CLINICAL QUESTION

Is surgery more effective than corticosteroid injections in adults with carpal tunnel syndrome?

BOTTOM LINE

Adults with carpal tunnel syndrome are more likely to achieve recovery after 18 months if they are treated with surgery rather than corticosteroid injections. (Level of Evidence = 2b)

SYNOPSIS

The researchers recruited adults from outpatient neurology clinics with at least 6 weeks of confirmed carpal tunnel syndrome for which surgery and corticosteroid injections were appropriate therapies. Patients were randomized to receive decompression surgery (n = 468) or corticosteroid injection (n = 466). Because this was a pragmatic study, the authors did not require a specific surgical specialty, specific corticosteroid regimen, or any cointerventions (eg, splints, physical therapy). Over 18 months, 14% of the participants were lost to follow-up. Additionally, 228 (49%) of the participants who received corticosteroid injection subsequently underwent surgery.

The authors properly used intention to treat to analyze the primary outcome of recovery at 18 months. Recovery was defined as having no or mild carpal tunnel syndrome symptoms (a score of less than 8 on a scale ranging from 6 to 30 points) and occurred in 60.6% of patients who had surgery and 44.6% of patients who received corticosteroid injection (number needed to treat = 7; 95% CI, 5–11). The crossover of participants who received corticosteroid injection to surgery underestimates the differences between the interventions. The patients who had surgery also had quicker median time to recovery (9 months vs 18 months). Patient global satisfaction was higher in those who had surgery (82% vs 61%). Adverse events occurred in less than 1% of patients in each group. Although most patients in each group (greater than 85%) reported an adverse event during the subsequent 18 months, more patients in the surgery group reported a wound or skin problem that needed treatment (14% vs 7%) and more patients in the corticosteroid group reported changed hand sensation (72% vs 66%).