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Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report
Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report Ying-Chen Kuo a, Chia-Cheng Lee a, Lin-Fen Hsieh a,b,⇑ a b
Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
a r t i c l e
i n f o
Article history: Received 22 February 2017 Accepted 18 June 2017 Available online xxxx Keywords: Carpal tunnel syndrome Platelet-rich plasma Injections Ultrasonography
a b s t r a c t Carpal tunnel syndrome (CTS) is a common and sometimes challenging condition, which causes pain; paresthesia; tingling of the thumb, index and long fingers; and even thenar weakness in the hands. The effectiveness of corticosteroid injections seems to be transient, and there is a lack of information around long-term effects in previous studies. In recent years, platelet-rich plasma (PRP) has proven to bean alternative as it encourages tissue regeneration. We hereby describe a patient with CTS showing significant improvements in electrophysiological parameters after receiving PRP injections. The results revealed significant improvements in the distal motor and sensory latencies as well as the sensory nerve action potential and compound muscle action potential amplitudes of the both median nerves. In summary, if patients are refractory to conservative treatments—such as splinting, oral medication, and corticosteroid injection—PRP may be used as an alternative before surgical intervention. Ó 2017 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Carpal tunnel syndrome (CTS) can cause pain; paresthesia; tingling; and even thenar weakness in the hands. Treatment of CTS spans from conservative therapeutic measures to surgical intervention. Local corticosteroid injections into the carpal tunnel provided a significantly clinical improvement [1]. However, the effectiveness seems to lack long-term benefits and adverse effects are common [2]. In recent years, platelet-rich plasma (PRP) has emerged as an alternative for tissue repair. After centrifuging whole blood, growth factors are concentrated and, when injected, can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells [3–6]. Malahia et al. reported that a single injection of PRP into the carpal tunnel significantly improved pain and upper limb function. However, electrophysiological improvement was not documented [7]. We hereby describe a patient with CTS showing significant improvements in electrophysiological parameters after receiving PRP injection. To the best of our knowledge, this is the first case report that compared the electrophysiological data before and after the procedure.
A 56-year-old woman suffered from pain and paresthesia in both hands for 2 months, especially in the thumb, index and third fingers. The symptoms were more severe in the left hand. Two months prior to a clinic visit, she received a corticosteroid injection into bilateral carpal tunnels, but in vain. On physical examination, both Tinel’s sign and Phalen’s sign were positive. Nerve conduction study (NCS) demonstrated prolonged distal motor and sensory latency of the median nerve bilaterally. Reduction of the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) amplitude occurred in relation to the left median nerve, and reduction of the SNAP amplitude in the right side. A significant decrease in median nerve sensory conduction velocity across the carpal tunnel was also found (Table 1). Electromyography of the abductor pollicis brevis muscle appeared actively denervated. Ultrasonography (US) (Esaote, MyLabFive, linear probe, LA435, 15 MHz) of the left median nerve at the level of the pisiform bones showed an ovoid hypo-echoic structure featuring a hyper-echoic rim with a cross-sectional area of 0.11 cm2 (Fig. 1). Two weeks later, ultrasound-guided perineural injection with PRP into the carpal tunnel was performed. PRP was prepared by taking 10 ml of venous blood, which was then mixed with 2 ml of thrombin and centrifuged in a specially designed tube at 3400
⇑ Corresponding author at: Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Fax: +886 2 28389319. E-mail addresses: [email protected], [email protected] (L.-F. Hsieh). http://dx.doi.org/10.1016/j.jocn.2017.06.053 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053
2
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Table 1 Series of nerve conduction study before and after treatment. Latency (ms) 0 mon
Peak amp (uV) 3 mon
Duration (ms)
Velocity (m/s)
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
3.20 1.40
2.00 3.60
5.40 19.40
10.60 18.60
2.85 1.45
2.30 2.05 36.96
2.45 1.85 46.34
35.20 33.30 55.56
44.60 45.20
53.10 50.00
3.45 1.50
3.10 1.30
8.10 8.80
31.60 18.60
28.00 17.50
2.30 1.65
2.20 2.30 32.73
2.55 2.30 46.15
36.80 43.80 55.56
46.40 46.70
54.80 53.80
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
Motor nerve conduction study L Median-APB Wrist 7.65 3.60 Elbow 11.60 7.75
4.45 9.20
0.40 0.40
3.40 2.70
4.50 4.20
1.60 4.60
22.20 16.90
18.20 16.90
48.10
42.10
43.70
R Median-APB Wrist 7.10 Elbow 11.05
3.50 7.35
4.50 4.70
6.80 6.30
7.00 6.70
16.30 16.70
22.90 23.00
24.00 23.10
45.60
50.70
49.40
Sensory nerve conduction study L Median-Digit 2 Wrist 4.55 3.60 Palm 2.25 1.55 Wrist to palm R Median-Digit 2 Wrist 4.35 Palm 1.60 Wrist to palm Latency (ms) 0 mon
Peak amp (mV)
3.15 6.90
Area (mV * ms)
Velocity (m/s)
R, right; L, left; mon, month; APB, abductor pollicis brevis.
