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Grand Rounds

Night Splints or Corticosteroids for Carpal Tunnel Syndrome?

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BACKGROUND AND PURPOSE:

  • Carpel Tunnel Syndrome
    • Results from entrapment of median nerve
    • Most common compression neuropathy of the arm and results in disturbed sleep
  • Chesterton et al. (Lancet, 2018) evaluated the two common therapies, night splints vs corticosteroid injections

METHODS:

  • Pragmatic, two-arm parallel group, open-label, randomized controlled trial (RCT)
    • INSTINCTS trial (INjection versus SplinTing in Carpal Tunnel Syndrome)
  • Participants
    • Recruited from general practices and MSK treatment clinics
    • ≥18 years
    • New onset idiopathic mild or moderate carpal tunnel syndrome, present for >6 weeks
  • Severity definitions
    • Mild: Intermittent paraesthesia in the distribution of the median nerve
    • Moderate: Constant paraesthesia and reversible numbness or pain
  • Randomized to either
    • 20 mg methylprednisolone acetate injection (single dose)
    • night-resting splint to be worn for 6 weeks
  • Primary outcome
    • Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks
    • BCTQ: Questionnaire that asks patients about severity and functional status over a typical 24 hour period
  • Economic cost-utility analysis was also performed

RESULTS:

  • 118 in night splint group | 116 in corticosteroid group
    • 91% completed the BCTQ at 6 weeks
  • Primary outcome: The BCTQ score was better in the corticosteroid injection group (p=0·0001)
    • Corticosteroid group: Mean score of 2.02
    • Night splint group: Mean score of 2.29
    • Adjusted mean difference −0.32 (95% C, −0.48 to −0.16)
  • No serious or unexpected adverse events were reported
  • Additional monitoring through 6 months
    • Some additional improvement in night splint group while injection group scores remained stable
    • Outcomes were not significantly different at that point in time
  • Economic analysis
    • Injection was more expensive but also more effective
    • More rapid improvement with less time off work over several months

CONCLUSION:

  • The authors conclude that a single corticosteroid injection should be the treatment of choice in mild and moderate carpel tunnel syndrome
  • Corticosteroid injection was both effective from both a clinical and cost standpoint

Learn More – Primary Sources:

The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial

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