Transient white hand after carpal tunnel injection

[dc2md]

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Heard from a friend today that performed a bilateral carpal tunnel steroid injection recently. Negative aspiration before injecting. 5 minutes later, ONE of the hands turned white and had a fullness/heavy feeling. No real temperature decrease. No increased pain. The other hand was fine. Radial pulse was palpable. No increased paresthesias. Took the patient to the ED and by that time (about 15 minutes) the hand started to very slowing normalize in color. After an hour or two, completely normal color. Patient called the next day and said she was completely fine and was out shopping.

What do you think? Transient vasospasm? Local sympathetic response? Particulate steroid was used so it could have been downstream occlusion of capillaries I guess.

Interesting case. Thought I'd share. Interesting how it was only unilateral too. Oh, and no history of smoking or Raynaud's.

 

[PMR2008]

Doubt it was a capillary blockage cause that would be probably cause symptoms in a single or 2-3 digits rather than the whole hand. Also you would likely have pain

"Ulnar artery ischaemia following corticosteroid injection for carpal tunnel syndrome"
http://journal.nzma.org.nz/journal/124-1335/4683/

I am putting my money on vasospasm.

"Digital Ischemia After Carpal Tunnel Injection: A Case Report"
http://www.archives-pmr.org/article/S0003-9993(08)00325-0/abstract

The safest way to perform the procedure IMHO is under ultrasound guidance.

 

[PMR 4 MSK]

Transient vasospasm

 

[RUOkie]

agree with vasospasm.
Was US used? If not, there could have been a median artery (I have one in my L hand)
Was any anesthetic used?
I do not use lidocaine with my CT injections to avoid doing a median N. block, but many people do.

 

[lobelsteve]

Like this one, a simple distal 3rd digit Raynaud's.

Or like this one: A reaction after CTS injection with severe vasospasm in a patient with soon to be diagnosed connective tissue disease. 0.5cc 1% plain lidocaine, 0.5cc Celestone via a 30G 1/2" needle using textbook approach (done in 2007 before US was vogue). She kept the nail but had a little flap done.

2 days post procedure:

2 weeks post-procedure after Ortho hand said do nothing and vascular did nothing.

12 weeks post, when plastics did something:

There are no little injections. Only little brains that fail to act when complications arise. She was seen same day in ER and sent for Vascular consult to meet her there as well as vascular studies. Study demonstrated vasospasm. Treatment could have been phentolamine injection to reverse vasospasm.

 

[dc2md]

Great pics Steve.

What is proposed as the cause of the vasospasm?

 

[lobelsteve]

Great pics Steve.

What is proposed as the cause of the vasospasm?

Stress, pain. Sympathetically mediated.

 

[DRacula]

The photographs are super helpful in driving home the point, LobelSteve. Thanks for sharing!!

 

[specepic]

now that I often do these under US I can appreciate that the ulnar artery is likely often violated when done non-guided. I would also worry, with a 1/2" needle, about intraart inj of partic

 

[DOctorJay]

now that I often do these under US I can appreciate that the ulnar artery is likely often violated when done non-guided. I would also worry, with a 1/2" needle, about intraart inj of partic

agreed. these injections are scary WITH ultrasound, never mind without. for those of you using ultrasound, do you inject next to the nerve or just in the tunnel?

 

[specepic]

agreed. these injections are scary WITH ultrasound, never mind without. for those of you using ultrasound, do you inject next to the nerve or just in the tunnel?

I inject near but not next to the nerve. I think if you try to target the nerve itself and you are not exactly on the money you loose some of the US safety factor. I think the idea of US for this inj is to get the needle in the tunnel while avoiding vascular or nerve injection.

I like an axial view, then needle long axis ulnar to radial direction (not oblique as I was taught, too easy to not know where tip is), and gel stand off to clear ulnar artery. I also do a test 'injection' with my marking pen in the gel stand off to know exactly where to enter skin, then mark that and numb it after prep but before sterile gel and probe reapplied.

 

[DOctorJay]

I do near but not next to as well for safety. Not trying to block the nerve here.

I like your planning tips and hadn't thought of doing it that way.

 

[RUOkie]

I inject near but not next to the nerve. I think if you try to target the nerve itself and you are not exactly on the money you loose some of the US safety factor. I think the idea of US for this inj is to get the needle in the tunnel while avoiding vascular or nerve injection.

I like an axial view, then needle long axis ulnar to radial direction (not oblique as I was taught, too easy to not know where tip is), and gel stand off to clear ulnar artery. I also do a test 'injection' with my marking pen in the gel stand off to know exactly where to enter skin, then mark that and numb it after prep but before sterile gel and probe reapplied.

that is the technique I was taught.

