Therapeutics

Methylprednisolone injections reduced

carpal tunnel syndrome symptoms at 10
weeks and surgery at 1 year

Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone

injections for the carpal tunnel syndrome: a randomized, placebocontrolled trial. Ann Intern Med. 2013;159:309-17.

Clinical impact rating: F

Question

Main results

In patients with primary idiopathic carpal tunnel syndrome (CTS),

what is the efficacy of local methylprednisolone injections?

The main results are in the Table.

Methods

In adults with idiopathic carpal tunnel syndrome, local injections

of methylprednisolone, 40 or 80 mg, reduced symptom severity at
10 weeks; methylprednisolone, 80 mg, reduced risk for surgery at
1 year compared with placebo.

Conclusion

Design: Randomized placebo-controlled trial. ClinicalTrials.gov

NCT00806871.
Allocation: Concealed.*
Blinding: Blinded* (patients, surgeons, physical therapists,
{data collectors, outcome assessors, data analysts, and safety
committee}).

*See Glossary.

Follow-up period: 1 year.

Sources of funding: Region of Scania Research and Development

Foundation and Hssleholm Hospital Organization.

Information provided by author.

Setting: Regional referral orthopedic department in Sweden.

For correspondence: Dr. I. Atroshi, Hssleholm Hospital, Hssleholm,

Sweden. E-mail Isam.Atroshi@skane.se.

Patients: 111 patients, 18 to 70 years of age (mean age 46 y, 73%

women) who had symptoms of classic or probable CTS (Katz
diagnostic criteria; numbness or tingling in 2 of 4 radial fingers);
unsuccessful treatment with wrist splinting for 2 months; referral
for surgery; and median neuropathy at the wrist or independent
diagnosis by 2 orthopedic surgeons. Exclusion criteria included
previous steroid injection or carpal tunnel release, thenar muscle
atrophy, sensory loss, diabetes, thyroid disorder, inflammatory
disease, polyneuropathy, or surgery on the contralateral hand in
the past 2 months.

Commentary
The randomized controlled trial by Atroshi and colleagues
showed that injections of 40 or 80 mg of methylprednisolone for
clinical CTS provided relief of symptoms compared with placebo.
This relief lasted to 10 weeks compared with previous RCTs,
which reported symptom relief only up to 1 month after steroid
injection (1, 2).
However, despite this symptom improvement, 75% of the
patients in the study had surgery at 1 year. As the definitive treatment for CTS presently remains carpal tunnel release, a prudent
clinician has to consider what steroid injections have to offer.

Intervention: Methylprednisolone, 2 mL (80 mg) (n = 37);

methylprednisolone, 1 mL (40 mg) plus saline, 1 mL (n = 37);
or saline, 2 mL (n = 37); each with lidocaine, 1 mL, injected
subfascially in the soft tissues of the carpal tunnel of the most
symptomatic hand.

The interpretation of this study is as follows: Steroid injection for

CTS should be considered as temporary relief before a definitive
carpal tunnel release. When steroid injection for symptomatic
relief is reasonable, reasons for postponing definitive carpal tunnel
release could include other health issues, inability to take time
off work, and caring for an ill spouse.

Outcomes: Primary outcomes were change in CTS symptom

severity score (possible score range 1 to 5; 1 = no symptoms,
5 = most severe) at 10 weeks and surgery at 1 year.
Patient follow-up: 97% at 10 weeks and 100% at 1 year.

Achilleas Thoma, MD
McMaster University
Hamilton, Ontario, Canada

Methylprednisolone (Methyl) 80 mg vs 40 mg vs placebo for the carpel

tunnel syndrome
Outcomes

Symptom severity

Mean change at 10 wk
Methyl,
Methyl, Placebo
80 mg
40 mg
0.90
1.17
0.90

0.30

0.64 (1.06 to 0.21)

0.30

0.88 (1.30 to 0.46)

0.24 (0.20 to 0.69)

1.17

Event rates at 1 y
Surgery

73%
81%
73%

81%

Mean difference

RRR (95% CI)

NNT (CI)

92%

20% (0.4 to 56)

6 (2 to 257)

92%

12% (3 to 45)

NS

10% (10 to 42)

NS

References
1. Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal
steroid injection is safe and effective for short-term management
of carpal tunnel syndrome. Muscle Nerve. 2004;29:82-8.
2. Dammers JW, Veering MM, Vermeulen M. Injection with
methylprednisolone proximal to the carpal tunnel: randomised
double blind trial. BMJ. 1999;319:884-6.

NS = not significant; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from control event rates and odds ratios in article.
Measure of severity, frequency, and duration of nighttime and daytime pain and numbness or tingling;
possible score range 1 to 5; 1 = no symptoms, 5 = most severe.

21 January 2014 | ACP Journal Club | Volume 160 Number 2

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2014 American College of Physicians

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