Platelet-rich plasma nerve hydrodissection is a new option for carpal tunnel syndrome.Carpal tunnel syndrome has a long history of many failed attempts to find lasting conservative treatments. It is characterized mainly as compression of the median nerve as it passes through the bony carpal tunnel in the wrist beneath the transverse carpal ligament. It shares the bony canal with finger flexor tendons which create a breeding ground for inflammation. It is thought to be caused by prolonged and excessive wrist flexion such as during typing and driving.
CONVENTIONAL CARPAL TUNNEL SYNDROME TREATMENTS
Treating carpal tunnel syndrome has always been very challenging and frustrating for me. Conventional treatments that I learned included nerve stretching, resting night splints, and numerous sessions of physical therapy. If these did not work I often tried oral medications such as Neurontin or Lyrica. In my experience these interventions are not only time-consuming but have frustratingly poor outcomes. The next step is often a steroid injection into the carpal tunnel. Again, in my experience blind injections have always had limited success as I do not know where I am injecting the medication. With ultrasound guidance I can see the tip of the needle in relation to the median nerve and can direct the medication more precisely but still the results are often short-lived.
THE WORLD OF STEROIDS
Steroid medications work by limiting the blood flow to the area which decreases the inflammatory mediators coming from the circulatory system. This prevents healing over the short term and just masks the symptoms for a later date. Patients usually request a repeat steroid injection when this occurs. Eventually the effectiveness of the cortisone injection wears off and patients tend to get carpal tunnel surgery. The surgery releases the transverse carpal ligament but does little to treat the median nerve. If the surgery is successful then the patient is, of course, happy but do we really need to do surgery in the first place? I have recently started to question the need for surgery at all.
WHAT TO DO?
When longtime patient John Stein saw me with carpal tunnel syndrome I was hesitant to treat him as he has a severe history of peripheral neuropathy. This means that anything that I do will most likely fail. A peripheral neuropathy means that his nerves are damaged to begin with, so if there is compression further down in the hand such as in the carpal tunnel, he is more likely to have really bad symptoms. He described the classic symptoms of median nerve damage. He experienced tingling and numbness in the tips of his thumb, index and middle finger. He also reports difficulty with grip and has difficulty opening jars and door knobs as well as carrying items. He often drops things from his hands. His pain is not bad in the daytime when he is active but at night he has difficulty sleeping because the pain wakes him up. To get relief he has to shake his hand quite vigorously in the middle of the night. He has tried physical therapy and resting wrist splints with no improvement. Oral medications were not helpful as well.
SURGERY WAS NOT HELPFUL SO NOW WHAT?
He decided to have a carpal tunnel release by an expert hand surgeon in the early part of 2013 which was minimally helpful. Of course, this caused him to be very frustrated by his carpal tunnel syndrome. Since then he has had multiple carpal tunnel start injections. Unfortunately he only reports 4 to 6 days improvement after each injection. We had to find an innovative solution for Mr. Stein’s pain as he had exhausted conventional treatment for his carpal tunnel syndrome. Mr. Stein is a wonderful person who has worked hard in the past several years to improve his health so I felt an obligation to go the extra mile to find a solution to his carpal tunnel syndrome. I reviewed the current research on carpal tunnel syndrome as well as talked to physician colleagues. I thought I came across a possible treatment option in the following paper which described a novel treatment option, Anjayani S, Wirohadidjojo YW, Adam AM, Suwandi D, Seweng A, Amiruddin MD.Sensory improvement of leprosy peripheral neuropathy in patients treated with perineural injection of platelet-rich plasma. Int J Dermatol. 2013 Oct 29.
LETS TRY PLATELET-RICH PLASMA NERVE HYDRODISSECTION
After reviewing the pros and cons of the procedure, we decided to try nerve hydrodissection using platelet-rich plasma. I hoped that the growth factors in the platelet rich plasma would provide an ideal solution to begin repairing the damage to the median nerve as it did in the leprosy patients. In late 2013 we proceeded with the nerve hydrodissection using platelet rich plasma. Mr. Stein understood that the results would take 4 to 6 weeks to be known unlike a cortisone injection where the results are usually known within several days. After the injection he said,
“I don’t want to say I’m pain-free but the difference is nothing short of remarkable. I’ll let you know if the trend continues. Thank you!”
A long axis view of the needle using ultrasound guidance as it targets the median nerve
I was very excited to receive an email from the patient 2 months later:
“Hi Andre:
About two months ago you tried PRP therapy in my right hand, and it worked. Almost immediately I noticed my pain was reduced at least 50%, to the point where I could sleep through the night and stop shaking my hand every few minutes. After about one month the pain slowly began returning so I went to the surgeon for a cortisone shot, which brought substantial improvement that’s continued to this day. I still have some discomfort in my middle finger and numbness (no feeling) in the tips of the thumb, index and middle fingers as well. But at least the pain is minimal. Once again, I thank you for your help dealing with my problems.
All my best,
John”
It made my day and reinforced a new approach to treating carpal tunnel syndrome. We will probably repeat the treatment in the future as there is a lot of underlying damage that one injection has very little chance of healing. It is a remarkable start that I hope to continue to build upon. Off to help the next patient.
Andre Panagos M.D.
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