손목통증 (드퀘르벵 건초염) 쉽게 치료하는 법목통증 (드퀘르벵 건초염) 쉽게 치료하는 법

[문형철]

https://www.youtube.com/watch?v=Hhl5vn-M3QI

Key Points

Question  What treatment modalities for de Quervain tenosynovitis are associated with better outcomes compared with other treatments?

Findings  This systematic review and network meta-analysis of 30 studies with 1663 patients found that adding thumb spica immobilization to a local corticosteroid injection was associated with significant pain-relieving and functional benefits. Administering the corticosteroid injection using ultrasonographic guidance was associated with greater pain reduction than conventional injections.

Meaning  These findings suggest that patients with de Quervain tenosynovitis should receive a local corticosteroid injection with thumb spica immobilization for 3 to 4 weeks as first-line treatment.

요점질문

드 쿠르뱅 건초염의 어떤 치료 방식이 다른 치료법에 비해 더 나은 결과와 관련이 있나요?

결과

1663명의 환자를 대상으로 한 30개의 연구를 체계적으로 검토하고 네트워크 메타분석한 결과, 국소 코르티코스테로이드 주사에 엄지 스피카 고정술을 추가하는 것이 상당한 통증 완화 및 기능적 이점과 관련이 있는 것으로 나타났습니다. 초음파 유도 하에 코르티코스테로이드 주사를 투여하는 것이 기존 주사보다 통증 감소 효과가 더 큰 것으로 나타났습니다.

의미

이러한 연구 결과는

드 쿠르뱅 건초염 환자는

1차 치료로 3~4주 동안

엄지손가락 도구 고정과 함께

국소 코르티코스테로이드 주사를 맞아야 함을 시사합니다.

Abstract

Importance  There is a plethora of treatment options for patients with de Quervain tenosynovitis (DQT), but there are limited data on their effectiveness and no definitive management guidelines.

Objective  To assess and compare the effectiveness associated with available treatment options for DQT to guide musculoskeletal practitioners and inform guidelines.

Data Sources  Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org were searched for published studies, and the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, The European Union Clinical Trials Register, and the ISRCTN registry were searched for unpublished and ongoing studies from inception to August 2022.

Study Selection  All randomized clinical trials assessing the effectiveness of any intervention for the management of DQT.

Data Extraction and Synthesis  This study was prospectively registered on PROSPERO and conducted and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) guidance. The Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Eval‎uations tool were used for risk of bias and certainty of evidence assessment for each outcome.

Main Outcomes and Measures  Pairwise and network meta-analyses were performed for patient-reported pain using a visual analogue scale (VAS) and for function using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale. Mean differences (MD) with their 95% CIs were calculated for the pairwise meta-analyses.

Results  A total of 30 studies with 1663 patients (mean [SD] age, 46 [7] years; 80% female) were included, of which 19 studies were included in quantitative analyses. From the pairwise meta-analyses, based on evidence of moderate certainty, adding thumb spica immobilization for 3 to 4 weeks to a corticosteroid injection (CSI) was associated with statistically but not clinically significant functional benefits in the short-term (MD, 10.5 [95% CI, 6.8-14.1] points) and mid-term (MD, 9.4 [95% CI, 7.0-11.9] points). In the network meta-analysis, interventions that included ultrasonography-guided CSI ranked at the top for pain. CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function.

Conclusions and Relevance  This network meta-analysis found that adding a short period of thumb spica immobilization to CSI was associated with statistically but not clinically significant short- and mid-term benefits. These findings suggest that administration of CSI followed by 3 to 4 weeks immobilization should be considered as a first-line treatment for patients with DQT.

중요성

드 쿠르뱅 건초염(DQT) 환자를 위한 치료 옵션은 많지만

그 효과에 대한 데이터는 제한적이며 확실한 관리 지침은 없습니다.

목적

근골격계 전문의에게 지침을 제공하고

가이드라인을 알리기 위해 DQT에 대해

사용 가능한 치료 옵션과 관련된 효과를 평가하고 비교합니다.

데이터 출처

Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, WorldCat.org에서 발표된 연구를 검색하고, 세계보건기구 국제 임상시험 레지스트리 플랫폼, ClinicalTrials.gov, 유럽 연합 임상시험 등록, ISRCTN 레지스트리에서 시작부터 2022년 8월까지 미발표 및 진행 중인 연구를 검색했습니다.

연구 선정 DQT 관리를 위한 개입의 효과를 평가하는 모든 무작위 임상시험.

데이터 추출 및 종합 이 연구는 PROSPERO에 전향적으로 등록되었으며, 체계적 문헌고찰 우선 보고 항목 및 보건의료 개입의 네트워크 메타분석을 통합한 체계적 문헌고찰 보고를 위한 메타분석 확장 진술(PRISMA-NMA) 및 운동, 재활, 스포츠 의학 및 스포츠 과학의 PRISMA(PERSIST) 지침에 따라 수행 및 보고되었습니다. 각 결과에 대한 편향성 위험과 근거 평가의 확실성을 평가하기 위해 코크란 편향성 위험 도구와 권고, 평가, 개발 및 평가 등급 도구가 사용되었습니다.

