1. ♦ RHEUMATOLOGY & REHABILITATION DEPARTMENT, MINIA U NIVERSITY, EGYPT. GIHAN OMAR♦, AYA RAGAEE♦, AYMAN DARWEISH♦, & FATMA ALI ♦. Ultrasound guided injection of carpal tunnel syndrome: a Comparative study to blind injection.

2. ANATOMY The median nerve is formed by C5-C7 fibers from the lateral cord and C8-T1 fibers from the medial cord of the brachial plexus. Muscular branches of the median nerve innervate most of the forearm flexor muscles and include the anterior interosseus nerve. The palmar cutaneous branch of the median nerve leaves the main trunk proximal to the wrist crease and provides sensation over the thenar eminence The median nerve crosses from the distal forearm to the hand through the carpal tunnel.

3. ANATOMY The carpal tunnel is the narrowest at the level of the distal carpal row, at the level of the hook of the hamate bone. Within the hand, the median nerve carries C8-T1 motor fibers to the abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis muscles (thenar or recurrent motor branch) and the first and second lumbrical muscles. It supplies sensory innervation to the palmar surface of the thumb, and digits 2, 3, and the lateral half of digit 4 (via the common palmar digits nerves 1-3).

4. WITHIN THE CARPAL TUNNEL, THE MEDIAN NERVE IS PHYSIOLOGICALLY FLATTENED IN CONFIGURATION, AND THIS FLATTENING IS MAXIMAL ABOUT 2-2.5 CM DISTAL TO THE PROXIMAL EDGE OF TRANSVERSE CARPAL LIGAMENT (TCL). at the wrist. The carpal tunnel is located at the base of the palm and is bounded on 3 sides by carpal bones and anteriorly by the transverse carpal ligament. Inside run the median nerve, flexor tendons, and their synovial sheaths.

5. CARPAL TUNNEL SYNDROME (CTS) Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve, It is the most common entrapment neuropathy, with repetitive, forceful angular hand movements or vibration placing persons at risk for the condition.compressive neuropathy of the median nerve Diagnosis is based on clinical history and findings, along with corroborating electrodiagnostic studies.

6. CARPAL TUNNEL SYNDROME (CTS) The prevalence of carpal tunnel syndrome in the United States is estimated at 3.7%, and the annual incidence is estimated at 0.4%. Early in the course of CTS, the neurologic findings are reversible. If untreated, CTS can result in thenar atrophy, chronic hand weakness, and numbness in the median nerve distribution of the hand. CTS is more prevalent in females than in males and most common in middle age

7. CARPAL TUNNEL SYNDROME (CTS) Carpal tunnel syndrome (CTS) has a collection of characteristic symptoms and signs that occurs following compression of the median nerve within the carpal tunnel. Usual symptoms include numbness, paresthesias, and pain in the median nerve distribution. These symptoms may or may not be accompanied by objective changes in sensation and strength of median- innervated structures in the hand.

8. ELECTROMYOGRAPHIC (EMG) AND NERVE CONDUCTION STUDIES EMG and nerve conduction studies help confirm the diagnosis of CTS. They are most helpful in the determination of the site and severity of nerve compression. Electrodiagnostic testing has been found to have an 85% sensitivity and a specificity greater than 95% for diagnosing CTS. Clinically symptomatic CTS may have normal nerve conduction findings

9. CARPAL TUNNEL SYNDROME (CTS) The development of high-resolution ultrasonography transducers (7-15 MHz) has allowed evaluation of normal and abnormal US appearances of the median nerve and adjacent tendons. High-resolution ultrasonography allows noninvasive imaging of the carpal tunnel and its contents. Since the shape of the nerve varies as it passes through the tunnel, indexes have been introduced to better quantify abnormal findings; a nerve cross-sectional area of greater than 9 mm 2 at the level of the proximal tunnel is reported to be the best criterion for the diagnosis.

