A Bayesian network meta-analysis: Comparing the clinical effectiveness of local corticosteroid injections using different treatment strategies for carpal tunnel syndrome

Po-Cheng Chen, Ching-Hui Chuang, Yu-Kang Tu, Chyi-Huey Bai, Chieh-Feng Chen, Mei- Yun Liaw, Po-Cheng Chen, Ching-Hui Chuang, Yu-Kang Tu, Chyi-Huey Bai, Chieh-Feng Chen, Mei- Yun Liaw

Abstract

Background: Local corticosteroid injections are commonly used to improve the short-term symptomatic severity and the functional status of the hands affected by carpal tunnel syndrome. We conducted a systematic review and Bayesian network-meta-analysis to compare the clinical effectiveness of local corticosteroid injections using different injection approaches.

Methods: Electronic literature in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and other sources were searched to identify clinical studies comparing different injection approaches with each other or placebo for carpal tunnel syndrome. Two review authors conducted selection of studies, data extraction, and assessment of risk of bias independently. Random-effects models were used to conduct the pairwise meta-analysis and the Bayesian network meta-analysis.

Results: Overall, 10 studies with 633 patients were included in the systematic review. Among the injection approaches, local corticosteroid injections using the ultrasound-guided in-plane injection (Ulnar-I) approach was the best treatment strategy for clinical response (median OR versus placebo 128.30, 95% CrI 9.76 to 2299.00), change in symptom severity scale (median MD versus placebo -1.16, 95% CrI -1.95 to -0.38) , and change in functional status scale (median MD versus placebo -0.74, 95% CrI -2.00 to 0.52) at short-term follow-up period in the network meta-analysis. Local corticosteroid injections using other injection approaches were better than placebo for clinical response (for the PI approach, median OR versus placebo 8.85, 95% CrI 3.00 to 33.15; for the DI approach, median OR versus placebo 7.00, 95% CrI 0.53 to 118.80) , change in symptom severity scale (for the Ulnar-O approach, median MD versus placebo -0.78, 95% CrI -1.43 to -0.16; for the PI approach, median MD versus placebo -0.58, 95% CrI -0.95 to -0.22), and change in functional status scale (for the Ulnar-O approach, median MD versus placebo -0.63, 95% CrI -1.67 to 0.43; for the PI approach, median MD versus placebo -0.46, 95% CrI -1.11 to 0.21) at short-term follow-up period. The quality of studies is good.

Conclusions: According to our analyses, the ultrasound-guided in-plane injection (Ulnar-I) approach was the most effective treatment among the injection approaches for carpal tunnel syndrome.

Figures

Fig. 1
Fig. 1
Flow diagram for literature search and identifications of articles for review
Fig. 2
Fig. 2
Risk of bias (a) graph and (b) summary: review authors’ judgements about each risk of bias item
Fig. 3
Fig. 3
Forest plot of the standard pair-wise meta-analysis for clinical response of local corticosteroid injections for carpal tunnel syndrome. Abbreviations: OR odds ratio, CI confidence interval, DI distal approach corticosteroid injection, PI proximal approach corticosteroid injection, Ulnar−I ultrasound-guided in-plane approach
Fig. 4
Fig. 4
Forest plot of the standard pair-wise meta-analysis for change in symptom severity scale of local corticosteroid injections for carpal tunnel syndrome. Abbreviations: WMD weighted mean difference, CI confidence interval, PI proximal approach corticosteroid injection, Ulnar−I ultrasound-guided in-plane injection, Ulnar−O ultrasound-guided out-plane injection
Fig. 5
Fig. 5
Forest plot of the standard pair-wise meta-analysis for change in functional status scale of local corticosteroid injections for carpal tunnel syndrome. Abbreviations: WMD weighted mean difference, CI confidence interval, PI proximal approach corticosteroid injection, Ulnar−I ultrasound-guided in-plane injection, Ulnar−O ultrasound-guided out-plane injection
Fig. 6
Fig. 6
Network plots of the treatments for (a) clinical response, (b) change in symptom severity scale (c) change in functional status scale
Fig. 7
Fig. 7
Ranking of treatment strategies based on probability of their effects on (a) clinical response (b) change in symptom severity scale (c) change in functional status scale
Fig. 8
Fig. 8
Comparison-adjusted funnel plots for (a) clinical response (b) change in symptom severity scale (c) change in functional status scale