주요 결과 및 측정값 환자가 보고한 통증에 대해서는 시각적 아날로그 척도(VAS)를, 팔, 어깨, 손의 빠른 장애(Q-DASH) 척도를 사용하여 기능에 대해서는 쌍방향 및 네트워크 메타분석을 수행했습니다. 쌍별 메타 분석에서는 95% CI와 함께 평균 차이(MD)를 계산했습니다.

결과

1663명의 환자를 대상으로 한

총 30개의 연구(평균 [SD] 연령, 46[7]세, 여성 80%)가 포함되었으며,

이 중 19개의 연구가 정량적 분석에 포함되었습니다.

중간 정도의 확실성을 가진 증거를 기반으로 한 쌍별 메타 분석 결과,

코르티코스테로이드 주사(CSI)에

3~4주 동안 엄지 손가락 스피카 고정술을 추가하면

단기(MD, 10.5 [95% CI, 6.8-14.1] 점)와 중기(MD, 9.4 [95% CI, 7.0-11.9] 점)에

통계적으로 유의하지는 않지만 임상적으로 유의한 기능적 이점이 있는 것으로 나타났습니다.

네트워크 메타 분석에서는

초음파 유도 CSI를 포함한 중재가

통증에 대해 가장 높은 순위를 차지했습니다.

엄지 척골 고정술을 포함한 CSI는

단기 및 중기 기능에

가장 효과적인 중재일 확률이 가장 높았습니다.

결론 및 관련성

이 네트워크 메타 분석에 따르면

엄지 척골 고정술을 CSI에 단기간 추가하는 것이 통

계적으로는 단기 및 중기적 이점과 관련이 있지만

임상적으로 유의미하지는 않은 것으로 나타났습니다.

이러한 결과는 DQT 환자의 일차 치료로 CSI를 시행한 후 3~4주 동안 고정하는 것을 고려해야 함을 시사합니다.

Introduction

De Quervain tenosynovitis (DQT) is a stenosing overuse condition of the synovial sheath of the first extensor compartment of the wrist affecting the extensor pollicis brevis (EPB) and abductor pollicis longus tendons.1 The exact pathophysiology of DQT is unknown, but it appears to be related to thickening of the tendon sheath and the overlying extensor retinaculum, as well as thinning and degeneration of the affected tendons.2 Involvement of inflammation remains controversial but intrinsic degeneration due to overuse appears to be the most likely mechanism.3 Possible associations have been made between a separate, septated EPB subcompartment and DQT; however, increasing evidence suggests that this is probably a normal anatomical variant.4 DQT manifests with pain and tenderness over and proximal to the radial styloid, and while its diagnosis is predominantly clinical, imaging modalities, such as ultrasonography and magnetic resonance imaging, can be useful where there is diagnostic uncertainty.1

Definitive guidelines for the management of DQT do not exist. In the published consensus statement from the European HANDGUIDE study,1 all experts who participated agreed that all patients with DQT should be given instructions about activity, function, and pain and these should be accompanied by 1 or more of the following interventions: nonsteroidal anti-inflammatory drugs (NSAIDs), splinting, corticosteroid injection (CSI), and surgery.1 The intervention should be chosen based on severity, duration of DQT, and previous treatments given. Consensus was reached on a therapeutic hierarchy, which starts with instructions plus NSAIDs and finishes with surgery.1

An increasing number of treatment options for DQT is becoming available, such as hyaluronic acid injections, extracorporeal shockwave therapy, acupuncture, ultrasonographic therapy, and laser therapy, all with limited evidence on their effectiveness. Therefore, management decisions can be challenging, given the several available treatment modalities and their possible combinations. Our aim was to present the highest quality of evidence on the comparative effectiveness associated with available interventions for DQT to facilitate clinical practice decisions and contribute to future guidelines.

드퀘르뱅 건초염(DQT)은

손목의 첫 번째 신전근 구획의 활액막에

협착이 생기는 과사용 상태로

신전근(EPB)과 외전근(납치근)에 영향을 미칩니다.1

extensor pollicis brevis (EPB) and

abductor pollicis longus tendons.

DQT의 정확한 병태생리는 알려져 있지 않지만

힘줄 피복과 그 위에 있는 신전근 망막의 비후,

영향을 받는 힘줄의 얇아짐 및 퇴화와 관련이 있는 것으로 보입니다.2

염증의 관여는 아직 논란이 있지만

과도한 사용으로 인한 내재적 퇴화가

가장 유력한 메커니즘으로 보입니다.3

별도의 분리된 EPB 소구획과 DQT 사이에 연관성이 있을 수 있지만, 이것이 정상적인 해부학적 변형일 가능성이 높다는 증거가 증가하고 있습니다.4 DQT는 요골 스타일로이드 위와 근위부에 통증과 압통이 나타나며, 진단은 주로 임상적이지만 진단이 불확실한 경우 초음파 및 자기공명영상과 같은 영상 촬영 방식이 유용할 수 있습니다.1

DQT 관리에 대한

명확한 가이드라인은 존재하지 않습니다.

