CTS Injection on 2 August 2011 ... Further Update

There is very litle hard evidence relating to multiple injections. Dammers in 2001 reported 76% success after two injections compared to 50% after one whereas Wong 2005 found identical outcomes at 40 weeks after either one or two injections of 15mg methyprednisolone. It is perhaps noteworthy that in the trial by Ly-Pen et al comparing injection with surgery the patients in the injection arm of the trial received two injections 2 weeks apart unless the first one produced complete resolution of symptoms and in that trial the results in the injected patients were particularly good. As a pragmatic approach in the absence of any definitive scientific data I would suggest that one might consider a second injection at the six week follow-up appointment if you yourself feel that any residual symptoms at that point are bad enough to justify it. I think the risk associated with a second injection at that point is so low that there is no real reason not to try it if you wish to. The other option of course is surgery! JB

Hello Dr Bland,

Thank you for your reply. As you do not indicate any great risk with a second injection I think that I would like to go ahead with that at the follow-up appointment with Dr Biggs on the 4th October. Do you contact the Referral Management Centre at Ashford to let Dr Biggs know of the change in the appointment, or do I?

Kind Regards

We have not established a uniform policy with all the injecting GPs to cover this situation so he may be able to carry out a second injection 'on the fly' at the follow-up appointment or he may not. It is an issue which I will take up with the injecting GPs next time we meet and also with the managers of the service who will probably have views on how all this is financed. I know this is a slightly unsatisactory answer but I will let you know if I can come up with a better one in the next week or two. JB

Hello Dr Bland,

Many thanks for your reply. As the appointment with Dr Biggs is not until the 4th October, there is ample time for me to wait for your further suggestion.

Kind regards.

Hello Dr Bland,

It is now two weeks until my 4th October appointment with Dr Biggs, for a check-up relating to the injection on the 2nd August. Since my last e-mail to you, there has been little change in my condition. I continue to be very much improved and suffer only occasional symptoms of Carpal Tunnel. Through this Forum, we have discussed the possible benefits of a second injection and you suggested the possibility of that being given when I see Dr Biggs.
I would like some advice from you on two points:
Considering that the condition is much improved but not "cured", is a second injection either unnecessary at this time or desirable to completely "cure" the Carpal Tunnel (for an admittedly indeterminate length of time)?
If you suggest the second injection, do I contact the Referral Management Team at Ashford or merely ask Dr Biggs at the appointment?

Kind regards.

I would quite like to know the answer to that first question :-). In the Spanish trial comparing injection with surgery(Ly-Pen et al, 2005) they used an unusual injection regime whereby a first injection was given and the patients were reviewed two weeks later and given a second injection if there were any residual symptoms. This approach seemed to give very good results in that trial but another small trial (Wong 2005) found no difference between one injection and two 8 weeks apart. Finally, Dammers (2001) found two injections better than one but I am still trying to obtain a copy of that paper. There are obviously many diferent permutations and we would quite like to run our own trial comparing the Ly-Pen injection regine with a single injection but the hurdle of getting ethics and research governance approval for that is deterring us at present. So the bottom line is that we really have little idea. In your individual case however, a second injection seems to be such a low risk option that you are welcome to try it if you think the residual symptoms are worth it. I am sure Dr Biggs will oblige if you ask him, as long as he has enough supplies to do it. I will discuss the issue again at the meeting of the SIPC GPs in October. JB

Hello Dr Bland,

Many thanks for your reply. As you suggest, I will ask Dr Biggs to give a second injection to me at the 4th October appointment. I will keep you informed of the progress.

Kind regards.

Hello Dr Bland,

I attended my appointment with Dr Biggs today. He asked for a summary of my symptoms since the 2nd August injection. I told him that my condition had very much improved but that I am still having intermittent problems. His advice was to delay a further injection as he did not consider my condition bad enough to justify a second injection. He would prefer to wait a little longer as he does not recommend the second dose so close (two months) to the first unless the condition is worse than mine at the moment. He did suggest that if I felt it necessary, I could make an appointment at any time and he would then administer the second injection.
I will use the splint on the occasions that I have any problems and see how I get on.
Naturally, I will continue to keep you updated through this forum and would be grateful for any advice that you could offer.

Kind regards.

Thanks for the update - we will discuss some of these issues at the annual meeting with the injecting and operating GPs next Tuesday. JB

Hello Dr Bland,

I last sent an e-mail to you in early October, informing you that Dr Biggs had recommended delaying a second injection for a few months. My condition has not changed much in that time, it has perhaps very slightly worsened. It is still necessary to wear the splint at night and even with this, I frequently suffer numbing and tingling. During the day, I occasionally suffer some symptoms, for instance when riding my bicycle.

In January, it will be 12 months since I first had a consultation with you and 6 months since my last. Therefore, it is my intention to visit the hospital soon and try to make an appointment to see you in late January. I would value you advice as to the best way forward. In your opinion, is that an appropriate course of action?

Kind regards.

There is a space in the coming afternoon's clinic if you want to drop in (14:30 on Thursday 29th Dec - someone cancelled today). We may be heading for surgery but it would not hurt to test it again and see exactly what we are dealing with at this point. If you read this early enough you can reply directly on here to say if you are coming along in the afternoon - I will have the website open all morning in the clinic. JB

Hello Dr Bland,

I have just read your e-mail and I would be able to attend at 2.30 today (29th Dec) as you suggest. Is the space still available?

Kind regards.

Sure no problem - see you this afternoon - if you can find time this morning it would be worth completing the online questionnaire here so that I get an updated subjective severity assessment. JB

Hello Dr Bland,

In order to keep you updated, I have an appointment with Dr Biggs for my second injection on the 7th February. I'll keep you informed of my progress and after a couple of weeks, I'll complete a second online questionnare.

Kind regards.

Looks like our waits for injection are creeping up again - was that the best date they could come up with from 29th December or are there other factors producing a delay? JB

Hello Dr Bland,

In answer to your question, I was under the impression that the 7th February was the earliest date that the Referral Management Centre could offer. They were most helpful and quick in coming back to me with that date but did not indicate that any other factors influenced the appointment. Anyway, I'm glad that the appointment is now less than a week away as the symptoms have worsened lately, especially at night and for some time after waking. Many thanks again for your interest.

Kind regards.

P.S.

Since sending my message a few minutes ago, I do recall that one possible reason for the lack of an earlier date was my desire to be treated only by Dr Biggs. As he is my GP and he gave the previous injection, I did prefer to wait for an appointment with him.

Kind regards.