I did CTS injections blind for 14 yrs (and never had a complication). When I got my US machine, I discovered that I have persistent median arteries bilaterally. When I spoke to my friend who is a neurosurgeon and told him, he replied: "I always thought you were nuts injecting that blind, I know what is in there." 😀

 

[bedrock]

that is the technique I was taught.

I did CTS injections blind for 14 yrs (and never had a complication). When I got my US machine, I discovered that I have persistent median arteries bilaterally. When I spoke to my friend who is a neurosurgeon and told him, he replied: "I always thought you were nuts injecting that blind, I know what is in there." 😀

exactly. you can get lucky for years, that doesn't mean you should.

Just like people who did cervical ESI with hanging drop. Sure they got away with it most of the time, but in this millennium its not standard of care, and it they get a complication now, their ass is on the line.

I would argue that carpal tunnel injections with US are the standard of care at this point. If you can't do, refer to someone who can.

 

[dc2md]

I would argue that carpal tunnel injections with US are the standard of care at this point. If you can't do, refer to someone who can.

Wouldn't say "standard of care" just yet. Is there even one article that shows that it is more accurate or safer?

 

[DOctorJay]

Not to my knowledge.

 

[PMR2008]

Wouldn't say "standard of care" just yet. Is there even one article that shows that it is more accurate or safer?

Definitely not standard of care yet. I am attaching a really nice point-counter point from the purple journal

" Chavez-Chiang et al reported on a randomized controlled study that addressed whether US needle guidance affected the outcomes of corticosteroid injection for CTS compared with blind, palpation guided injection. The study involved randomizing 76 patients with veri&#64257;ed CTS to injection by using either US guidance or blind, palpation-guided injection of the carpal tunnel. A 1-needle, 2-syringe technique was used in which US-guided hydrodissection injection of 1% lidocaine from a &#64257;rst syringe was performed followed by injection with 80 mg of triamcinolone acetonide from a second syringe. Baseline pain, procedural pain, pain at outcome (at 2 weeks and 6 months), responder rate, therapeutic duration, re-injection rates, total cost, and cost per responder were determined and compared between the 2 methods of injection. These researchers found that there were no signi&#64257;cant complications in either treatment group. However, relative to conventional palpation-guided injection, US guidance resulted in a 77.1% reduction in procedural pain (P <.001), a 63.3% reduction in pain scores at outcome (P< .002), a 84.6% increase in the responder rate (P < .001), a 51.6% reduction in the nonresponder rate (P<.001), a 71.0% increase in duration of therapeutic effect (P< .001), a 59.3% ($150) reduction in cost per responder per year for a hospital outpatient(P < .001), and a 20.8% reduction in cost per patient per year for a hospital outpatient (P< .001). Based on this randomized controlled trial, it was concluded that US needle guidance signi&#64257;cantly improves the performance, clinical outcomes, and cost-effectiveness of injection of the carpal tunnel compared with conventional blind, palpation-guided injection"

 

[bedrock]

Wouldn't say "standard of care" just yet. Is there even one article that shows that it is more accurate or safer?

How good is the evidence that a carpal tunnel injection is standard of care for patients that have failed splinting and postural adjustments?



How hard we push non-surgical options should correlate with the relative risks and clinical responses to the surgical options-



Carpal tunnel releases are very effective for treating clinical symptoms and have minimal morbidity, so I don't even inject these patients, I just refer them for a carpal tunnel release if they failed other conservative measures.

Now ulnar neuropathy at the cubital tunnel is different and the surgical outcomes are not as good much of the time, and I try everything possible to avoid surgery for those patients including injection(s)

 

[lobelsteve]

How good is the evidence that a carpal tunnel injection is standard of care for patients that have failed splinting and postural adjustments?



How hard we push non-surgical options should correlate with the relative risks and clinical responses to the surgical options-



Carpal tunnel releases are very effective for treating clinical symptoms and have minimal morbidity, so I don't even inject these patients, I just refer them for a carpal tunnel release if they failed other conservative measures.

Now ulnar neuropathy at the cubital tunnel is different and the surgical outcomes are not as good much of the time, and I try everything possible to avoid surgery for those patients including injection(s)

As a 1st and 2nd year grad, I'd inject 1 per week. As a 7th year out- 6-7 per year. The surgery takes as long as the injection and fixes the problem.

 

[dc2md]

How much rehab is there after an endoscopic release?