Abstract
Several studies have revealed the risk factors for carpal tunnel syndrome (CTS). However, no studies have evaluated the influence of these risk factors on the selection of treatment modalities for CTS. This study aimed to determine the influence of CTS risk factors on the selection of CTS treatment modalities with a focus on corticosteroid injection (CI) and surgery. We conducted a retrospective cohort study of patients aged ≥20 years with newly diagnosed CTS in the Korean health insurance review and assessment service between 2010 and 2019. We evaluated the demographic information, the existence of CTS risk factors, and the applied treatment modalities for CTS, including CI and operation. The CTS risk factors include age, sex, diabetes mellitus, osteoarthritis of the hand or wrist, rheumatoid arthritis, hypothyroidism, gout, chronic kidney disease (CKD) on dialysis, antiestrogen or aromatase inhibitor medication, and a history of distal radius fracture (DRF). Multivariable logistic regression analyses were conducted. Age over 80 years was the most significantly associated factor for the selection of CI in CTS (odd ratio [OR], 2.149; 95% confidence interval [CI], 2.092 to 2.209; P < .001). Among underlying diseases or medications, CKD on dialysis (OR, 4.001; 95% CI, 3.819–4.193; P < .001) was the most significant associated factor for the selection of operation for CTS, followed by a history of DRF (OR, 1.803; 95% CI, 1.749–1.860; P < .001). Old age was the most significantly related factor for selecting CI. Among underlying diseases or medications, CKD on dialysis and the history of DRF were the most significantly related factors for selecting operative treatment. For these patients, clinicians should proactively consider an operation to reduce the long-term discomfort and economic burdens.
Keywords: carpal tunnel syndrome, chronic kidney disease, corticosteroid injection, distal radius fracture
1. Introduction
Carpal tunnel syndrome (CTS) is the most common peripheral compression neuropathy in the upper extremities. It occurs when the median nerve experiences dysfunction due to elevated carpal tunnel pressure resulting from tenosynovitis of the flexor tendons and anatomical change within the carpal tunnel.[1,2] Despite unclear mechanisms, CTS is common and seems related to tendinopathy; thus, several studies have attempted to identify the risk factors of CTS for early prevention.[3]
Recently, one population-based study revealed that female sex age between 50 and 59 years, rheumatoid arthritis (RA), diabetes mellitus (DM), and estrogen antagonist therapy are the risk factors for hand tendinopathy, including CTS.[1] Another population-based study revealed that female sex, age between 50 and 59 years, high body mass index, RA, and Raynaud syndrome are the risk factors for CTS.[4] However, the relationship between these risk factors and the selection of treatment modalities has not been evaluated in a nationwide population-based study.
Like many other diseases, CTS is often first treated nonoperatively. The conservative treatments include limiting the use of hands, applying a splint or brace, nonsteroidal anti-inflammatory drug medication, and corticosteroid injection (CI).[2,5] However, well-defined criteria for distinguishing between conservative and surgical treatments are lacking. Consequently, many patients experience conservative treatment failure and end up with operative treatment despite a long period of conservative treatment.[6] This treatment strategy leads to excessive economic burden and patient discomfort.[7] Therefore, we thought that understanding the relevant factors in selecting treatment modalities will enable clinicians to choose appropriate early-stage treatment strategies. This study aimed to determine the influence of CTS’s risk factors on the selection of CTS treatment modalities with a focus on CI and surgery. We hypothesized that advanced age and underlying diseases, including chronic kidney disease (CKD) on dialysis, RA, and a history of distal radius fracture (DRF), are significantly associated with the selection of operation for CTS.
2. Methods
2.1. Data source
In Korea, the National Health Insurance Service covers 100% of the population; 97% have health insurance, and 3% have medical aid.[8] All healthcare providers submit claims data for inpatient and outpatient management to the Health Insurance Review and Assessment Service (HIRA) to reimburse medical costs. These include diagnosis codes (classified according to the International Classification of Diseases, 10th revision [ICD-10]), procedure codes, medication codes, and demographic information. HIRA provides some of these national data anonymously to support public policy developments and research activities when requested. This investigation was a retrospective cohort study of patients aged ≥20 years registered as CTS in the HIRA service of Korea between 2009 and 2019. This study was approved to satisfy the conditions for exemption by the Institutional Review Board of Asan Medical Center (No. 2021-0975). The Institutional Review Board also specifically waived the consent requirement, as HIRA provides data anonymously.