유럽 HANDGUIDE 연구에서 발표된 합의성명서에서1 참여한 모든 전문가들은 모든 DQT 환자에게 활동, 기능 및 통증에 대한 지침을 제공해야 하며 비스테로이드성 항염증제(NSAID), 부목, 코르티코스테로이드 주사(CSI) 및 수술 중 하나 이상의 개입이 동반되어야 한다는 데 동의했습니다.1 개입은 DQT의 중증도, 기간 및 이전에 받은 치료를 기반으로 선택해야 합니다. 치료 계층 구조에 대한 합의가 이루어졌는데, 이는 지침과 NSAID로 시작하여 수술로 마무리됩니다.1

히알루론산 주사,

체외충격파 치료,

침술,

초음파 치료,

레이저 치료 등 DQT에 대한 치료 옵션이 점점 더 많아지고 있지만

그 효과에 대한 증거는 제한적입니다.

따라서 사용 가능한 여러 치료 방법과 가능한 조합을 고려할 때 관리 결정이 어려울 수 있습니다. 우리의 목표는 임상 진료 결정을 용이하게 하고 향후 가이드라인에 기여하기 위해 DQT에 사용할 수 있는 중재와 관련된 비교 효과에 대한 최고 품질의 증거를 제시하는 것이었습니다.

Methods

This systematic review and network meta-analysis was registered on PROSPERO (registration No. CRD42022346986). This study is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) reporting guidelines. Outcomes of interest were patient-reported pain, assessed using a visual analogue scale (VAS; range, 0-10; higher score indicates worse pain),5 and function, assessed using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale (range, 0-80; higher score indicates worse function).6

We searched Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org for published studies, and we searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, European Union Clinical Trials Register, and ISRCTN registry for unpublished and ongoing studies from inception to August 2022 (Figure 1). The Cochrane Risk of Bias (ROB) tool7 and the Grading of Recommendations, Assessment, Development, and Eval‎uations (GRADE) tool8 were used for risk of bias and certainty of evidence assessment for each outcome. Complete details on eligibility criteria, the literature search, data extraction, data handling, protocol deviations, and risk of bias and strength of evidence assessments are provided in the eMethods in Supplement 1.

Statistical Analysis

The Review Manager software version 5 (RevMan) was used to calculate pooled mean differences (MDs) with 95% CIs and generate forest plots for pairwise meta-analyses and their accompanying heterogeneity tests (χ2 and I2) and P values. Stata software version 16.1 (StataCorp) with multivariate random-effects meta-regression was used for network meta-analyses. Statistical significance was set at 2-sided P < .05. Data were analyzed from August 2022 to June 2023.

Results

A total of 37 studies9-45 were initially found to be eligible. Of those, 7 studies9-15 did not include 1 of our predefined outcome measures or included patients with conditions other than DQT and did not analyze data separately and were therefore excluded (Figure 1). A total of 30 studies17-46 with 1663 patients (mean age [SD] age, 46 [7] years; 80% female) were included in further data collection. eTable 1 in Supplement 1 summarizes the patient, intervention, comparator, and outcome characteristics and the individual findings of these studies for pain and function, as well as the results of our pairwise meta-analyses where pooling of studies was possible. There was a total of 25 treatment comparisons. Study publication year ranged from 2009 to 2022. eTable 2 in Supplement 1 shows the risk of bias assessment results of the ROB assessment. Of 19 studies16-19,21,24-27,29,35-39,41-43,45 that participated in quantitative analyses (pairwise or network meta-analyses), 1 study was of low ROB and 8 studies were of high overall ROB, while the remaining 10 studies were rated as having some concerns (eTable 2 in Supplement 1).

결과

처음에 총 37개의 연구9-45가 적격하다고 판단되었습니다. 이 중 7개의 연구9-15는 사전 정의된 결과 측정 항목 중 하나를 포함하지 않았거나 DQT 이외의 질환을 가진 환자를 포함했으며 데이터를 별도로 분석하지 않았으므로 제외되었습니다(그림 1). 추가 데이터 수집에는 총 30건의 연구17-46, 1663명의 환자(평균 연령[SD] 46[7]세, 여성 80%)가 포함되었습니다. 부록 1의 e표 1에는 환자, 중재, 비교군, 결과 특성, 통증 및 기능에 대한 이들 연구의 개별 결과와 연구 풀링이 가능했던 쌍별 메타분석 결과가 요약되어 있습니다. 총 25개의 치료법이 비교되었습니다. 연구 발표 연도는 2009년부터 2022년까지입니다. 부록 1의 e표 2는 ROB 평가의 비뚤림 위험 평가 결과를 보여줍니다. 정량적 분석(쌍별 또는 네트워크 메타분석)에 참여한 19개 연구16-19,21,24-27,29,35-39,41-43,45 중 1개 연구는 ROB가 낮았고 8개 연구는 전체 ROB가 높았으며 나머지 10개 연구는 일부 우려가 있는 것으로 평가되었습니다( 보충자료 1의 eTable 2 ).