MN Lunate Triquetrum
Triquetrum Lunate
Medial
Lateral
Medial
Lateral
Fig. 1. Ultrasonographic findings of the left median nerve. The ultrasound probe was placed at the level of the pisiform bone to demonstrate the median nerve in the transverse view. The cross-sectional area before the first PRP injection (left) was 0.11 cm2 and 0.06 cm2, 6 months later (right). MN, median nerve.
rotations per minute for 15 min. Then, approximately 5 ml of PRP (2.5 ml buffy coat and 2.5 ml supernatant serum) was administered under ultrasound guidance. The injection procedure was an in-plane approach with technique of hydrodissection, from distal to proximal at the wrist. Pain, paresthesia, and hypesthesia of both hands decreased gradually over 2 weeks. During the period, the patient did not receive other treatment. Follow-up NCS of both median nerves 3 months after the injection revealed significant improvements in the distal motor and sensory latencies as well as SNAP and CMAP amplitudes (Table 1). The SNAP and CMAP amplitudes of the left median nerve were larger than the first examination. The patient received the second PRP injection to her left carpal tunnel 2 weeks later, and the electrophysiological parameters at the third NCS improved significantly. No adverse reactions were observed.
3. Discussion In this patient, considering the severity of symptoms of CTS as reported in the electrophysiological study and poor response to
corticosteroid injections, PRP injection was considered. After the first injection, improvement was observed based on electrophysiology data showing distal latency, conduction velocity, and SNAP and CMAP amplitudes. We compared the electrophysiological study before and after PRP injection which provided us more objective evidence to prove the effectiveness. Although the evidence of PRP use in CTS is still limited, the effect of promoting nerve regeneration had been discussed in peripheral nerve [3]. Two animal studies concluded that PRP may enhance the number of regenerating nerve fibers and improve neuromuscular function [4,5]. Generally, growth factors and proteins are released from platelets’ alpha granules after platelets are activated, leading to improvements in nerve regeneration [3–5]. In this patient, the improvement of the CMAP amplitude was more prominent in the left hand. It is possible that the effect of PRP in more damaged nerves is even more important. In recent years, with ultrasound-guided approach of injection, the needle can get closer to the epineurium of the nerve, thus improving the effect of injection and also avoiding nerve or tendon injury. Also, the ultrasound-guided procedure of percutaneous hydrodissection of the median nerve away from the deep surface
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
of the flexor retinaculum can separate a potential soft tissue adhesion from the nerve [8]. 4. Conclusion If patients with CTS are refractory to conservative treatments, ultrasound-guided PRP injection may be an option. However, we required larger samples, a control group, and long-term followup to validate the efficacy and safety. Acknowledgments The authors would like to acknowledge the financial support provided by the Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
3
References [1] Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. The Cochrane Library 2002. [2] Sevim S, Dogu O, Camdeviren H, et al. Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci 2004;25:48–52. [3] Yu WJ, Wang J, Yin J. Platelet-rich plasma: a promising product for treatment of peripheral nerve regeneration after nerve injury. Int J Neurosci 2011;121:176–80. [4] Elgazzar RF, MutabaganiMA Abdelaal SE, et al. Platelet rich plasma may enhance peripheral nerve regeneration after cyanoacrylate reanastomosis: a controlled blind study on rats. Int J Oral Maxillofac Surg 2008;37:748–55. [5] Cho HH, Jang S, Lee SC, et al. Effect of neural-induced mesenchymal stem cells and platelet-rich plasma on facial nerve regeneration in an acute nerve injury model. Laryngoscope 2010;120:907–13. [6] Anjayani S, Wirohadidjojo YW, Adam AM, et al. Sensory improvement of leprosy peripheral neuropathy in patients treated with perineural injection of plateletrich plasma. Int J Dermatol 2014;53:109–13. [7] Malahias MA, JohnsonEO Babis GC, et al. Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. Neural Regen Res 2015;10:1856. [8] Cass Shane P. Ultrasound-guided nerve hydrodissection: what is it? A review of the literature. Curr Sports Med Rep 2016;15:20–2.
