PRP for Carpal Tunnel

Dr. John Pitts how and why PRP for Carpal Tunnel Syndrome can help you avoid surgery. 

Hello, everybody, this is Dr. John Pitts at the Centeno-Schultz Clinic, where we lead and invented much of the field of Interventional Orthopedics and Regenerative medicine. Meaning: we treat musculoskeletal or orthopedic problems with injections of your own healing factors to get your body to heal itself, rather than to rely on drugs and surgeries that have lots of risk. So, one of the most common things that we see and treat is carpal tunnel syndrome. And I’d like to talk about that today. What is it? What are the treatment options? And how can we use PRP for Carpal Tunnel to potentially help this problem instead of the traditional  approaches.

So, first, when we talk about carpal tunnel, we’re talking about in the wrist here. So in the wrist, there’s a nerve called the median nerve that goes through this carpal tunnel, as it’s called, that has other tendons and is covered on top by a transverse carpal ligament, a tight band. And at the bottom there are bones, the carpal bones.

And, so when you bend the wrist a lot, work with your hands a lot from various problems, the nerve and that carpal tunnel can get irritated, and when that nerve is getting irritated it gets squished. The blood supply to it can decrease. And so that nerve can get irritated or injured. And so will lose the protective covering around it that helps the nerve to transmit signals, and it can cause some problems. And, so, typically the type of problems that would cause would be numbness and tingling in the hand or fingers. It can happen at night or with activity. When it gets really bad, it can cause not only numbness, but weakness in the hands. And you maybe get even atrophy or decreased  size of the muscles because the nerve is getting damaged. To diagnose this, you can take a good history from a patient and do some exam tests. Here in our clinic, we ultrasound every person that comes in so we can actually look at the nerve directly, and we can look to see if it’s swollen and compare it to the other side – a normal side – and take measurements to see. And there’s also a nerve conduction study where they send electrical signals to the nerve and report that information to see how well the nerve is functioning.

So, if you do have this diagnosis, usually the first step is trying to avoid the positions in the daytime that have the wrist bent and at night time wearing a brace for about six weeks to see if we keep your hand in neutral, to take pressure off that nerve, to see if it can heal up. Whwn it’s very mild, these conservative measures can help, along with maybe some physical therapy or occupational therapy. When those things fail, traditional doctors will inject the area with steroids with the idea of just reducing some of the inflammation around the nerve. We stopped using steroids a long time ago because steroids have many, many drug side effects. It can cause atrophy of the tendons that are close to that nerve as well and so we we don’t recommend that. But that is one non surgical treatment option that sometimes can help. Then when things are really bad, or conservative care is not working, then there’s a surgery where either they cut you open and cut that ligament on the top part of the tunnel or they can use a little scope and cut that ligament to open up some space. And so that can help and, you know, in two thirds to 75% of patients. But surgeries are always bigger risk. So that means a higher risk of nerve injury or nerve damage, risk of infection, risk of causing some more problems, which typically means making the entire wrist more unstable because that ligament is there for a reason. Even now there is a new needle based procedure to cut the transverse carpal ligament but when you cut it, no matter how, it may lead to arthritis in other wrist areas or the CMC (thumb) joint. Dr. Schultz did an excellent recent blog on the CMC joint arthritis and having carpal tunnel surgery can contribute to that. So I encourage you to read that blog, as well. But that can lead into that having this type of surgery.

So what are the other alternatives? Other alternatives would be using platelet rich plasma or PRP. And so PRP can be used and injected around a nerve under ultrasound guidance to put growth factors around a nerve to naturally try to reduce swelling and help with the healing. There are actually many studies that show PRP is effective for carpal tunnel syndrome listed below (1-14). This disproves a common criticism or myth from orthopedic surgeons that there is no evidence for PRP and stem cell treatments. Now, most clinics have a bedside machine that spins your blood down to get the platelets out. But we have an advanced lab here at the Centeno-Schultz Clinic where we can not only just get the blood platelets out, but we can open up those platelets and get the growth factors out. And that’s called platelet lysate. That has advantages; it’s less  inflammatory around a nerve and those growth factors have basic science research that it can help nerve regeneration. And so that’s what we use because that is a safer, easier and more effective around nerves than traditional PRP. But many types of PRP do have evidence that they can help you avoid surgery.