Pairwise Meta-Analyses

Figure 2 illustrates the results of the pairwise meta-analyses of comparisons that were based on either moderate or high certainty of evidence, with their forest plots and accompanying statistical heterogeneity tests. eFigures 2 through 7 in Supplement 1 show the forest plots of the pairwise meta-analyses of comparisons that were based on low or very low certainty of evidence. eTable 3 in Supplement 1 summarizes the certainty of evidence assessment process for all pairwise meta-analyses. Information on complications is provided in the eAppendix in Supplement 1.

CSI Plus Thumb Spica Immobilization vs CSI Alone

Among 4 studies25,35,37,42 in this meta-analysis; 1 was of high overall ROB and 3 were of some concerns of ROB. Postinjection immobilization was for either 3 weeks25,35 or 4 weeks,37,42 in a cast,25,37 a splint,42 or either.35 For both short-term and mid-term pain, the group that included immobilization was associated with statistically but not clinically significant improvements in VAS scores (short-term MD, 1.3 [95% CI, 0.4-2.1] points; I2 = 86%; 3 studies25,35,37; 207 participants; very low certainty of evidence; mid-term MD, 1.2 [95% CI, 0.3-2.2] points; I2 = 93%; 4 studies25,35,37,42; 289 participants; very low certainty of evidence). The benefits of adding immobilization to CSI were also evident for short-term and mid-term function based on Q-DASH scores, and this was also statistically but not clinically significant (short-term MD, 10.5 [95% CI, 6.8-14.1] points; I2 = 0%; 3 studies25,35,37; 207 participants; moderate certainty of evidence; mid-term MD, 9.4 [95% CI, 7.0, 11.9] points; I2 = 0%; 4 studies25,35,37,42; 289 participants; moderate certainty of evidence).

Ultrasonography-Guided CSI vs Conventional CSI

Two studies21,38 with some concerns in their overall ROB assessments were pooled for the comparison of ultrasonography-guided vs conventional CSI. For short-term pain VAS scores, although the pooled outcome favored the ultrasonography-guided group at clinical significance, this was not statistically significant due to a very wide CI (MD, 2.1 [95% CI, −0.5 to 4.6] points; I2 = 91%; 2 studies21,38; 92 participants; very low certainty of evidence).

Open Surgery With Transverse Incision vs Longitudinal Incision

Two studies19,26 of overall high ROB were pooled for the comparison of transverse vs longitudinal incision for open surgery. Despite the large ORs for total complications (OR, 6.8 [95% CI, 0.9 to 48.1]; I2 = 64%; 2 studies19,26; very low certainty of evidence) and superficial radial nerve injury (OR, 7.7 [95% CI, 0.9, 64.0]; I2 = 0%; 2 studies19,26; very low certainty of evidence) in favor of longitudinal incisions, these did not reach statistical significance due to very wide CIs. The incidence of hypertrophic scar was similar between incision types (OR 2.0 [95% CI, 0.4-10.8]; I2 = 47%; 2 studies19,26; very low certainty of evidence).

Network Meta-Analyses

A total of 17 studies16-18,21,24,25,27,29,35-39,41-43,45 were included in network meta-analyses, which were performed separately for short-term pain (15 studies16-18,21,24,25,27,29,35-39,41,43,45; 14 interventions), mid-term pain (9 studies17,18,25,27,35,37,41-43; 7 interventions), short-term function (8 studies24,25,27,35-37,41,43; 7 interventions), and mid-term function (6 studies25,27,35,37,41,42; 3 interventions). eFigures 17 through 20 in Supplement 1 show the comparative treatment class effects for short-term pain, mid-term pain, short-term function, and mid-term function. eTables 4 through 7 in Supplement 1 represent the summary of findings of the network meta-analyses, comparing all included interventions with the reference comparator (conventional CSI) for each outcome at each follow up time period.

Short-Term Pain

For pain at 0 to 12 weeks, the most effective interventions were ultrasonography-guided CSI in EPB compartment only (where there is subcompartmentalization), ultrasonography-guided CSI injection plus delayed injection of hyaluronic acid, ultrasonography-guided CSI injection plus delayed injection of normal saline, neural therapy (local anesthetic therapy directed at the autonomic nervous system) plus thumb spica splint, and extracorporeal shockwave therapy plus thumb spica splint. Of these, ultrasonography-guided CSI in EPB compartment only (where there is subcompartmentalization) had the highest probability (22%) of being the most effective. Placebo injection (normal saline) had the highest probability of being the least effective, followed by as-decided thumb spica splint wear and full-time thumb spica splint wear. Figure 3 details the network map, the network forest plots, and the rank bar graphs for short-term pain.