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report Ying-Chen Kuo a, Chia-Cheng Lee a, Lin-Fen Hsieh a,b,⇑ a b
Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
a r t i c l e
i n f o
Article history: Received 22 February 2017 Accepted 18 June 2017 Available online xxxx Keywords: Carpal tunnel syndrome Platelet-rich plasma Injections Ultrasonography
a b s t r a c t Carpal tunnel syndrome (CTS) is a common and sometimes challenging condition, which causes pain; paresthesia; tingling of the thumb, index and long fingers; and even thenar weakness in the hands. The effectiveness of corticosteroid injections seems to be transient, and there is a lack of information around long-term effects in previous studies. In recent years, platelet-rich plasma (PRP) has proven to bean alternative as it encourages tissue regeneration. We hereby describe a patient with CTS showing significant improvements in electrophysiological parameters after receiving PRP injections. The results revealed significant improvements in the distal motor and sensory latencies as well as the sensory nerve action potential and compound muscle action potential amplitudes of the both median nerves. In summary, if patients are refractory to conservative treatments—such as splinting, oral medication, and corticosteroid injection—PRP may be used as an alternative before surgical intervention. Ó 2017 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Carpal tunnel syndrome (CTS) can cause pain; paresthesia; tingling; and even thenar weakness in the hands. Treatment of CTS spans from conservative therapeutic measures to surgical intervention. Local corticosteroid injections into the carpal tunnel provided a significantly clinical improvement [1]. However, the effectiveness seems to lack long-term benefits and adverse effects are common [2]. In recent years, platelet-rich plasma (PRP) has emerged as an alternative for tissue repair. After centrifuging whole blood, growth factors are concentrated and, when injected, can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells [3–6]. Malahia et al. reported that a single injection of PRP into the carpal tunnel significantly improved pain and upper limb function. However, electrophysiological improvement was not documented [7]. We hereby describe a patient with CTS showing significant improvements in electrophysiological parameters after receiving PRP injection. To the best of our knowledge, this is the first case report that compared the electrophysiological data before and after the procedure.
A 56-year-old woman suffered from pain and paresthesia in both hands for 2 months, especially in the thumb, index and third fingers. The symptoms were more severe in the left hand. Two months prior to a clinic visit, she received a corticosteroid injection into bilateral carpal tunnels, but in vain. On physical examination, both Tinel’s sign and Phalen’s sign were positive. Nerve conduction study (NCS) demonstrated prolonged distal motor and sensory latency of the median nerve bilaterally. Reduction of the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) amplitude occurred in relation to the left median nerve, and reduction of the SNAP amplitude in the right side. A significant decrease in median nerve sensory conduction velocity across the carpal tunnel was also found (Table 1). Electromyography of the abductor pollicis brevis muscle appeared actively denervated. Ultrasonography (US) (Esaote, MyLabFive, linear probe, LA435, 15 MHz) of the left median nerve at the level of the pisiform bones showed an ovoid hypo-echoic structure featuring a hyper-echoic rim with a cross-sectional area of 0.11 cm2 (Fig. 1). Two weeks later, ultrasound-guided perineural injection with PRP into the carpal tunnel was performed. PRP was prepared by taking 10 ml of venous blood, which was then mixed with 2 ml of thrombin and centrifuged in a specially designed tube at 3400
⇑ Corresponding author at: Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Fax: +886 2 28389319. E-mail addresses: [email protected], [email protected] (L.-F. Hsieh). http://dx.doi.org/10.1016/j.jocn.2017.06.053 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053
2
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Table 1 Series of nerve conduction study before and after treatment. Latency (ms) 0 mon
Peak amp (uV) 3 mon
Duration (ms)
Velocity (m/s)
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
3.20 1.40
2.00 3.60
5.40 19.40
10.60 18.60
2.85 1.45
2.30 2.05 36.96
2.45 1.85 46.34
35.20 33.30 55.56
44.60 45.20
53.10 50.00
3.45 1.50
3.10 1.30
8.10 8.80
31.60 18.60
28.00 17.50
2.30 1.65
2.20 2.30 32.73
2.55 2.30 46.15
36.80 43.80 55.56
46.40 46.70
54.80 53.80
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
0 mon
3 mon
6 mon
Motor nerve conduction study L Median-APB Wrist 7.65 3.60 Elbow 11.60 7.75
4.45 9.20
0.40 0.40
3.40 2.70
4.50 4.20
1.60 4.60
22.20 16.90
18.20 16.90
48.10
42.10
43.70
R Median-APB Wrist 7.10 Elbow 11.05
3.50 7.35
4.50 4.70
6.80 6.30
7.00 6.70
16.30 16.70
22.90 23.00
24.00 23.10
45.60
50.70
49.40
Sensory nerve conduction study L Median-Digit 2 Wrist 4.55 3.60 Palm 2.25 1.55 Wrist to palm R Median-Digit 2 Wrist 4.35 Palm 1.60 Wrist to palm Latency (ms) 0 mon
Peak amp (mV)
3.15 6.90
Area (mV * ms)
Velocity (m/s)
R, right; L, left; mon, month; APB, abductor pollicis brevis.