10. ULTRASONOGRAPHY (MSU) On transverse us scans, the normal median nerve is elliptical and flattens progressively as it courses distally. Median nerve compression is revealed on us by the classic triad of : 1.nerve flattening in the distal tunnel. 2.nerve swelling at the level of the distal radius (less frequently in the proximal tunnel). 3. palmar bowing of the flexor retinaculum.

11. ULTRASONOGRAPHY (MSU) VERSUS MRI A good correlation has been demonstrated between the measured ultrasonographic area of the median nerve and the degree of findings of EMG or functional outcome of the patient. Ultrasonography has several advantages over MRI, including being relatively fast and inexpensive and allowing additional dynamic and blood flow imaging with relatively little additional time. US is capable of producing results similar to MRI. MRI has been shown to be superior to ultrasonography in the identification of subtle cases, and MRI demonstrates better sensitivity than color and power Doppler ultrasonography in showing changes caused by nerve edema and blood perfusion abnormalities,

12. CONSERVATIVE TREATMENT WITH LOCAL INJECTION STEROID corticosteroid injectionscorticosteroid injections have been shown to have a statistically significant benefit in CTS. The effects of. Local injections have been shown to be superior to systemic corticosteroids. Steroid injection combined with splinting has been shown to be superior to splinting alone.

13. AIM OF THE WORK To compare the clinical outcomes of the ultrasound guided injection Vs blinded one for management of carpal tunnel syndrome..

14. PATIENTS & METHODS

15. Thirty patients ( 28 F and 2 M; mean age ± SD of 35.3 ± 7.5 years ) with unilateral carpal tunnel syndrome (CTS)(30 wrists); were included in this study. Their duration of illness mean ± SD of 8.8 ± 1.9 months. Patients were recruited from the Rheumatology and Rehabilitation outpatient clinic,Minia University Hospital,, Minia Governorate, Egypt.; in the period from October, 2014 to March, 2015. Patients were diagnosed both clinically and electro-physiologically.

16. PATIENTS & METHODS All Patients underwent local injection with steroid and according to their method of injection we subdivided our study population into: Group (I): Patients with ultrasound guided in 15 patients. Group (II): Patients injected blindly in 15 patients. Follow up was performed in patients each group at base line and after one month (4weeks). According to the electro-physiological studies, there were 28 patients with moderate CTS and 2 patients with mild CTS and they were equally distributed in both groups. A consent was obtained from all patients after The nature of the present study was explained to all patients.

17. PATIENTS & METHODS All patients were subjected to : full history taking. complete clinical examination, including: Provocative tests for median nerve compression using phalen test (Phalen, 1966) and tinel sign (Kuschner et al., 1992). Boston Carpal Tunnel Questionnaire (BCTQ ) assessment questionnaire for severity and function at baseline and after 4 weeks from injection. The questionnaire originally developed by Levine et al., 1993, and comprises of two scales; a Symptom Severity Scale (SSS) and a Functional Status Scale (FSS)..

18. PATIENTS & METHODS Electrophysiological study of the median nerve by sensory nerve conduction velocity (SNCV) and distal motor latency (DML) at the base line examination and after 4 weeks of injection., according to CTS severity classification of the American Academy of Orthopaedic Surgeons Work Group Panel (AAOS ). ( American Academy of Orthopaedic Surgeons Work Group), 2007) Ultrasonnographic examination (MSU) to carpal tunnel was performed using high ‑ resolution USG (system HD11Philips; 18 MHz). The flattening ratio and the cross ‑ sectional area (CSA) of the median nerve were measured. according to the gradring system proposed by El Miedany and colleagues ( El Miedany YM, et al., 2004).

19. PATIENTS & METHODS Local injection either US guided or blindly at wrist with 40 mg of triamcinolone plus 1% lidocaine was performed to all 30 patients once at base line using longitudinal proximal median nerve approach at proximal wrist crease.