2.2. Data collection
The authors used ICD-10 codes to identify patients with CTS (G560). A washout period of more than 1 year was set to ensure the newly diagnosed CTS. Therefore, patients recently diagnosed with CTS between 2010 and 2019 were analyzed. For these patients, all details of inpatient and outpatient management were reviewed between 2009 and 2020.
For the risk factors of CTS, age, sex, DM, osteoarthritis of hand or wrist, RA, hypothyroidism, gout, CKD on dialysis, antiestrogen or aromatase inhibitor medication, and history of DRF, were assessed.[1,4] All risk factors were confirmed with the diagnostic and procedure codes registered before the diagnosis of CTS. For CKD on dialysis and a history of antiestrogen or aromatase inhibitor medication, any participant with a registration within 1 year before the diagnosis of CTS was considered to have those risk factors to reflect the current treatment status.[9] In the case of hypothyroidism, patients prescribed proper medication under the diagnostic code were considered hypothyroidism due to the vague diagnostic criteria of this disease[5,10] (Table 1).
Table 1.
Diagnostic, medication, and procedure codes from the Health Insurance Review and Assessment Service of South Korean for risk factors for carpal tunnel syndrome.
| Risk factors | Codes |
|---|---|
| Diabetes mellitus | E10, E11, E12, E13, and E14 |
| Osteoarthritis of the hand or wrist | M1903, M1904, M1913, M1914, M1923, M1924, M1983, M1984, M1993, and M1994 |
| Rheumatoid arthritis | M05 and M06 |
| Hypothyroidism | Medication codes (1836, 1844, and 2968) under E02, E03, and E89 |
| Gout | M10 |
| Chronic kidney disease on dialysis | Procedure codes (O7020, O9991, O7061, O7062, and O7071–7077) under N18 and N19 |
| Antiestrogen or aromatase inhibitor medication | Medication codes: 2345, 2421, 5689, 1090, 1630, 1822, and 3584 |
| History of distal radius fracture | S525 and S526 |
For the treatment status, patients registered with a prescription of injectable CI (triamcinolone acetonide or dexamethasone) under the diagnostic code of CTS were defined as having CI for CTS. In addition, patients registered with operation codes under the diagnostic code of CTS were defined as having surgery. We identified all operation codes possible for CTS: simple resection or release of the ligament (N0931), complex resection or release of the ligament (N0932), neuroplasty of the major peripheral plexus (S4595), and neuroplasty of the hand (S4596). Since the data were collected until the end of 2020, treatments conducted within a minimum of 1 year of the initial diagnosis were included. Moreover, to avoid overestimating each treatment, we set 5 years as the available period for the initial diagnosis.[11] For patients who underwent several operations under the diagnostic code, only the first event was analyzed since we cannot evaluate the laterality of the involved hand. The flowchart for patient identification and enrollment is described in Figure 1.
Figure 1.
Flowchart of patient identification and enrollment. CTS = carpal tunnel syndrome, ICD-10 = International Classification of Diseases, 10th revision.
2.3. Statistical analysis
All statistical analyses were performed using IBM-SPSS v.22.0 (IBM Corp., Armonk, NY), and a P < .05 was considered significant. We compare the subjects’ characteristics, underlying diseases, treatment, and medication history using a Chi-square test between the patients with CI and patients without CI in CTS. A multivariable logistic regression analysis was conducted to calculate the odds ratio (OR) with a 95% CI for selecting CI as a treatment with the known risk factors of CTS (binary logistic regression, backward elimination method). The same analyses were performed with patients who had an operation.