Only when the thumb muscles severely atrophy do you need to go the surgical route. Typically, if we get things while mild to moderate, before it gets too severe, then doing that PRP nerve hydrodissection can really help. We have a nice video that shows how we perform this procedure under ultrasound guidance as well. I also have a good procedure showing how we treat that thumb joint arthritis that can be caused after carpal tunnel surgery and other reasons  as well.

So just to show you what I mean, if we’re in that  Carpal Tunnel, this is our nerve and above it would be the ligament, the Tranverse Carpal ligament that’s cut during surgery, the nerves around that ligament and under it would be the bones. What we would do is; under ultrasound guidance we use a very tiny needle and inject right outside the nerve. It serves two purposes. The fluid itself can help loosen the nerves from the tight tissue around it. And then in that fluid is that platelet lysate or those growth factors from the PRP that help to stimulate the nerve to repair and reduce inflammation. This is opposed to just cutting this ligament out, which then makes the bones around that ligament more unstable. And so that can lead to wrist arthritis, thumb arthritis, and other problems. And again, a big surgery has more risk than a little bitty tiny needle. So our goal here at the Centeno Schultz clinic is to try to treat you before they get severe enough for needing surgery, avoiding drugs like steroid injections, which may help temporarily, but do have some potential long term consequences or don’t help address the underlying issue.

So if you or anyone else you know, has this problem of Carpal Tunnel Syndrome or any other musculoskeletal problem and want to avoid drugs and surgery and get your body to heal itself we’re the experts and leaders in that. So, please give us a call and see if you’re candidate for PRP for Carpal Tunnel or any treatments. You guys take care.

References

1. Raeissadat SA, Karimzadeh A, Hashemi M, Bagherzadeh L. Safety and efficacy of platelet-rich plasma in treatment of carpal tunnel syndrome; a randomized controlled trial. BMC Musculoskelet Disord. 2018 Feb 13;19(1):49. doi: 10.1186/s12891-018-1963-4. PMID: 29433485; PMCID: PMC5810049. https://pubmed.ncbi.nlm.nih.gov/29433485/

2. Senna MK, Shaat RM, Ali AAA. Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome. Clin Rheumatol. 2019 Dec;38(12):3643-3654. doi: 10.1007/s10067-019-04719-7. Epub 2019 Aug 16. PMID: 31420812. https://pubmed.ncbi.nlm.nih.gov/31420812/

3. Güven SC, Özçakar L, Kaymak B, Kara M, Akıncı A. Short-term effectiveness of platelet-rich plasma in carpal tunnel syndrome: A controlled study. J Tissue Eng Regen Med. 2019 May;13(5):709-714. doi: 10.1002/term.2815. Epub 2019 Apr 8. PMID: 30707787. https://pubmed.ncbi.nlm.nih.gov/30707787/

4. Medina-Porqueres I, Martin-Garcia P, Sanz-De Diego S, Reyes-Eldblom M, Cantero-Tellez R. Platelet-rich plasma for thumb carpometacarpal joint osteoarthritis in a professional pianist: case-based review. Rheumatol Int. 2019 Dec;39(12):2167-2175. doi: 10.1007/s00296-019-04454-x. Epub 2019 Oct 14. PMID: 31608418. https://pubmed.ncbi.nlm.nih.gov/31608418/

5. Kuo YC, Lee CC, Hsieh LF. Ultrasound-guided perineural injection with platelet-rich plasma improved the neurophysiological parameters of carpal tunnel syndrome: A case report. J Clin Neurosci. 2017 Oct;44:234-236. doi: 10.1016/j.jocn.2017.06.053. Epub 2017 Jul 5. PMID: 28688621. https://pubmed.ncbi.nlm.nih.gov/28688621/