20. RESULTS

21. TTABLE 1: DEMOGRAPHIC DATA OF OUR STUDY POPULATION Age (years) Group I (N=15) Range25-45 Mean ± SD 34.86±6.63 Group II (N=15) Range 25-60 Mean ± SD 35.80±8.59 Sex Group I (N=15) Male (N, %) 1 (6%) Female (N, %) 14 (93%) Group II (N=15) Male (N, %) 1 (6%) Female (N, %) 14 (93%) Duration of illness (months) Group I (N=15) Range 2-12 Mean ± SD 6.06±3.21 Group II (N=15) Range 1-12 Mean ± SD5.66±3.30

22. (TABLE 2):CLINICAL PARAMETERS IN BOTH GROUPS (I & II). Group II N=15 Group I N=15 p-valueAfterBeforeP -valueAfter Before.000 * 3(20%)13(86%).000 * 1(6%)14(93%) Paresthesia.130 4(26%)8(53%).010 * 1(6%)7(46%) Night awakening.660 11(73%) 12(80%) 0.001 * 2(13%) 13(86%) Tingling and numbness.030 * 0(0%)4(26%).030 * 0(0%)3(20%) Hand-forearm pain 1.00 3(20%).140 1(6%) 4(26%) Hypo/hyperesthesia in median innervated fingers.010 * 4(26%)14(93%).000 * 2(13%)14(93%) Tinel sign.010 * 4(26%)13(86%).000 * 1(6.6%)14(93%)Phalen test

23. (TABLE 3 ): BOSTON CARPAL TUNNEL QUESTIONNAIRE (BCTQ) {SSS } IN BOTH GROUPS ( I& II) Group I (N=15) Group II (N=15) Before After P-valueBeforeAfterp-value Normal 0(0%)6(40%) 0.03 * 0(0%)2(13%) 0.05 * Minimal 0(0%)5(34%)0(0%)6(40%) Mild 1(6%)4(26%)0(0%)5(34%) Moderate 5(34%)0(0%)4(26%)2(13%) Sever 6(40%)0(0%)8(53%)0(0%) extreme 3(20%)0(0%)3(20%)0(0%)

24. (TABLE 4): BOSTON CARPAL TUNNEL QUESTIONNAIRE (BCTQ) {FSS } IN BOTH GROUPS (I & II) Group I (N=15) Group II (N=15) Before After P-valueBeforeAfterp-value Normal 1(6%)9(60%) 0.06 1(6%)8(53%) 0.08 Minimal 3(20%)4(26%)3(20%)5(34%) Mild 5(34%)2(13%)5(34%)2(13%) Moderate 5(34%)0(0%)6(40%)0(0%) Sever 1(6%)0(0%) Extreme 0(0%)

25. (TABLE 5): NERVE CONDUCTION STUDY IN BOTH GROUPS (I& II) Group I N=15 Group II N=15 Before Afterp-valueBeforeAfterp-value Normal 0(0%)4(26%) 0.00 * 0(0%)1(6%) 0.00 * Very mild (abnormal comparative study) 0(0%)9(60%)0(0%)1(6%) Mild (slow SCV& normal DML) 1(6%)2(13%)1(6%)13(86%) Moderate (slow SCV& increased DML) 14(93%)0(0%)14(93%)0(0%)

26. ( TABLE 6) : MUSCULOSKELETAL- ULTRASOUND(MSUS) IMAGING (CSA) IN BOTH GROUPS Group II (N=15) Group I (N=15) p-value AfterBefore P –value AfterBefore 0.00 * 12.06±1.48 14.46±1.68 0.00 * 9.60±1.7214.46±1.68 Mean ± SD 9-1412-187-1211-17Range

27. ( TABLE 7) : MUSCULOSKELETAL-ULTRASOUND (MSUS) IMAGING (CSA) IN BOTH GROUPS Group I N=15 Group II N=15 Before After P-valueBeforeAfterp-value Normal 0(0%)7(46%) 0.00 * 0(0%)1(6%) 0.01 * Mild (10-13) 1(6%)8(53%)1(6%)8(53%) Moderate (13-15) 9(60%)0(0%)11(73%)6(40%) Sever (>15) 5(34%)0(0%)3(20%)0(0%)