References

    1. Sternbach G. The carpal tunnel syndrome. J Emerg Med. 1999;17(3):519–523. doi: 10.1016/S0736-4679(99)00030-X.
    1. Katz JN, Simmons BP. Clinical practice. Carpal tunnel syndrome. N Engl J Med. 2002;346(23):1807–1812. doi: 10.1056/NEJMcp013018.
    1. Viera AJ. Management of carpal tunnel syndrome. Am Fam Physician. 2003;68(2):265–272.
    1. Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J. 2008;77(1):6–17.
    1. Bland JD, Rudolfer SM. Clinical surveillance of carpal tunnel syndrome in two areas of the United Kingdom, 1991-2001. J Neurol Neurosurg Psychiatry. 2003;74(12):1674–1679. doi: 10.1136/jnnp.74.12.1674.
    1. Tanaka S, Wild DK, Seligman PJ, Behrens V, Cameron L, Putz-Anderson V. The US prevalence of self-reported carpal tunnel syndrome: 1988 National Health Interview Survey data. Am J Public Health. 1994;84(11):1846–1848. doi: 10.2105/AJPH.84.11.1846.
    1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158. doi: 10.1001/jama.282.2.153.
    1. Luckhaupt SE, Dahlhamer JM, Ward BW, Sweeney MH, Sestito JP, Calvert GM. Prevalence and work-relatedness of carpal tunnel syndrome in the working population, United States, 2010 National Health Interview Survey. Am J Ind Med. 2013;56(6):615–624. doi: 10.1002/ajim.22048.
    1. Harris-Adamson C, Eisen EA, Dale AM, Evanoff B, Hegmann KT, Thiese MS, et al. Personal and workplace psychosocial risk factors for carpal tunnel syndrome: a pooled study cohort. Occup Environ Med. 2013;70(8):529–537. doi: 10.1136/oemed-2013-101365.
    1. Palmer KT, Harris EC, Coggon D. Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond) 2007;57(1):57–66. doi: 10.1093/occmed/kql125.
    1. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004;17(2):309–319. doi: 10.1197/j.jht.2004.02.015.
    1. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol. 1998;51(12):1235–1241. doi: 10.1016/S0895-4356(98)00131-0.
    1. Padua L, Padua R, Aprile I, Pasqualetti P, Tonali P. Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology. 2001;56(11):1459–1466. doi: 10.1212/WNL.56.11.1459.
    1. Agee JM, McCarroll HR, Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg Am. 1992;17(6):987–995. doi: 10.1016/S0363-5023(09)91044-9.
    1. Ariyan S, Watson HK. The palmar approach for the visualization and release of the carpal tunnel. An analysis of 429 cases. Plast Reconstr Surg. 1977;60(4):539–547. doi: 10.1097/00006534-197710000-00007.
    1. Klein RD, Kotsis SV, Chung KC. Open carpal tunnel release using a 1-centimeter incision: technique and outcomes for 104 patients. Plast Reconstr Surg. 2003;111(5):1616–1622. doi: 10.1097/01.PRS.0000057970.87632.7e.
    1. Huisstede BM, Friden J, Coert JH, Hoogvliet P, European HG. Carpal tunnel syndrome: hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline-results from the European HANDGUIDE Study. Arch Phys Med Rehabil. 2014;95(12):2253–2263. doi: 10.1016/j.apmr.2014.06.022.
    1. Sim H, Shin BC, Lee MS, Jung A, Lee H, Ernst E. Acupuncture for carpal tunnel syndrome: a systematic review of randomized controlled trials. J Pain. 2011;12(3):307–314. doi: 10.1016/j.jpain.2010.08.006.
    1. Duncan KH, Lewis RC, Jr, Foreman KA, Nordyke MD. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: results of a questionnaire. J Hand Surg Am. 1987;12(3):384–391. doi: 10.1016/S0363-5023(87)80011-4.
    1. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician. 2003;67(4):745–750.
    1. Hutten-Czapski P. The occasional carpal tunnel injection. Can J Rural Med. 2007;12(3):176–177.
    1. Rifat SF, Moeller JL. Site-specific techniques of joint injection. Useful additions to your treatment repertoire. Postgrad Med. 2001;109(3):123-126, 129-130, 135-126. doi: 10.3810/pgm.2001.03.879.