From the combined direct and indirect comparisons neural therapy plus thumb spica splint, extracorporeal shockwave therapy plus thumb spica splint, and ultrasonography-guided CSI were each found to be clinically and statistically significantly superior to thumb spica splint alone. Additionally, ultrasonography-guided CSI was superior to conventional CSI, and conventional CSI with or without thumb spica, ultrasonography-guided CSI with or without delayed injection of normal saline or hyaluronic acid, neural therapy plus thumb spica splint, ultrasonography-guided CSI in EPB compartment only or in both compartments (where there is subcompartmentalization), and ultrasonography-guided CSI were each superior to placebo saline injection alone (eFigure 17 in Supplement 1).

Mid-Term Pain

Neural therapy plus thumb spica splint ranked at the top as having the highest probability of being the most effective intervention for pain at 13 to 52 weeks, followed by conventional CSI plus thumb spica immobilization. Thumb spica splint and thumb spica cast had the highest probabilities of being the least effective interventions. eFigures 8 through 10 in Supplement 1 show the network map, the network forest plots, and the rank bar graphs for short-term pain. Out of all combined direct and indirect comparisons, only the comparison between neural therapy plus thumb spica splint vs thumb spica splint alone was statistically and clinically significant, favoring the neural therapy (eFigure 18 in Supplement 1).

Short-Term Function

Conventional CSI plus thumb spica immobilization had the highest probability of being the most effective intervention for function at 0 to 12 weeks, followed by acupuncture. Thumb spica splint had the highest probability of being the least effective. eFigures 11 to 13 in Supplement 1 show the network map, the network forest plots, and the rank bar graphs for short-term pain.

From the combined direct and indirect comparisons, conventional CSI plus thumb spica immobilization was clinical and statistically superior to thumb spica cast and thumb spica splint with full-time wear or as-decided wear (eFigure 19 in Supplement 1).

Mid-Term Function

Of 3 included interventions, conventional CSI plus thumb spica immobilization had the highest probability of being the most effective intervention and thumb spica splint had the highest probability of being the least effective for function at 13 to 52 weeks. eFigures 14 to 16 in Supplement 1 show the network map, the network forest plots, and the rank bar graphs for short-term pain. There were no combined direct and indirect comparisons that produced both statistically and clinically significant results (eFigure 20 in Supplement 1).

Discussion

This is systematic review and network meta-analysis on the management of DQT is the largest of its kind to date, to our knowledge. We found through direct comparisons that adding thumb spica immobilization for 3 to 4 weeks to a CSI was associated with benefits for pain and function in the short- and mid-term. While these differences were statistically significant, they did not reach clinical significance due to our predefined minimal clinically important differences for pain and function. Our results were based on low certainty of evidence for pain and moderate certainty of evidence for function; therefore, only function-related recommendations for clinical practice can be considered strong. In the network meta-analysis for short-term pain, interventions that included ultrasonography-guided CSI ranked at the top. Placebo injection (normal saline), and thumb spica immobilization alone (splint or cast) had the highest probability of being the least effective interventions. Data for promising treatments that ranked high in the network meta-analyses, such as neural therapy and extracorporeal shockwave therapy, originated from single studies of high overall ROB; therefore, recommendations for their use cannot be made at this point.

Surgical interventions were not eligible for inclusion in pairwise meta-analyses, since no comparison of the same 2 interventions was assessed by any more than 1 study. Additionally, they could not be included in the network meta-analyses because the studies that assessed surgical interventions did not include any of the other interventions that already participated in our network. The RCT by Kang et al22 compared open and endoscopic surgical release for DQT and found better short-term outcomes in the open release group but similar mid-term outcomes. The endoscopic group also had fewer superficial radial nerve complications and greater scar satisfaction.22 The RCT by Lu et al32 demonstrated possible additional benefits of adding a platelet-rich plasma injection to open surgical release for DQT at mid-term follow-up.32 A 2019 study by Kim et al34 showed that a dorsoulnar incision of the retinaculum did not have better outcomes compared with a midline incision and neither did postoperative immobilization. A 2016 study by Kumar26 compared longitudinal and transverse incisions in patients with DQT and found that the latter had a greater number of total complications, including superficial radial nerve injury, vein injury and scar hypertrophy. Similarly, in a 2011 RCT, Abrisham et al19 found that transverse incisions were associated with a greater total number of complications than longitudinal incisions. Finally, an RCT44 comparing pulley release vs pulley reconstruction found no difference in clinical outcomes between groups. In a systematic review,46 surgical release for DQT has been shown to be highly effective, associated with full resolution of symptoms in up to 95% of patients; however, due to its potential complications, especially injury to the superficial radial nerve, it should be reserved for patients for whom nonsurgical treatment has failed.

