背景:腕管综合征(CTS)是一种非常常见的临床综合征,表现为腕部腕管正中神经刺激的体征和症状。CTS的直接和间接成本是巨大的,仅在美国,CTS手术的费用估计为20亿美元。局部皮质类固醇注射多年来一直被用作CTS的非手术治疗,但其有效性仍有争议。
目的:评估与手术相比,在腕管内或周围注射皮质类固醇治疗腕管综合征(CTS)的益处和危害。
方法:我们使用标准,广泛的Cochrane搜索方法。我们搜索了Cochrane神经肌肉专业注册,中部,MEDLINE,Embase,CINAHL,ClinicalTrials.gov,世卫组织ICTRP。最新的搜索是2022年5月26日。
方法:我们纳入了成人CTS患者的随机对照试验(RCT)或准随机试验,其中包括至少一个腕部局部皮质类固醇注射(LCI)的对照组和一个任何手术干预组。
方法:我们使用标准Cochrane方法。我们的主要结果是1。在长达三个月的随访中症状改善。我们的次要结果是2。功能改进,3.在超过三个月的随访中症状改善,4.改善神经生理参数,5.改善成像参数,6.生活质量的提高和7。
结果:我们使用GRADE来评估每个结果的证据的确定性。
结果:我们纳入了7项研究,涉及569个“手”(尽管有2项研究的数据无法用于定量分析)。所有研究都使用一次性LCI作为比较,使用几种不同类型和剂量的皮质类固醇。在每一项研究中,对于手术组和LCI组,我们所有的主要和次要结局均显示从治疗前到治疗后的改善.然而,综合分析的证据太不确定,我们无法得出可靠的结论,以比较手术治疗与LCI在长达3个月随访时症状缓解的主要结局(标准平均差(SMD)0.63,95%置信区间(CI)-0.61至1.88;I2=95%;5项试验,305名参与者;非常低的确定性证据)。在超过三个月的随访中,关于症状缓解的次要结局指标的发现(SMD0.94,95%CI-0.31至2.19;I2=93%;4项试验,235名参与者),在长达三个月的随访中功能改善(SMD-0.11,95%CI-0.94至0.72;I2=84%;3项试验,215名参与者)和超过三个月随访时的功能改善(SMD0.19,95%CI-1.22至1.59;I2=93%;3项试验,185名参与者)也不确定(确定性非常低的证据),并且在手术或LCI方面没有明显优势。手术可以改善神经生理学(正中神经远端运动潜伏期)超过LCI(平均差异(MD)0.87ms,95%CI0.32至1.42;I2=72%;3项试验,162名参与者;低确定性证据)。生活质量和不良事件的证据也不确定;LCI后生活质量(EuroQol-5D-3L)可能比手术后略有改善(差异可能不是临床重要的)(MD0.07,95%CI0.02至0.12;1项试验,38名参与者;确定性证据非常低),并且LCI的不良事件可能比手术少(风险比(RR)0.34,95%CI0.04至3.26;3项试验,112名参与者;非常低的确定性证据)。
结论:将LCI与CTS手术进行比较的证据,短期或长达12个月的随访,太不确定了,无法得出任何可靠的结论。
Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS for many years, but its effectiveness is still debated.
To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome (CTS) compared to surgery.
We used standard, extensive Cochrane search methods. We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and WHO ICTRP. The latest search was 26 May 2022.
We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local corticosteroid injection (LCI) into the wrist and one group of any surgical intervention.
We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. improvement in quality of life and 7.
We used GRADE to assess the certainty of evidence for each outcome.
We included seven studies involving 569 \'hands\' (although two studies had unusable data for quantitative analyses). All studies used a one-time LCI as a comparator, using several different types and doses of corticosteroids. In every study, for both surgery and LCI groups, all our primary and secondary outcomes showed improvement from pre- to post-treatment. However, evidence from the combined analysis was too uncertain for us to draw reliable conclusions for the comparison of surgical treatment versus LCI with respect to our primary outcome of symptom relief at up to three months\' follow-up (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) -0.61 to 1.88; I2 = 95%; 5 trials, 305 participants; very low-certainty evidence). Findings with respect to secondary outcome measures of symptom relief at greater than three months\' follow-up (SMD 0.94, 95% CI -0.31 to 2.19; I2 = 93%; 4 trials, 235 participants), functional improvement at up to three months\' follow-up (SMD -0.11, 95% CI -0.94 to 0.72; I2 = 84%; 3 trials, 215 participants) and functional improvement at greater than three months\' follow-up (SMD 0.19, 95% CI -1.22 to 1.59; I2 = 93%; 3 trials, 185 participants) were also uncertain (very low-certainty evidence) and showed no clear advantage for surgery or LCI. Surgery may improve neurophysiology (median nerve distal motor latency) more than LCI (mean difference (MD) 0.87 ms, 95% CI 0.32 to 1.42; I2 = 72%; 3 trials, 162 participants; low-certainty evidence). Evidence for quality of life and adverse events was also uncertain; quality of life (EuroQol-5D-3L) may be slightly improved after LCI than after surgery (the difference may not be clinically important) (MD 0.07, 95% CI 0.02 to 0.12; 1 trial, 38 participants; very low-certainty evidence) and there may be fewer adverse events with LCI than with surgery (risk ratio (RR) 0.34, 95% CI 0.04 to 3.26; 3 trials, 112 participants; very low-certainty evidence).
The evidence comparing LCI to surgery for CTS, either in the short term or up to 12 months\' follow-up, is too uncertain for any reliable conclusions to be drawn.