    1. Habib GS, Badarny S, Rawashdeh H. A novel approach of local corticosteroid injection for the treatment of carpal tunnel syndrome. Clin Rheumatol. 2006;25(3):338–340. doi: 10.1007/s10067-005-0002-7.
    1. Lee JY, Park Y, Park KD, Lee JK, Lim OK. Effectiveness of ultrasound-guided carpal tunnel injection using in-plane ulnar approach: a prospective, randomized, single-blinded study. Medicine (Baltimore) 2014;93(29) doi: 10.1097/MD.0000000000000350.
    1. Ustun N, Tok F, Yagz AE, Kizil N, Korkmaz I, Karazincir S, et al. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: A single-blind randomized prospective study. Am J Phys Med Rehabil. 2013;92(11):999–1004. doi: 10.1097/PHM.0b013e31829b4d72.
    1. Marshall Shawn C, Tardif G, Ashworth Nigel L. Cochrane Database of Systematic Reviews. Hoboken: Wiley; 2007. Local corticosteroid injection for carpal tunnel syndrome.
    1. Makhlouf T, Emil NS, Sibbitt WL, Jr, Fields RA, Bankhurst AD. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Clin Rheumatol. 2014;33(6):849–858. doi: 10.1007/s10067-013-2438-5.
    1. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54. doi: 10.1186/1471-2296-11-54.
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from .
    1. Newell DJ. Intention-to-treat analysis: implications for quantitative and qualitative research. Int J Epidemiol. 1992;21(5):837–841. doi: 10.1093/ije/21.5.837.
    1. Tu YK, Baelum V, Gilthorpe MS. The problem of analysing the relationship between change and initial value in oral health research. Eur J Oral Sci. 2005;113(4):271–278. doi: 10.1111/j.1600-0722.2005.00228.x.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634. doi: 10.1136/bmj.315.7109.629.
    1. Begg CB. A comparison of methods to detect publication bias in meta-analysis by P. Macaskill, S. D. Walter and L. Irwig, Statistics in Medicine, 2001; 20:641-654. Stat Med. 2002;21(12):1803. doi: 10.1002/sim.1162.
    1. Chaimani A, Higgins JPT, Mavridis D, Spyridonos P, Salanti G. Graphical tools for network meta-analysis in STATA. PLoS One. 2013;8(10) doi: 10.1371/journal.pone.0076654.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188. doi: 10.1016/0197-2456(86)90046-2.
    1. Mills EJ, Ioannidis JP, Thorlund K, Schunemann HJ, Puhan MA, Guyatt GH. How to use an article reporting a multiple treatment comparison meta-analysis. JAMA. 2012;308(12):1246–1253. doi: 10.1001/2012.jama.11228.
    1. Cipriani A, Higgins JPT, Geddes JR, Salanti G. Conceptual and technical challenges in network meta-analysis. Ann Intern Med. 2013;159(2):130–137. doi: 10.7326/0003-4819-159-2-201307160-00008.
    1. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med. 2004;23(20):3105–3124. doi: 10.1002/sim.1875.
    1. Glenny AM, Altman DG, Song F, Sakarovitch C, Deeks JJ, D'Amico R, et al. Indirect comparisons of competing interventions. Health Technol Assess. 2005;9(26):1–134. doi: 10.3310/hta9260.
    1. Salanti G, Marinho V, Higgins JPT. A case study of multiple-treatments meta-analysis demonstrates that covariates should be considered. J Clin Epidemiol. 2009;62(8):857–864. doi: 10.1016/j.jclinepi.2008.10.001.
    1. Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol. 2011;64(2):163–171. doi: 10.1016/j.jclinepi.2010.03.016.
    1. Akarsu S, Karadas O, Tok F, Levent Gul H, Eroglu E. Single versus repetitive injection of lignocaine in the management of carpal tunnel syndrome--a randomized controlled trial. J Hand Surg Eur Vol. 2015;40(2):179–183. doi: 10.1177/1753193413517326.
