Advertisement

Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial

  • Liang-Cheng Chen
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
  • Tsung-Yen Ho
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China

    Department of Physical Medicine and Rehabilitation, Taichung Armed Forces General Hospital, Taichung City, Taiwan, Republic of China
    Search for articles by this author
  • Yu-Ping Shen
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
  • Yu-Chi Su
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
  • Tsung-Ying Li
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China

    Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
  • Chia-Kuang Tsai
    Affiliations
    Department of Neurology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China

    Graduate Institute of Medical Science, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
  • Yung-Tsan Wu
    Correspondence
    Corresponding author Dr Yung-Tsan Wu, MD, Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Rd, Neihu District, Taipei, Taiwan, Republic of China.
    Affiliations
    Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China

    Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
    Search for articles by this author
Published:April 20, 2020DOI:https://doi.org/10.1016/j.apmr.2020.03.016

      Abstract

      Objective

      To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE).

      Design

      Prospective, randomized, double-blind, controlled trial (6-month follow-up).

      Setting

      Outpatients of local medical center settings.

      Participants

      Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis.

      Interventions

      Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively.

      Main Outcome Measures

      The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection.

      Results

      Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward.

      Conclusions

      We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.

      Keywords

      List of abbreviations:

      CSA (cross-sectional area), CTS (carpal tunnel syndrome), DASH (Disabilities of the Arm), Shoulder (and Hand questionnaire), D5W (5% dextrose water), MCID (minimum clinically important difference), MNCV (motor nerve conduction velocity), UNE (ulnar neuropathy at the elbow), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mondelli M.
        • Giannini F.
        • Ballerini M.
        • Ginanneschi F.
        • Martorelli E.
        Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy).
        J Neurol Sci. 2005; 234: 5-10
        • Mondelli M.
        • Filippou G.
        • Frediani B.
        • Aretini A.
        Ultrasonography in ulnar neuropathy at the elbow: relationships to clinical and electrophysiological findings.
        Neurophysiol Clin. 2008; 38: 217-226
        • Gelberman R.H.
        • Yamaguchi K.
        • Hollstien S.B.
        • et al.
        Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera.
        J Bone Joint Surg Am. 1998; 80: 492-501
        • Kroonen L.T.
        Cubital tunnel syndrome.
        Orthop Clin North Am. 2012; 43: 475-486
        • Szabo R.M.
        • Kwak C.
        Natural history and conservative management of cubital tunnel syndrome.
        Hand Clin. 2007; 23: 311-318
        • Boone S.
        • Gelberman R.H.
        • Calfee R.P.
        The management of cubital tunnel syndrome.
        J Hand Surg Am. 2015; 40: 1897-1904
        • Harder K.
        • Diehm J.
        • Fassola I.
        Current diagnostics and treatment of the cubital tunnel syndrome in Austria.
        GMS Interdiscip Plast Reconstr Surg DGPW. 2016; 5
        • Dellon A.L.
        • Hament W.
        • Gittelshon A.
        Nonoperative management of cubital tunnel syndrome: an 8-year prospective study.
        Neurology. 1993; 43: 1673-1677
        • Nakamichi K.
        • Tachibana S.
        • Ida M.
        • Yamamoto S.
        Patient education for the treatment of ulnar neuropathy at the elbow.
        Arch Phys Med Rehabil. 2009; 90: 1839-1845
        • Assmus H.
        • Antoniadis G.
        • Bischoff C.
        Carpal and cubital tunnel and other, rarer nerve compression syndromes.
        Dtsch Arztebl Int. 2015; 112: 14-25
        • Assmus H.
        • Antoniadis G.
        • Bischoff C.
        • et al.
        Cubital tunnel syndrome–a review and management guidelines.
        Cent Eur Neurosurg. 2011; 72: 90-98
        • Tang P.
        • Hoellwarth J.S.
        • Chauhan A.
        Recurrent cubital tunnel syndrome: a critical analysis review.
        JBJS Rev. 2016; 4
        • Marshall S.
        • Tardif G.
        • Ashworth N.
        Local corticosteroid injection for carpal tunnel syndrome.
        Cochrane Database Syst Rev. 2007; 2: CD001554
        • Pechan J.
        • Kredba J.
        Treatment of cubital tunnel syndrome by means of local administration of cortisonoids. II. Long-term follow-up.
        Acta Univ Carol Med (Praha). 1980; 26: 135-140
        • Hong C.Z.
        • Long H.A.
        • Kanakamedala R.V.
        • Chang Y.M.
        • Yates L.
        Splinting and local steroid injection for the treatment of ulnar neuropathy at the elbow: clinical and electrophysiological evaluation.
        Arch Phys Med Rehabil. 1996; 77: 573-577
        • Alblas C.L.
        • van Kasteel V.
        • Jellema K.
        Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study.
        Eur J Neurol. 2012; 19: 1582-1584