3. Results
Between 2010 and 2019, 1,449,284 patients were newly diagnosed with CTS. For treating CTS, 401,232 patients (27.7% of 1,449,284 patients) were treated with CI, and 163,089 patients (11.3% of 1,449,284 patients) had an operation.
In multivariable analysis to find the related factors with CI, older age over 30, DM, osteoarthritis of the hand or wrist, RA, CKD on dialysis, gout, and history of DRF were significantly related to performing CI in CTS. Among them, the OR values of the older age over 30 were higher than those of sex, underlying diseases, and medication, and age over 80 years was the most significantly related factor for CI in CTS (OR, 2.149; 95% CI, 2.092–2.209; P < .001) (Table 2).
Table 2.
Bivariate and multivariable logistic regression analysis for the related factors with the selection of corticosteroid injection in patients with carpal tunnel syndrome.
| Variables | Bivariate analysis | Multivariable logistic regression* | ||
|---|---|---|---|---|
| P value | Odd ratio (95% CI) | P value | ||
| Age | 20–29 yr | Ref. | ||
| 30–39 yr | <.001* | 1.293 (1.265–1.321) | <.001* | |
| 40–49 yr | <.001* | 1.693 (1.660–1.727) | <.001* | |
| 50–59 yr | <.001* | 1.940 (1.903–1.978) | <.001* | |
| 60–69 yr | <.001* | 1.869 (1.831–1.907) | <.001* | |
| 70–79 yr | <.001* | 1.961 (1.919–2.004) | <.001* | |
| >80 yr | <.001* | 2.149 (2.092–2.209) | <.001* | |
| Sex | Female | <.001* | 1.128 (1.120–1.137) | <.001* |
| Insurance type | Medical aids | <.001* | 1.007 (0.992–1.022) | .367 |
| Underline disease or medication | OA: hand and wrist | <.001* | 1.235 (1.222–1.247) | <.001* |
| Distal radius fracture | .031* | 0.872 (0.849–0.896) | <.001* | |
| Diabetes mellitus | <.001* | 1.028 (1.019–1.036) | <.001* | |
| Rheumatic arthritis | <.001* | 1.089 (1.076–1.101) | <.001* | |
| Hypothyroidism | .112 | 0.947 (0.892–1.006) | .075 | |
| Gout | <.001* | 1.106 (1.088–1.124) | <.001* | |
| CKD on dialysis | <.001* | 1.183 (1.126–1.244) | <.001* | |
| Antiestrogen and aromatase inhibitor | .388 | 1.024 (0.809–1.296) | .845 | |
CKD chronic kidney disease, CI confidence interval.
The results of multivariable logistic regression analysis were presented only for the variables that were retained in the final model.
*P < .05.
In multivariable analysis to find the related factors with the operation, older age over 30, DM, osteoarthritis of the hand or wrist, RA, hypothyroidism on medication, CKD on dialysis, gout, and history of DRF were significantly related with operating CTS. Among underlying diseases or medications, CKD on dialysis (OR, 4.001; 95% CI, 3.819–4.193; P < .001) was the most significantly related factor of operation for CTS, followed by a history of DRF (OR, 1.803; 95% CI, 1.749–1.860; P < .001) (Table 3).
Table 3.
Bivariate and multivariable logistic regression analysis for the related factors with the selection of operation in patients with carpal tunnel syndrome.