MN Lunate Triquetrum
Triquetrum Lunate
Medial
Lateral
Medial
Lateral
Fig. 1. Ultrasonographic findings of the left median nerve. The ultrasound probe was placed at the level of the pisiform bone to demonstrate the median nerve in the transverse view. The cross-sectional area before the first PRP injection (left) was 0.11 cm2 and 0.06 cm2, 6 months later (right). MN, median nerve.
rotations per minute for 15 min. Then, approximately 5 ml of PRP (2.5 ml buffy coat and 2.5 ml supernatant serum) was administered under ultrasound guidance. The injection procedure was an in-plane approach with technique of hydrodissection, from distal to proximal at the wrist. Pain, paresthesia, and hypesthesia of both hands decreased gradually over 2 weeks. During the period, the patient did not receive other treatment. Follow-up NCS of both median nerves 3 months after the injection revealed significant improvements in the distal motor and sensory latencies as well as SNAP and CMAP amplitudes (Table 1). The SNAP and CMAP amplitudes of the left median nerve were larger than the first examination. The patient received the second PRP injection to her left carpal tunnel 2 weeks later, and the electrophysiological parameters at the third NCS improved significantly. No adverse reactions were observed.
3. Discussion In this patient, considering the severity of symptoms of CTS as reported in the electrophysiological study and poor response to
corticosteroid injections, PRP injection was considered. After the first injection, improvement was observed based on electrophysiology data showing distal latency, conduction velocity, and SNAP and CMAP amplitudes. We compared the electrophysiological study before and after PRP injection which provided us more objective evidence to prove the effectiveness. Although the evidence of PRP use in CTS is still limited, the effect of promoting nerve regeneration had been discussed in peripheral nerve [3]. Two animal studies concluded that PRP may enhance the number of regenerating nerve fibers and improve neuromuscular function [4,5]. Generally, growth factors and proteins are released from platelets’ alpha granules after platelets are activated, leading to improvements in nerve regeneration [3–5]. In this patient, the improvement of the CMAP amplitude was more prominent in the left hand. It is possible that the effect of PRP in more damaged nerves is even more important. In recent years, with ultrasound-guided approach of injection, the needle can get closer to the epineurium of the nerve, thus improving the effect of injection and also avoiding nerve or tendon injury. Also, the ultrasound-guided procedure of percutaneous hydrodissection of the median nerve away from the deep surface
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
of the flexor retinaculum can separate a potential soft tissue adhesion from the nerve [8]. 4. Conclusion If patients with CTS are refractory to conservative treatments, ultrasound-guided PRP injection may be an option. However, we required larger samples, a control group, and long-term followup to validate the efficacy and safety. Acknowledgments The authors would like to acknowledge the financial support provided by the Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
3
References [1] Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. The Cochrane Library 2002. [2] Sevim S, Dogu O, Camdeviren H, et al. Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci 2004;25:48–52. [3] Yu WJ, Wang J, Yin J. Platelet-rich plasma: a promising product for treatment of peripheral nerve regeneration after nerve injury. Int J Neurosci 2011;121:176–80. [4] Elgazzar RF, MutabaganiMA Abdelaal SE, et al. Platelet rich plasma may enhance peripheral nerve regeneration after cyanoacrylate reanastomosis: a controlled blind study on rats. Int J Oral Maxillofac Surg 2008;37:748–55. [5] Cho HH, Jang S, Lee SC, et al. Effect of neural-induced mesenchymal stem cells and platelet-rich plasma on facial nerve regeneration in an acute nerve injury model. Laryngoscope 2010;120:907–13. [6] Anjayani S, Wirohadidjojo YW, Adam AM, et al. Sensory improvement of leprosy peripheral neuropathy in patients treated with perineural injection of plateletrich plasma. Int J Dermatol 2014;53:109–13. [7] Malahias MA, JohnsonEO Babis GC, et al. Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. Neural Regen Res 2015;10:1856. [8] Cass Shane P. Ultrasound-guided nerve hydrodissection: what is it? A review of the literature. Curr Sports Med Rep 2016;15:20–2.
Please cite this article in press as: Kuo Y-C et al. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.06.053