        • vanVeen K.E.
        • Alblas K.C.
        • Alons I.M.
        • et al.
        Corticosteroid injection in patients with ulnar neuropathy at the elbow: a randomized, double-blind, placebo-controlled trial.
        Muscle Nerve. 2015; 52: 380-385
        • Choi C.K.
        • Lee H.S.
        • Kwon J.Y.
        • Lee W.J.
        Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study.
        Ann Rehabil Med. 2015; 39: 176-182
        • Rampen A.J.
        • Wirtz P.W.
        • Tavy D.L.
        Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow.
        Muscle Nerve. 2011; 44: 128-130
        • Wu Y.T.
        • Ho T.Y.
        • Chou Y.C.
        • et al.
        Six-month efficacy of perineural dextrose for carpal tunnel syndrome: a prospective, randomized, double-blind, controlled trial.
        Mayo Clin Proc. 2017; 92: 1179-1189
        • Wu Y.T.
        • Ke M.J.
        • Ho T.Y.
        • Li T.Y.
        • Shen Y.P.
        • Chen L.C.
        Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients.
        Ann Neurol. 2018; 84: 601-610
        • Shen Y.P.
        • Wu Y.Y.
        • Chu H.Y.
        • Li T.Y.
        • Chen L.C.
        • Wu Y.T.
        Extracorporeal shock wave therapy in cubital tunnel syndrome: a pilot study.
        Neurol Asia. 2018; 23: 233-238
        • McGowan A.J.
        The results of transposition of the ulnar nerve for traumatic ulnar neuritis.
        J Bone Joint Surg Br. 1950; 32: 293-301
      1. Practice parameter for electrodiagnostic studies in ulnar neuropathy at the elbow: summary statement. American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation.
        Muscle Nerve. 1999; 22: 408-411
        • Wu Y.T.
        • Ke M.J.
        • Chou Y.C.
        • et al.
        Effect of radial shock wave therapy for carpal tunnel syndrome: a prospective randomized, double-blind, placebo-controlled trial.
        J Orthop Res. 2016; 34: 977-984
        • Huskisson E.
        Measurement of pain.
        Lancet. 1974; 304: 1127-1131
        • Bijur P.E.
        • Chang A.K.
        • Esses D.
        • Gallagher E.J.
        Identifying the minimum clinically significant difference in acute pain in the elderly.
        Ann Emerg Med. 2010; 56: 517-521
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        • et al.
        Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand).
        Am J Ind Med. 1996; 29: 602-608
        • Ido Y.
        • Uchiyama S.
        • Nakamura K.
        • et al.
        Postoperative improvement in DASH score, clinical findings, and nerve conduction velocity in patients with cubital tunnel syndrome.
        Sci Rep. 2016; 6: 27497
        • Liang H.W.
        • Wang H.K.
        • Yao G.
        • Horng Y.S.
        • Hou S.M.
        Psychometric evaluation of the Taiwan version of the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire.
        J Formos Med Assoc. 2004; 103: 773-779
        • Wiesler E.R.
        • Chloros G.D.
        • Cartwright M.S.
        • Shin H.W.
        • Walker F.O.
        Ultrasound in the diagnosis of ulnar neuropathy at the cubital tunnel.
        J Hand Surg. 2006; 31: 1088-1093
        • Beekman R.
        • Van Der Plas J.P.
        • Uitdehaag B.M.
        • Schellens R.L.
        • Visser L.H.
        Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow.
        Muscle Nerve. 2004; 30: 202-208
        • Volpe A.
        • Rossato G.
        • Bottanelli M.
        • et al.
        Ultrasound evaluation of ulnar neuropathy at the elbow: correlation with electrophysiological studies.
        Rheumatology (Oxford). 2009; 48: 1098-1101
        • Bayrak A.O.
        • Bayrak I.K.
        • Turker H.
        • Elmali M.
        • Nural M.S.
        Ultrasonography in patients with ulnar neuropathy at the elbow: comparison of cross-sectional area and swelling ratio with electrophysiological severity.
        Muscle Nerve. 2010; 41: 661-666
        • Faul F.
        • Erdfelder E.
        • Lang A.G.
        • Buchner A.
        G∗Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Kim J.M.
        Comment on corticosteroid injection in patients with ulnar neuropathy at the elbow: a randomized, double-blind, placebo-controlled trial.
        Muscle Nerve. 2016; 53: 494-495
        • Wu Y.T.
        • Chen S.R.
        • Li T.Y.
        • et al.
        Nerve hydrodissection for carpal tunnel syndrome: a prospective, randomized, double-blind, controlled trial.
        Muscle Nerve. 2019; 59: 174-180
        • Evers S.
        • Bryan A.J.
        • Sanders T.L.
        • Selles R.W.
        • Gelfman R.
        • Amadio P.C.
        Effectiveness of ultrasound-guided compared to blind steroid injections in the treatment of carpal tunnel syndrome.
        Arthritis Care Res (Hoboken). 2017; 69: 1060-1065
        • Lam S.K.H.
        • Reeves K.D.
        • Cheng A.L.
        Transition from deep regional blocks toward deep nerve hydrodissection in the upper body and torso: method description and results from a retrospective chart review of the analgesic effect of 5% dextrose water as the primary hydrodissection injectate to enhance safety.
        Biomed Res Int. 2017; 2017: 7920438
        • Shen Y.P.
        • Li T.Y.
        • Chou Y.C.
        • et al.
        Comparison of perineural platelet-rich plasma and dextrose injections for moderate carpal tunnel syndrome: a prospective randomized, single-blind, head-to-head comparative trial.
        J Tissue Eng Regen Med. 2019; 13: 2009-2017