The overall incidence of a separate EPB subcompartment within the first extensor compartment has been reported to be as high as 80%, with up to 90% of patients experiencing DQT and 70% of asymptomatic patients having a separate EPB.47 This high incidence implies that this should perhaps be regarded as an expectant anatomical component of the normal wrist rather than a variant. An association between this separate subcompartment and EPB acting as a thumb interphalangeal joint extensor has also been reported.48 Some researchers have speculated that DQT is secondary to EPB entrapment alone, as evidence suggests that surgically releasing the septated EPB subcompartment only and administering ultrasonography-guided CSI into the EPB subcompartment only are as effective as release of the subcompartment and the first extensor compartment sheath plus CSI into both the subcompartment and the main first extensor compartment.45,49 Indeed, CSI into the EPB subcompartment alone ranked among the top interventions in our network meta-analysis for short-term pain.45 Finally, a more dorsal incision to the extensor retinaculum has been recommended to avoid tendon subluxation, or even a partial excision of the extensor retinaculum to prevent reannealing of the retinaculum and recurrent symptoms; however, there is currently no convincing evidence to support these recommendations.34,50

Although oral NSAIDs have been recommended as first-line treatment for DQT, their use is not supported by the existing literature.1 An RCT by Ansari11 found that treatment of DQT with NSAIDs, splinting, and local application of ointment had much worse outcomes in terms of treatment success at 1 and 2 weeks compared with a CSI. Another RCT14 comparing CSI with or without oral NSAID found no additional benefits associated with the use of the NSAID. Finally, an RCT51 that was published after we performed our literature search and was therefore not included in our study found that a CSI was more effective for pain, function, and grip strength at 6 weeks than an NSAID injection.

The findings of previously published systematic reviews of RCTs were largely limited by inadequate evidence. An early Cochrane review52 only included 1 RCT of CSI vs thumb spica immobilization in pregnant or postpartum patients, and the superiority of the CSI could not be generalized to the wider population. Similarly, a systematic review53 on surgical outcomes for DQT was unable to make any useful conclusions for pain or function since only 3 studies were eligible for inclusion. Another systematic review54 of 2 RCTs found that CSI was more effective than splinting. A study by Cavaleri et al55 showed that both thumb spica immobilization, acupuncture, and CSI were associated with improved pain and function but CSI plus orthoses interventions were the most effective, which is in agreement with our results. A systematic review46 of all study types found that surgery for DQT was effective in up to 95% of patients, and there were no differences in outcomes or complications among different types of surgery and incision. Finally, a study by Huisstede et al56 reported moderate evidence for the effectiveness of CSI in DQT in the very short-term, and for adding splinting to CSI in the short- and mid-term.

Based on our findings, we recommend that clinicians offer patients with DQT of any chronicity a conventional CSI at first contact. This should be supplemented with thumb spica immobilization for 3 to 4 weeks in the form of a full-time (minus grooming and simple daily range-of-movement exercises) thumb spica splint that includes the wrist and the thumb metacarpophalangeal joint but not the thumb interphalangeal joint. If the symptoms persist 3 to 4 months later, we recommend that a diagnostic ultrasonographic scan is performed, at which point a further ultrasonography-guided CSI can be administered on confirmation of the diagnosis of DQT. This should also be supplemented with a thumb spica splint for 3 to 4 weeks. If this does not result in resolution of symptoms within 3 to 4 months, then surgical release is recommended. No definitive recommendations can be provided for the type of surgery or type of incision due to inadequate evidence. All patients should be warned about complications of surgery as part of the informed consent process, especially injury to the superficial radial nerve and its consequences. At all stages of treatment, advice about lifestyle modifications should be provided to limit overuse of the affected tendons. Figure 4 illustrates our recommended management pathway.

토론

이 연구는

DQT 관리에 대한 체계적인 검토 및 네트워크 메타분석으로,

현재까지 저희가 아는 한 가장 큰 규모의 연구입니다.

직접 비교를 통해 3~4주 동안

엄지손가락 스피카 고정 치료를 추가하는 것이

단기 및 중기적으로 통증과 기능에 도움이 된다는 사실을 발견했습니다.

이러한 차이는 통계적으로 유의미했지만, 통증과 기능에 대해 미리 정의한 임상적으로 중요한 최소한의 차이로 인해 임상적 유의미성에 도달하지는 못했습니다. 본 연구 결과는 통증에 대한 근거의 확실성이 낮고 기능에 대한 근거의 확실성이 중간 정도이므로 임상 진료에 대한 기능 관련 권고안만 강력한 것으로 간주할 수 있습니다. 단기 통증에 대한 네트워크 메타 분석에서는 초음파 유도 CSI를 포함한 중재가 가장 높은 순위를 차지했습니다. 위약 주사(생리식염수)와 엄지손가락 스피카 고정 단독(부목 또는 깁스)은 효과가 가장 낮은 중재법일 확률이 가장 높았습니다. 신경 치료 및 체외 충격파 치료와 같이 네트워크 메타 분석에서 높은 순위를 차지한 유망한 치료법에 대한 데이터는 전체 ROB가 높은 단일 연구에서 비롯된 것이므로 현재로서는 그 사용에 대한 권장 사항을 제시할 수 없습니다.

