VIDEO GALLERY

Ultrasound-Guided Injection for the

Treatment of Carpal Tunnel Syndrome
Jia-Pei Hong, MD, Henry L. Lew, MD, PhD,
Chih-Hong Lee, MD, and Simon F.T. Tang, MD
From the Departments of Physical Medicine & Rehabilitation (J-PH,
SFTT) and Neurology (C-HL), Chang Gung Memorial Hospital and
Chang Gung University, Tao-Yuan County, Taiwan; Defense and
Veterans Brain Injury Center, Richmond, Virginia (HLL);
Department of Physical Medicine and Rehabilitation, Virginia
Commonwealth University, Richmond, Virginia (HLL); and John A.
Burns School of Medicine, University of Hawaii at Manoa, Honolulu,
Hawaii (HLL).
Financial disclosure statements have been obtained, and no
conflicts of interest have been reported by the authors or by any
individuals in control of the content of this article.
0894-9115/15/0000-0000
American Journal of Physical Medicine & Rehabilitation
Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/PHM.0000000000000367

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arpal tunnel syndrome (CTS) accounts for approximately 90% of all entrapment neuropathies.1 Among the
conservative treatments, several studies supported the
effectiveness of local corticosteroid injection for CTS and
actually demonstrated superior benets compared with
other interventions.2Y4 Steroid injection into the wrist can
produce short-term complete or signicant relief of symptoms in 22%Y81% of patients,5Y8 but the major complication of steroid injection is iatrogenic injury to the median
nerve, which manifests as shooting pain at the injection time,
chronic disabling paresthesia, motor weakness, and muscle
atrophy after injection.9,10 Habib et al.11 have reported the
novel blinded approach to the carpal tunnel, which injected
from 2 to 3 cm distal to the middle of wrist crease. These
authors demonstrated an ultrasound-guided technique in

All correspondence and requests for reprints should be addressed to: Simon F.T.
Tang, MD, Department of Physical Medicine & Rehabilitation, Chang Gung Memorial
Hospital, 5 Fu-Hsing St, Kuei Shan Hsiang, Taoyuan Hsien, Taiwan.

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treating CTS to avoid damaging the median nerve and

adjacent soft tissue. Because the median nerve goes deeper
at the distal hamate level, this distal approach may provide
a larger space for initial needle insertion. Under long-axial
view, the whole stretch of median nerve can be visualized
when the needle progresses proximally.
To demonstrate the carpal tunnel, the patient is seated
in a comfortable position with the hands supported by
rolled-up towels to keep a position of slight wrist extension
and forearm supination. The median nerve is examined at
the level of the pisiform bone. The pisiform is a superficial
bony prominence, located at the ulnar side of the wrist_s
carpal base. It attaches to the flexor carpi ulnaris tendon.
Opposite to the pisiform bone is the scaphoid, which is
attached to the flexor carpi radialis tendon. The transducer
is placed transversely between the pisiform and the scaphoid
bone to obtain an image of the carpal tunnel.
After the transducer is placed at the pisiform level, a
transverse view of the carpal tunnel can be observed. The pisiform appears as a prominent rounded hyperechoic structure.
The ulnar nerve and artery lie just radial to the pisiform. The
hyperechoic flexor retinaculum stretches across the pisiform
and scaphoid bone. The median nerve lies just below the flexor
retinaculum (Fig. 1). Then, the ultrasound probe is rotated
90 degrees to the long-axial view. The median nerve is an
echogenic fibrillar echotexture and runs deeper from the skin
at the distal side than the proximal side (Fig. 2). The flexor
tendons lie below the median nerve. The authors recommend
that 23-gauge needles are feasible to reduce the injection pain.
Under the long-axial view, sonographic-assisted injection of
betamethasone (as dipropionate) 5 mg/mL is performed and
the needle can be accurately guided toward the median nerve
under direct real-time visualization without traumatizing the
nerve and other nearby vessels.
Blinded local steroid injection of the median nerve
using a distal approach for treatment of CTS has been
previously reported.11 The rates of favorable response and

FIGURE 1 Transverse sonographic view of the carpal tunnel at

pisiform level showing that the hypoechoic oval
median nerve lies under the hyperechoic flexor
retinaculum (shown with arrowheads). The ulnar
nerve and artery are located above the flexor retinaculum and radial to the pisiform bone.

Ultrasound-Guided Injection for Carpal Tunnel

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

2. Piazzini DB, Aprile I, Ferrara PE, et al: A systematic review

of conservative treatment of carpal tunnel syndrome. Clin
Rehabil 2007;21:299Y314
3. Ayhan-Ardic FF, Erdem HR: Long-term clinical and electrophysiological results of local steroid injection in patients with
carpal tunnel syndrome. Funct Neurol 2000;15:157Y65
4. Dammers JW, Veering MM, Vermeulen M: Injection with
methylprednisolone proximal to the carpal tunnel: Randomised
double blind trial. BMJ 1999;319:884Y6
5. McGrath MH: Local steroid therapy in the hand. J Hand Surg
Am 1984;9:915Y21
6. Gelberman RH, Aronson D, Weisman MH: Carpal-tunnel
syndrome. Results of a prospective trial of steroid injection and
splinting. J Bone Joint Surg Am 1980;62:1181Y4

FIGURE 2 Sonographic longitudinal view of the median

nerve showing that the median nerve runs deeper
at the distal carpal tunnel, which may provide
more space for needle insertion.

improvement of electrophysiologic results using a distal approach were similar to the results obtained using the classic
approach.12 The current video demonstrated using this technique as a real-time image. It may provide a safe and more
accurate technique for treatment of CTS. More research needs
to be done to prove the above assumption.
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Hong et al.

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Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2015

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.