By Chris Faubel, MD —
- Carpal Tunnel Syndrome
- ICD-9 code: 354.0 “carpal tunnel syndrome”
- ICD-10 code: G56.0 “carpal tunnel syndrome”
CPT code: 20526
- Pen – clicking type
- Gloves – non-sterile
- Alcohol swabs or iodine
- Tuberculin needle/syringe
- 1-ml of 40mg/ml Depo-Medrol or Kenalog
Technique / Procedure Steps
- Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
- Mark the injection site with the pen tip in order to leave an impression in the skin — see injection site below in the tips section.
- Clean the skin thoroughly with as many alcohol swabs as needed (usually only one is needed).
- Patient position: Perform lying supine with arm externally rotated and the elbow extended, OR, seated with elbow flexed to 90 and hand supinated.
- With the tuberculin needle/syringe, enter the skin going perpendicular to the skin. Use all of the 1/2″ needle length.
- Aspirate to make sure you’re not in any vessel.
- After negative aspiration, inject the full contents of the syringe. If resistance is felt while injecting, pull back 1-2mm until injectate flows easily.
- Withdraw the needle and apply band-aid.
- Finding the injection site
- With the hand supinated and the fingers together, come straight down (proximal) along the 4th digit to a point 1.5-2cm distal to the wrist crease.
- Note: May want to first perform the Allen’s test to ensure patient has good collateral circulation in the hand.
- Numbing the skin
- Find out all about “Taking the Sting Out” (of injections) by going here.
- Since I use a tiny tuberculin needle, most patients have no problem with the injection and don’t need any extra lidocaine skin wheal or freezing spray.
- I tell them numbing the skin with lidocaine will probably hurt more than the actual injection.
- Procedure for a “pain free” injection
- Fill a 27G 1/2″ tuberculin syringe with 0.5ml of 1% lidocaine.
- Use ethyl chloride spray to “numb” the skin over the injection site; then quickly create the skin wheal of lidocaine.
- Insert the tip of the needle just below the surface of the skin, almost at a parallel angle. Then inject about 1/4-1/2ml to create the skin wheal.
- Do NOT create a deep lidocaine track with the needle, as you may likely enter the carpal tunnel and anesthetize the median nerve; then the patient won’t be able to tell you if your needle (during the steroid injection) inadvertently pierces the median nerve.
- After the injection
- Explain to the patient that the steroids may not start kicking in until anywhere from 1-7 days.
- Tell the patient to continue using their wrist splints each night.