28. ( TABLE 8) : MUSCULOSKELETAL-ULTRASOUND (MSUS) IMAGING (FR) IN BOTH GROUPS Group I N=15 Group II N=15 BeforeAfterP-valueBeforeAfterp-value Low (<50%) 1(6%)15(100%) 0.00 * 1(6%)11(73%) 0.00 * High (>50%) 14(93%)0(0%)14(93%)4(26%)

29. (TABLE 9) :COMPARISON BETWEEN GROUP I AND II AS REGARD NERVE CONDUCTION STUDY AFTER INJECTION: Group I (N=15) Group II (N=15) P-value Normal 4(26%)1(6%) 0.00 * Very mild (abnormal comparative study) 9(60%)1(6%) Mild (slow SCV& normal DML) 2(13%)13(87%) Moderate (slow SCV& increased DML) 0(0%)

30. (TABLE 10) : COMPARISON BETWEEN PATIENTS AS REGARD CROSS-SECTIONAL AREA BY MSUS- IMAGING AFTER INJECTION. P –valueRangeMean ± SD 0.001 * 7-12 9.60±1.72 Group I (N=15) 9-1412.06±1.48Group II (N=15) Group I (N=15) Group II (N=15) P –value Normal 7(46%)1(6%) 0.005 * Mild 8(53%) Moderate 0(0%)6(40%) Sever 0(0%)

31. (TABLE 11): COMPARISON BETWEEN GROUP I AND GROUP II AS REGARD (FR) IN MSUS- IMAGING AFTER INJECTION. Group I (N=15) Group II (N=15) P-value Low (<50%) 15(100%)11(73%) 0.03 * High (>50%) 0(0%)4(26%) Complications at base line are in the form of pain during insertion and injection, paresthesia and tingling in the ring and little finger, tingling sensation Group I (N=15) Group II (N=15) Complication at baseline 0(0%)6(40%) Complication after 4 weeks 0(0%)

32. US IMAGING STUDY IN MEDIAN NERVE CSA Normal CSASevere CSA

33. US –IMAGING PLANE STUDY FOR MEDIAN NERVE Longtudinal AxisTransverse Axis

34. RESULTS there was a significant reduction of pain in ultrasound guided injection (group I), symptoms as well as functions improved in SSS 100% improvement with p-value=0.025 and FSS 100% improvement with p=0.001 after 4weeks of injection. there was an improvement in the symptom severity scale in ultrasound guided injection group and the blinded injection group after 4 weeks of injection but with insignificant difference with (p=0.525).

35. RESULTS Nerve conduction study parameters showed significant improvement in both groups but with higher results in group I with p-value=0.00. In a Comparison between group I and group II as regard cross-sectional area by musculoskeletal ultrasound imaging there is a decrease in the cross- sectional area in both groups with higher results in group I as well. Hundred percent of patient in group I had low flattening ratio in musculoskeletal ultrasound imaging however in group II only 73% of patients got improved.

36. CONCLUSIONS & RECOMMENDATIONS Although both US-guided and blind steroid injections were effective in reducing the symptoms of CTS and improving the function, electro- diagnostic and sonographic findings (cross-sectional area, flattening ratio); US-guided carpal tunnel injection was more effective than blind injection especially in electro-diagnostic and sonographic findings and did not showed any complication either at baseline or after 4 weeks of injection. Ultrasound guided injection had shown precise injection of the carpal tunnel which maximize the effectiveness and reduce complications than blind. one.

37. CONCLUSIONS & RECOMMENDATIONS Further longitudinal studies, including equal gender distribution between groups is recommended. Comparing two planes of local injection in the ultrasound guided one will be of value. Further longitudinal studies, including equal gender distribution between groups is recommended. Comparing two planes of local injection in the ultrasound guided one will be of value. The use of US guided injection offers the opportunity of precise injection and less complications.

38. THANK YOU FOR YOUR ATTENSION

39. ♦ RHEUMATOLOGY & REHABILITATION DEPARTMENT, MINIA U NIVERSITY, EGYPT. GIHAN OMAR♦, AYA RAGAEE♦, AYMAN DARWEISH♦, & FATMA ALI ♦. Ultrasound guided injection of carpal tunnel syndrome: a Comparative study to blind injection.