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Clinical Procedures > Anesthetic and Analgesic Techniques
Steroid Injection, Carpal Tunnel
Article Last Updated: Apr 9, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Arie Gluzman, BS, MD, Staff Physician, Physical Medicine & Rehabilitation, UCLA/Greater Los Angeles Veterans Administration
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
carpal tunnel injection, carpal, carpal tunnel, carpal tunnel syndrome, carpel tunnel syndrome, carpal syndrome, CTS, steroid injection, median nerve block, wrist steroid injection, CTS steroid injection, palmaris longus tendon, flexor carpi radialis tendon, median nerve steroid injection, nerve conduction study, electromyography, flexor retinaculum
Median nerve corticosteroid (steroid) injection at the wrist is used to treat the symptoms of carpal tunnel syndrome by injecting a steroid solution into the ulnar bursa surrounding the median nerve. This procedure is also commonly called a carpal tunnel injection. This injection can be used when conservative measures such as physical therapy, ergonomic modifications, rest, regular exercise, splinting, and nonsteroidal antiinflammatory drug (NSAID) therapies have proved ineffective at relieving symptoms.1, 2, 3, 4
Electrodiagnostic studies such as nerve conduction studies and electromyography are typically obtained to determine the severity of nerve damage prior to performing the procedure.5 Steroid injections should be avoided prior to planned electrodiagnostic testing, as the presence of steroids may alter test results.
Historically, median nerve steroid injections were typically used for only mild median nerve entrapment (as documented by electroneurography) as well as for temporary pain relief in anticipation of definitive flexor retinaculum surgical release. Recent research indicates that local median nerve steroid injections may be more effective than surgical intervention in providing symptom relief over the short term.6, 7 The use of anesthetics in conjunction with steroids offers diagnostic information as well as temporary relief.
For a more thorough discussion on pain control, see the Medscape Pharmacologic Management of Pain Resource Center.
- Carpal tunnel syndrome not relieved by conservative measures
- Electrodiagnostic changes consistent with mild-to-moderate median nerve entrapment
- Adverse reaction to injectable steroid or anesthetic
- Uncontrolled diabetes mellitus
- Active systemic or local infection
- Compromised skin integrity over the area
- Immunosuppression
- Needle, 1 in, 27 or 30 gauge (ga)
- Syringe, 5 mL
- Antiseptic solution with skin swabs
- Small rolled towel
- Triamcinolone acetonide (Kenalog), 10-20 mg; or methylprednisolone acetate (Depo-Medrol), 10-20 mg
- Lidocaine 1% or bupivacaine 0.25%
- Patient should be positioned comfortably in a seated or supine position.
- The affected arm should be supinated with the palmar aspect of the wrist resting over a small rolled towel.
- First, locate the flexor carpi radialis (FCR) and palmaris longus (PL) tendons. The PL tendon is medial to the FCR and is best located by actively pinching all fingers together while the wrist is flexed.
Solid blue line - palmaris longus tendon; solid red line - flexor carpi radialis tendon; dotted blue line - proximal palmar crease. - Carefully disinfect the skin.
- Insert the needle 1 cm proximal to the proximal wrist crease and directly ulnar to the PL tendon. Direct the needle distally toward the ring finger at an angle of 30 degrees.
Needle placement - Medial of palmaris longus tendon. - Advance the needle approximately 1.5-2 cm or until the tendon is touched.
- Aspirate to verify that no vasculature is affected, and inject the steroid solution with little or no resistance.
- Lastly, remove the needle and place the wrist in a gravity-dependent position.
- Advise the patient to actively move the fingers for several minutes to distribute the solution evenly.
Steroid injection, carpal tunnel.
- Some people do not have a palmaris longus (PL) tendon.8 In these cases, the needle is inserted at the midline between the radial and ulnar aspects of the wrist, proximal to the wrist crease, and is directed toward the ring finger.
Needle placement in absence of palmaris longus tendon. - If contact is made with the PL tendon while advancing the needle, retract slightly and redirect.
- The use of a needle smaller in diameter may require increased effort and slower injection time but dramatically reduces pain at the site of injection.
- Sudden worsening pain or paresthesia indicates the possibility of improper needle placement. If this occurs, retract the needle and redirect more medially (ulnar).
- To avoid potential complications of vascular or nerve ischemia, tissue necrosis, and serious damage to nerve, lidocaine with epinephrine should not be used.
- Bleeding
- Infection
- Injury to nerve9, 10
- Temporary paresthesia
- Alteration in blood glucose levels in patients with diabetes mellitus
- Pain
eMedicine from WebMD: Physical Medicine and Rehabilitation Journal American Family Physician: Diagnostic and Therapeutic Injection of the Wrist and Hand Region Family Practice Notebook: Procedure Chapter Wheeless’ Textbook of Orthopaedics: Carpal Tunnel Injection/Median Nerve Block
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
| Media file 2:
Solid blue line - palmaris longus tendon; solid red line - flexor carpi radialis tendon; dotted blue line - proximal palmar crease. |
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| Media file 3:
Needle placement - Medial of palmaris longus tendon. |
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| Media file 4:
Needle placement in absence of palmaris longus tendon. |
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- Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. Apr 18 2007;CD001554. [Medline].
- Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J. Jan 2008;77(1):6-17. [Medline].
- Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, et al. A systematic review of conservative treatment of carpal tunnel syndrome. Clin Rehabil. Apr 2007;21(4):299-314. [Medline].
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- Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. Feb 2005;52(2):612-9. [Medline].
- Nonsurgical treatment is effective for carpal tunnel syndrome. J Fam Pract. Sep 2004;53(9):685. [Medline].
- Sebastin SJ, Puhaindran ME, Lim AY, Lim IJ, Bee WH. The prevalence of absence of the palmaris longus--a study in a Chinese population and a review of the literature. J Hand Surg [Br]. Oct 2005;30(5):525-7. [Medline].
- Linskey ME, Segal R. Median nerve injury from local steroid injection in carpal tunnel syndrome. Neurosurgery. Mar 1990;26(3):512-5. [Medline].
- Hennink S, van der Horst CM, Breugem CC. Complications following steroid treatment for carpal tunnel syndrome. J Hand Surg Eur Vol. Jun 2007;32(3):362-3. [Medline].
Steroid Injection, Carpal Tunnel excerpt Article Last Updated: Apr 9, 2008
Topic originally published: Apr 9, 2008
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