patients do very well on conservative treatment with splinting, or steroid injection or a combination of both. [6,7] Certain clinical and electrophysiologic predictors for poor response have been proposed, including the presence of thenar wasting, long duration of symptoms, prolonged or absent median motor distal latencies or absent median sensory responses on nerve conduction study. We agree that further work to determine prognostic factors will be worthwhile, possibly including sonographic assessment of the cross sectional area of median nerve, as our preliminary experience shows that those with swollen nerves respond better to steroid injection. References 3. Chang MH, Ger LP, Hsieh PF, Huang SY. A randomised clinical trial of oral steroids in the treatment of carpal tunnel syndrome: a long term follow up. J Neurol Neurosurg Psych. 2002;73:710-4. 4. O'Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis. 2000;59:918-9. 5. Hui AC, Wong S, Lo SK, Chiu JH, Poon D, Wong L. Single vs two steroid injections for carpal tunnel syndrome: a randomized clinical trial. Int J Clin Pract 2005 (in press). 6. Gelberman RH, Aronson D, Weisman MH carpal tunnel syndrome. Results of a prospective trial of steroid injection and splinting. J Bone Joint Surg. [Am] 1980;62:1181-1184. 7. Girlanda P, Dattola R, Venuto C, Mangiapane R, Nicolosi C, Messina C. Local steroid treatment in idiopathic carpal tunnel syndrome: short- and long-term efficacy. J Neurol. 1993;240:187-190. The authors report no conflicts of interest.
A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome 20 September 2005
José Luis Andreu, Department of Rheumatology. Hospital Universitario Puerta de Hierro. c/San Martín de Porres 4, 28035 Madrid, Spain, Domingo Ly-Pen Send Correspondence to journal: Re: A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome jlandreu{at}arrakis.es José Luis Andreu, et al.	We read with interest the article by Hui et al. [1] This study adds to our previous work [2] comparing local injections versus surgery in a prospective, randomized manner in carpal tunnel syndrome (CTS). The differences have been explained by Hui et al but we would like to add some observations. Firstly, our study analysis was performed on an intention-to-treat basis. After randomization was done, rejection of treatment was considered as a clinical failure. This happened in 11 wrists of the surgery group and in only 1 wrist of the injection group. Secondly, although the ideal number of injections in the treatment of CTS has not been stipulated, we believe that a two injection effect (with approximately two weeks between them) is better than a single injection. In our study [2], a single injection was given only if symptoms completely disappeared in 15 days (i.e., if Visual Analogue Scale of pain and VAS of nocturnal paresthesia was 0). This happened in 13 of 83 wrists. That meant that 69 wrists (1 rejected injection) needed a second -and last- injection according to the protocol of the clinical trial two weeks after the first injection, which does not indicate that repeated injections were needed to maintain the response during the follow-up of the study. Of these 69 wrists: 25 also reached a value of 0 mm in both VAS-pain and VAS-nocturnal paresthesia in the next visit; 11 wrists reached a value of 0 mm in VAS-pain but not in VAS-nocturnal paresthesia; and 2 wrists got 0 mm in VAS-nocturnal paresthesia but not in VAS-pain. Perhaps in Hui et al's study [1], the results in the injection group would have been better if two injections were performed instead of one. We believe that further research is needed to determine the optimal personalized treatment of each patient; and also to know what other alternative treatment is available if a patient does not want the recommended treatment. References 1. Hui ACF, Wong S, Leung CH, et al. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology 2005; 64: 2074-2078. 2. Ly-Pen D, Andreu JL, Blas G, Sánchez-Olaso A, Millán I. Surgical decompression versus local steroid injection in carpal tunnel syndrome. Arthritis and Rheumatism 2005; 52: 612-619. The authors report no conflicts of interest.