    1. Breuer B, Sperber K, Wallenstein S, Kiprovski K, Calapa A, Snow B, et al. Clinically significant placebo analgesic response in a pilot trial of botulinum B in patients with hand pain and carpal tunnel syndrome. Pain Med. 2006;7(1):16–24. doi: 10.1111/j.1526-4637.2006.00084.x.
    1. Dammers JW, Roos Y, Veering MM, Vermeulen M. Injection with methylprednisolone in patients with the carpal tunnel syndrome: a randomised double blind trial testing three different doses. J Neurol. 2006;253(5):574–577. doi: 10.1007/s00415-005-0062-2.
    1. 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(3):187–190. doi: 10.1007/BF00857526.
    1. Kamanli A, Bezgincan M, Kaya A. Comparison of local steroid injection into carpal tunnel via proximal and distal approach in patients with carpal tunnel syndrome. Bratisl Lek Listy. 2011;112(6):337–341.
    1. Karadas O, Tok F, Ulas UH, Odabasi Z. The effectiveness of triamcinolone acetonide vs. procaine hydrochloride injection in the management of carpal tunnel syndrome: a double-blind randomized clinical trial. Am J Phys Med Rehabil. 2011;90(4):287–292. doi: 10.1097/PHM.0b013e31820639ec.
    1. Wong SM, Hui AC, Lo SK, Chiu JH, Poon WF, Wong L. Single vs. two steroid injections for carpal tunnel syndrome: a randomised clinical trial. Int J Clin Pract. 2005;59(12):1417–1421. doi: 10.1111/j.1368-5031.2005.00696.x.
    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(1):82–88. doi: 10.1002/mus.10512.
    1. Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013;159(5):309–317. doi: 10.7326/0003-4819-159-5-201309030-00004.
    1. Dammers JW, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ. 1999;319(7214):884–886. doi: 10.1136/bmj.319.7214.884.
    1. Karadas O, Tok F, Akarsu S, Tekin L, Balaban B. Triamcinolone acetonide vs procaine hydrochloride injection in the management of carpal tunnel syndrome: randomized placebo-controlled study. J Rehabil Med. 2012;44(7):601–604. doi: 10.2340/16501977-0990.
    1. O'Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis. 2000;59(11):918–919. doi: 10.1136/ard.59.11.918.
    1. Amirfeyz R, Gozzard C, Leslie IJ. Hand elevation test for assessment of carpal tunnel syndrome. J Hand Surg Br. 2005;30(4):361–364. doi: 10.1016/j.jhsb.2005.04.007.
    1. Kim DH, Jang JE, Park BK. Anatomical basis of ulnar approach in carpal tunnel injection. Pain Physician. 2013;16(3):E191–198.
    1. Moritomo H, Imaeda T, Gotani H, Momose T, Abe Y, Oi H, et al. Reliability of the Hand20 questionnaire: comparison with the 36-Item Short-Form Health Survey. Hand Surg. 2014;19(1):1–6. doi: 10.1142/S0218810414500014.
    1. Hayward AC, Bradley MJ, Burke FD. Primary care referral protocol for carpal tunnel syndrome. Postgrad Med J. 2002;78(917):149–152. doi: 10.1136/pmj.78.917.149.
    1. Kohl KS, Bonhoeffer J, Braun MM, Chen RT, Duclos P, Heijbel H, et al. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology) Rockville MD: Agency for Healthcare Research and Quality (US); 2005.
    1. Bian ZX, Tian HY, Gao L, Shang HC, Wu TX, Li YP, et al. Improving reporting of adverse events and adverse drug reactions following injections of Chinese materia medica. J Evid Based Med. 2010;3(1):5–10. doi: 10.1111/j.1756-5391.2010.01055.x.
    1. Coplan P, Chiacchierini L, Nikas A, Shea J, Baumritter A, Beutner K, et al. Development and evaluation of a standardized questionnaire for identifying adverse events in vaccine clinical trials. Pharmacoepidemiol Drug Saf. 2000;9(6):457–471. doi: 10.1002/1099-1557(200011)9:6<457::AID-PDS529>;2-R.
    1. Higgins JPT, Altman DG: Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration, 2008. Available from . 2008.

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