외과적 중재는 동일한 두 가지 중재의 비교가 1개 이상의 연구에서 평가되지 않았기 때문에 쌍별 메타 분석에 포함할 수 없었습니다. 또한 외과적 중재를 평가한 연구에는 이미 네트워크에 참여한 다른 중재가 포함되지 않았기 때문에 네트워크 메타 분석에 포함할 수 없었습니다. Kang 등22의 RCT에서는 DQT에 대한 개복 및 내시경 수술적 방출을 비교한 결과, 개복 그룹에서 단기 결과는 더 좋았지만 중기 결과는 비슷한 것으로 나타났습니다. 또한 내시경 그룹은 표면 요골 신경 합병증이 더 적고 흉터 만족도가 더 높았습니다.22 Lu 등32의 RCT는 중간 추적 관찰에서 DQT를 위한 개방적 수술적 방출에 혈소판이 풍부한 혈장 주사를 추가하는 것이 추가적인 이점이 있음을 보여주었습니다.32 Kim 등34의 2019년 연구에서는 망막의 배등절개는 중간선 절개에 비해 결과가 더 좋지 않았고 수술 후 고정도 더 좋지 않은 것으로 나타났습니다. 2016년 Kumar26의 연구에서는 DQT 환자의 세로 절개와 가로 절개를 비교한 결과, 후자의 경우 표면 요골 신경 손상, 정맥 손상, 흉터 비대를 포함한 총 합병증이 더 많이 발생하는 것으로 나타났습니다. 마찬가지로 2011년 RCT에서 Abrisham 등19은 가로 절개가 세로 절개보다 더 많은 총 합병증과 관련이 있다는 사실을 발견했습니다. 마지막으로, 풀리 릴리스와 풀리 재건술을 비교한 RCT44에서는 두 그룹 간 임상 결과에 차이가 없는 것으로 나타났습니다. 체계적 문헌고찰에 따르면,46 DQT에 대한 수술적 방출은 최대 95%의 환자에서 증상이 완전히 해결되는 등 매우 효과적인 것으로 나타났지만, 잠재적인 합병증, 특히 표재성 요골 신경 손상으로 인해 비수술적 치료에 실패한 환자에게만 시행해야 합니다.

첫 번째 신근 구획 내에 별도의 EPB 하위 구획의 전체 발생률은 80%에 달하며, 최대 90%의 환자가 DQT를 경험하고 70%의 무증상 환자가 별도의 EPB를 갖는 것으로 보고되었습니다.47 이러한 높은 발생률은 이것이 변이가 아닌 정상 손목의 해부학적 구성 요소로 간주되어야 함을 시사합니다. 이 별도의 소구획과 엄지 지간 관절 신근으로 작용하는 EPB 사이의 연관성도 보고되었습니다.48 일부 연구자들은 DQT가 EPB 포획 단독에 이차적이라고 추측했는데, 이는 수술적으로 분리된 EPB 소구획만 방출하고 초음파 유도 CSI를 EPB 소구획에만 투여하는 것이 소구획과 제1 신근 구획 피복을 방출하고 소구획과 주 제1 신근 구획 모두에 CSI를 투여하는 것과 같은 효과가 있다고 증거가 제시하기 때문입니다.45,49 실제로 네트워크 메타 분석에서 단기 통증에 대한 중재 중 가장 높은 순위를 차지한 것은 EPB 하위 구획으로의 CSI였습니다.45 마지막으로, 힘줄 아 탈구를 피하기 위해 신근 망막에 더 등쪽 절개를하거나 망막의 재 탈구와 증상 재발을 방지하기 위해 신근 망막의 부분 절제가 권장되었지만 현재 이러한 권장 사항을 뒷받침하는 확실한 증거는 없습니다.34,50

DQT의 일차 치료로 경구용 NSAID가 권장되고 있지만, 기존 문헌에서는 그 사용이 뒷받침되지 않습니다.1 Ansari11의 RCT에 따르면 NSAID, 부목, 국소 연고 도포로 DQT를 치료하는 것이 CSI에 비해 1주 및 2주 후 치료 성공률 측면에서 훨씬 나쁜 결과를 보인 것으로 나타났습니다. 경구용 NSAID를 사용하거나 사용하지 않고 CSI를 비교한 또 다른 RCT14에서는 NSAID 사용과 관련된 추가적인 이점을 발견하지 못했습니다. 마지막으로, 문헌 검색을 수행한 후에 발표되어 본 연구에는 포함되지 않은 RCT51에서는 6주 후 통증, 기능, 악력에서 CSI가 NSAID 주사보다 더 효과적이라는 결과가 나왔습니다.