| Variables | Bivariate analysis | Multivariable logistic regression* | ||
|---|---|---|---|---|
| P value | Odd ratio (95% CI) | P value | ||
| Age | 20–29 yr | Ref. | ||
| 30–39 yr | <.001* | 1.792 (1.710–1.878) | <.001* | |
| 40–49 yr | <.001* | 3.244 (3.107–3.388) | <.001* | |
| 50–59 yr | <.001* | 3.899 (3.736–4.069) | <.001* | |
| 60–69 yr | <.001* | 3.316 (3.175–3.464) | <.001* | |
| 70–79 yr | <.001* | 3.507 (3.352–3.669) | <.001* | |
| >80 yr | <.001* | 3.601 (3.416–3.795) | <.001* | |
| Sex | Female | <.001* | 1.498 (1.480–1.517) | <.001* |
| Insurance type | Medical aids | <.001* | 0.955 (0.933–0.977) | <.001* |
| Underline disease or medication | OA: hand and wrist | <.001* | 1.124 (1.107–1.143) | <.001* |
| Distal radius fracture | <.001* | 1.803 (1.749–1.860) | <.001* | |
| Diabetes mellitus | <.001* | 1.204 (1.189–1.218) | <.001* | |
| Rheumatic arthritis | <.001* | 1.159 (1.139–1.179) | <.001* | |
| Hypothyroidism | <.001* | 1.240 (1.151–1.336) | <.001* | |
| Gout | <.001* | 1.090 (1.063–1.117) | <.001* | |
| CKD on dialysis | <.001* | 4.001 (3.819–4.193) | <.001* | |
| Antiestrogen and aromatase inhibitor | 0.343 | 1.096 (0.787–1.526) | .589 | |
The results of multivariable logistic regression analysis were presented only for the variables that were retained in the final model.
*P < .05.
4. Discussion
Among risk factors for CTS, advanced age over 30s, especially age over 80 years, was the most significantly related factor to performing CI in CTS. Demographic characteristics such as age groups older than their 30s and female sex are significantly related to selecting operative treatment for CTS. Moreover, among underlying diseases or medications, CKD requiring dialysis and a history of DRF are substantial risk factors for the operative treatment of CTS.
The theoretical background of CI for treating CTS is controlling the inflammation of teno-synovium around the flexor tendon to decrease the pressure in the carpal tunnel.[12] The proper indication for CI in patients with CTS includes mild symptoms, short symptom duration of <1-year, normal sensibility, normal thenar strength and mass, and minimal changes at electrodiagnostic changes.[13] Among several risk factors for CTS, older age, especially in patients over 80 years, was the most significantly related factor to performing CI in CTS. These results could be explained, at least in part, by the fact that nonoperative treatment was preferred for elderly patients traditionally due to their age and lower demand for using their hands than younger patients.[14] In contrast, the portion of patients who underwent an operation was significantly lower for those in their 20s than in other age groups, and the OR value for the operation was low for those in their 30s compared with other older age groups. In the population of young patients, shorter duration of symptoms and less objective clinical and electrophysiologic evidence are found compared to older patients.[15] The short duration of symptoms and less proven EMG abnormalities often contribute as a positive prognostic factor for spontaneous improvement of symptoms.[16] In addition, the complications of operative treatment, including hand grip weakness and postoperative scar pain after the operation, might cause younger patients to hesitate to undergo operative treatment due to delayed return to work.[17,18]
CTS is a well-known musculoskeletal complication in patients with CKD on dialysis.[19] The known mechanisms of this involvement include the infiltration of dialysis-related amyloidosis to the tendon, synovium, and nerve and soft tissue calcification, which is related to the alterations in the phosphate and calcium metabolisms in CKD patients.[20] Previous studies have reported a higher incidence of operation in CKD on dialysis patients to treat CTS. Tuppin et al[21] reported that the relative risk of CKD on dialysis for the operative treatment of CTS is 3.3.
After experiencing a DRF, patients often report a tingling sensation and numbness in the median nerve territory. CTS symptoms could develop within a few days after the injury due to a significant increase in carpal tunnel pressure resulting from wrist deformity caused by fracture displacement, hematoma formation, and generalized edema. It could be improved after fracture reduction and control of hand swelling, but many patients with severe symptoms require carpal tunnel release.[22] Delayed CTS, with an incidence of 0.5% to 22% after DRF, can present months to years after injury. The etiology includes malunion, chronic tenosynovitis, volar displaced fragments, fibrous tissue, and enlarged volar callus.[23] Even up to 66% of cases of delayed CTS could avoid operation with conservative treatment, but some patients eventually undergo a standard CTR with or without median nerve neurolysis.[24]
The proper treatments for CTS are strongly related to the socioeconomic burden of the medical field due to their high incidences. Most patients are treated conservatively at first, but the failure rate of conservative management is substantial. The failure rate of CIs, one of the most effective forms of conservative management, was up to 67.4% in CTS.[6,25] Therefore, many studies have attempted to determine the most cost-effective tactic combining surgical and traditional modalities. In some studies, surgical treatment as the initial treatment method for CTS is proposed as the most effective treatment guideline when patients are confirmed in a nerve conduction study.[26,27] However, these studies did not consider independent risk factors and thus cannot be generally implemented for patients with specific risk factors. The results of our study could help clinicians choose the treatment modalities appropriately at an early stage and explain the possibility of conservative treatment failure for patients with related factors.