6. Malahias MA, Chytas D, Mavrogenis AF, Nikolaou VS, Johnson EO, Babis GC. Platelet-rich plasma injections for carpal tunnel syndrome: a systematic and comprehensive review. Eur J Orthop Surg Traumatol. 2019 Jan;29(1):1-8. doi: 10.1007/s00590-018-2278-8. Epub 2018 Jul 18. PMID: 30022241. https://pubmed.ncbi.nlm.nih.gov/30022241/

7. Catapano M, Catapano J, Borschel G, Alavinia SM, Robinson LR, Mittal N. Effectiveness of Platelet-Rich Plasma Injections for Nonsurgical Management of Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arch Phys Med Rehabil. 2020 May;101(5):897-906. doi: 10.1016/j.apmr.2019.10.193. Epub 2019 Dec 7. PMID: 31821797. https://pubmed.ncbi.nlm.nih.gov/31821797/

8. Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Huang GS, Chen LC. Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep. 2017 Dec;7(1):94. doi: 10.1038/s41598-017-00224-6. Epub 2017 Mar 7. PMID: 28273894; PMCID: PMC5427966. https://pubmed.ncbi.nlm.nih.gov/28273894/

9. Shen YP, Li TY, Chou YC, Ho TY, Ke MJ, Chen LC, Wu YT. Comparison of perineural platelet-rich plasma and dextrose injections for moderate carpal tunnel syndrome: A prospective randomized, single-blind, head-to-head comparative trial. J Tissue Eng Regen Med. 2019 Nov;13(11):2009-2017. doi: 10.1002/term.2950. Epub 2019 Aug 20. PMID: 31368191. https://pubmed.ncbi.nlm.nih.gov/31368191/

10. Lin CP, Chang KV, Huang YK, Wu WT, Özçakar L. Regenerative Injections Including 5% Dextrose and Platelet-Rich Plasma for the Treatment of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-Analysis. Pharmaceuticals (Basel). 2020 Mar 18;13(3):49. doi: 10.3390/ph13030049. PMID: 32197544; PMCID: PMC7151714. https://pubmed.ncbi.nlm.nih.gov/32197544/

11. Trull-Ahuir C, Sala D, Chismol-Abad J, Vila-Caballer M, Lisón JF. Efficacy of platelet-rich plasma as an adjuvant to surgical carpal ligament release: a prospective, randomized controlled clinical trial. Sci Rep. 2020 Feb 7;10(1):2085. doi: 10.1038/s41598-020-59113-0. PMID: 32034241; PMCID: PMC7005701. https://pubmed.ncbi.nlm.nih.gov/32034241/

12. Chang CY, Chen LC, Chou YC, Li TY, Ho TY, Wu YT. The Effectiveness of Platelet-Rich Plasma and Radial Extracorporeal Shock Wave Compared with Platelet-Rich Plasma in the Treatment of Moderate Carpal Tunnel Syndrome. Pain Med. 2020 Aug 1;21(8):1668-1675. doi: 10.1093/pm/pnz309. PMID: 31774510. https://pubmed.ncbi.nlm.nih.gov/31774510/

13. Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet-rich plasma ultrasound-guided injection in the treatment of carpal tunnel syndrome: A placebo-controlled clinical study. J Tissue Eng Regen Med. 2018 Mar;12(3):e1480-e1488. doi: 10.1002/term.2566. Epub 2017 Dec 17. PMID: 28873284. https://pubmed.ncbi.nlm.nih.gov/28873284/

14. Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet-rich plasma ultrasound-guided injection in the treatment of carpal tunnel syndrome: A placebo-controlled clinical study. J Tissue Eng Regen Med. 2018 Mar;12(3):e1480-e1488. doi: 10.1002/term.2566. Epub 2017 Dec 17. PMID: 28873284. https://pubmed.ncbi.nlm.nih.gov/28873284/