이전에 발표된 RCT에 대한 체계적 문헌고찰의 결과는 대부분 근거가 불충분하여 제한적이었습니다. 초기 코크란 리뷰52에는 임산부 또는 산후 환자를 대상으로 한 CSI와 엄지손가락 스피카 고정술에 대한 RCT가 1건만 포함되어 있었으며, CSI의 우수성을 더 많은 인구에 일반화할 수 없었습니다. 마찬가지로, DQT의 수술 결과에 대한 체계적 고찰53에서는 3개의 연구만 포함할 수 있었기 때문에 통증이나 기능에 대한 유용한 결론을 내리지 못했습니다. 2건의 RCT에 대한 또 다른 체계적 문헌고찰54에서는 CSI가 부목 고정보다 더 효과적이라는 결과가 나왔습니다. Cavaleri 등55의 연구에 따르면 엄지손가락 가시 고정, 침술, CSI 모두 통증 및 기능 개선과 관련이 있지만 CSI와 보조기 중재가 가장 효과적이었으며, 이는 본 연구 결과와 일치하는 결과입니다. 모든 연구 유형에 대한 체계적 문헌고찰46에 따르면 DQT 수술은 최대 95%의 환자에게 효과적이며, 수술 및 절개 유형에 따른 결과나 합병증에는 차이가 없는 것으로 나타났습니다. 마지막으로, Huisstede 등의 연구56에서는 DQT에서 매우 단기적으로 CSI의 효과와 단기 및 중기적으로 CSI에 부목을 추가하는 것에 대한 중간 정도의 증거를 보고했습니다.

이러한 연구 결과에 근거하여, 임상의는 모든 만성 DQT 환자에게 첫 접촉 시 기존의 CSI를 제공할 것을 권장합니다. 여기에 3~4주 동안 손목과 엄지 중수지 관절은 포함하되 엄지 지간 관절은 포함하지 않는 풀타임(손질 및 간단한 일상 운동 범위 운동 제외) 엄지 스피카 부목의 형태로 엄지 스피카 고정으로 보완해야 합니다. 3~4개월 후에도 증상이 지속되면 진단용 초음파 검사를 실시하는 것이 좋으며, 이 시점에 DQT 진단이 확인되면 초음파 유도하 CSI를 추가로 시행할 수 있습니다. 또한 3~4주 동안 엄지손가락 스피카 부목으로 보조해야 합니다. 이렇게 해도 3~4개월 이내에 증상이 해결되지 않으면 수술적 치료를 권장합니다. 증거가 불충분하여 수술 유형이나 절개 유형에 대한 명확한 권장 사항을 제공할 수 없습니다. 모든 환자에게는 사전 동의 절차의 일환으로 수술 합병증, 특히 표재성 요골 신경 손상과 그 결과에 대해 경고해야 합니다. 치료의 모든 단계에서 영향을 받은 힘줄의 과도한 사용을 제한하기 위해 생활 습관 교정에 대한 조언을 제공해야 합니다. 그림 4는 권장 관리 경로를 보여줍니다.

Limitations

Our study has some limitations. Chronicity of the condition, which could influence effectiveness of interventions, was not considered and neither was type, number, or dose of CSIs. Similarly, simultaneous consumption of NSAIDs was not controlled for, as the included studies did not provide relevant data. Additionally, not all interventions were available for participation in all networks; specifically surgical interventions could not be included in any quantitative analyses for pain and function. Furthermore, the diagnostic criteria of some studies may have been inadequate, having only included the Finkelstein test. However, we did include all eligible studies that derived from a thorough literature search and combined data appropriately in quantitative analyses that included a network meta-analysis. Additionally, we performed detailed ROB and certainty of evidence assessments for each outcome separately.

Conclusions

In this systematic review and network meta-analysis of RCTs, we found that adding a short period of thumb spica immobilization to a CSI was associated with significant benefits and administering the CSI with ultrasonographic guidance was associated with superior results compared with conventional CSI. CSI with thumb spica immobilization had the highest probability of being the most effective treatment for function and also ranked very highly for pain relief among treatments in analyses. Therefore, we recommend the use of CSI with thumb spica immobilization for 3 to 4 weeks as first-line treatment for patients with DQT. Surgery should be used only when nonsurgical management fails. Further research should take into account chronicity of the condition, as this may influence effectiveness of specific interventions, and NSAIDs should both be assessed as a management option for DQT, with or without thumb spica immobilization, and controlled for in studies where other interventions are assessed. Finally, more high-quality RCTs should be conducted to investigate the potential benefits of administering CSIs with ultrasonographic guidance and comparing different surgical approaches so that conclusions can be made with higher certainty of evidence.

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Article Information

Accepted for Publication: August 28, 2023.

Published: October 27, 2023. doi:10.1001/jamanetworkopen.2023.37001

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Challoumas D et al. JAMA Network Open.

Corresponding Author: Neal L. Millar, MD, PhD, School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, 120 University Ave, Glasgow G12 8TA, United Kingdom (neal.millar@glasgow.ac.uk).