Like any registry study, our research has several limitations. First, the data source is an imperfect registry for identifying all CTS cases accurately. Confirming CTS diagnosis typically requires clinical assessment by specialists; therefore, some patients who have been misdiagnosed with CTS could be included in health insurance claim data. However, CTS data are relatively more reliable than other diseases since considerable cases of CTS were confirmed with electrodiagnostic studies.[5] Second, the time limitations of this study could lead to an underestimation of the incidence of CTS and their surgical treatments. Some CTS symptoms could be aggravated or relapse 5 years after the initial diagnosis. Since the time is limited to 5 years from initial diagnosis, all surgical cases cannot be included. Third, because of the retrospective study design based on a large anonymous registry dataset, we could not address other factors that may potentially influence decisions on CTS treatment modalities, such as socioeconomic level, occupation, patients’ psychological status, and symptom severity.[28] Finally, since our study only calculated the ORs of CTS risk factors about treatment modality, it only shows the association between each treatment modality and CTS risk factors. Therefore, higher ORs of surgical treatment over CI does not mean that early surgical treatment must be done over conservative treatment.
5. Conclusion
Older age was the most significantly related factor to CI in CTS, especially in patients with age over 80 years, reflecting the tendency to avoid operative treatment for old patients. Among the underlying diseases or medications, CKD on dialysis was the most significantly associated factor with the selection of operative treatment in CTS, followed by a history of DRF. Clinicians should consider proactive operative treatment for patients with these CTS risk factors.
Acknowledgments
This study used Health Insurance Review & Assessment Service (HIRA) research data (M20210707359) made by HIRA of the Republic of Korea. The views expressed are those of the author(s) and not necessarily those of the HIRA and the Ministry of Health and Welfare of the Republic of Korea.
Author contributions
Conceptualization: Ye-Jee Kim, Jae Kwang Kim, Jongjin Lee, Young Ho Shin.
Data curation: Ye-Jee Kim, Young Ho Shin.
Formal analysis: Ye-Jee Kim, Young Ho Shin.
Investigation: Chang Hyun Doh, Jongjin Lee.
Methodology: Ye-Jee Kim, Jongjin Lee, Young Ho Shin.
Project administration: Chang Hyun Doh, Jongjin Lee.
Supervision: Jae Kwang Kim.
Validation: Chang Hyun Doh, Jae Kwang Kim, Young Ho Shin.
Writing—original draft: Chang Hyun Doh, Young Ho Shin.
Writing—review & editing: Jae Kwang Kim, Young Ho Shin.
Abbreviations:
- CI
- corticosteroid injection
- CKD
- chronic kidney disease
- CTS
- carpal tunnel syndrome
- DM
- diabetes mellitus
- DRF
- distal radius fracture
- HIRA
- Health Insurance Review and Assessment Service
- RA
- rheumatoid arthritis
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
How to cite this article: Doh CH, Kim Y-J, Kim JK, Lee J, Shin YH. Association of carpal tunnel syndrome risk factors with treatment modality selection focusing on corticosteroid injection and surgery: A nationwide population-based study. Medicine 2024;103:16(e37781).
Contributor Information
Chang Hyun Doh, Email: dorazi941106@gmail.com.
Ye-Jee Kim, Email: orth4535@gmail.com.
Jae Kwang Kim, Email: orth4535@gmail.com.
Jongjin Lee, Email: jjnglee88@gmail.com.
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