Post Surgery Sensations

I have to say that I think the idea that tingling is a sign of nerve healing is fantasy. You can get tingling/pins and needles type sensations at any phase in the process of nerve injury and repair and all it indicates is hyperexcitability of the nerve cell membrane - nothing to do with healing and by itself it doesn't mean a lot for prognosis - it's better if its tingling than if it is just numb but that's about it. The doctor who gave you that story might perhaps have been misinterpreting Tinel's sign where the point at which a regrowing nerve is mechanically sensitive can indicate the position of a terminal neuroma.

The second odd comment there is the idea of thenar atrophy recovering in 3 weeks - this is, to be honest, unlikely. If there was enough loss of muscle bulk to produce visible atrophy it takes more than 3 weeks to rebuild that. What can happen very quickly is that a weak muscle which is still there but not contracting because of conduction block in the nerve can start contracting again. The simplest objective guide to thenar wasting in most CTS cases is the amplitude of the median motor potential recorded from APB but this will be affected by conduction block too.

Third point - there is no uniformly accepted meaning for 'severe' on nerve conduction studies so that could indicate a wide variety of different findings. I'm sure this must seem odd to the public - that we can't agree amongst ourselves on what we mean when we say these things - but that's the way it is. There are two main schools of thought at present - I think we should define precisely what we mean in numerical terms, the opposing group think we should eschew using terms like 'mild' and 'severe' completely and not say anything.

So... the answers to your two questions

1) Don't worry about it (see the comments about healing above) - if it continues tingling long-term then that is a problem - the aim of treatment, ideally, is to get your hand back to normal, not leave you with a tingly one.

2) If you can find the article I would like to see how evidence based it is as I haven't seen anything scientifically valid that is as precise as this statement. You do have a better chance of recovering at 53 than at 93 but I don't think anyone could put an accurate figure to that. Recovery from severe sensory loss and atrophy can continue for up to about 2 years so don't give up on it too early. It is only realistic however to say that recovery from severe wasting and sensory loss in grade 6 CTS cases is usually incomplete. There is an Italian study of recovery from neurophysiologically defined severe CTS as demonstrated by absent thenar motor potentials which showed that about 50% of the patients considered their operation a success.... but that didn't necessarily mean that they had recovered normal muscle power

I'm sorry if those answers are more vague than you wanted but I am afraid there remain many unknowns in medicine, even for such a simple condition as CTS. JB.

Not vague at all. Honest and hopeful.

As far as fantasy, if my current physician was one bit communicative, I'd not be here on the internet.

I'll interpret your response as follows:

Ive always recovered well from surgery, I'm healthy and active. Things seem to be going well (Ive realized a significant improvement already) and there is no reason to believe at this point that I won't continue to get better, if not 100 percent. Probably gonna be a while. Fair statement?

Here is the source of my information:

http://www.healio.com/orthopedics/hand-wrist/news/print/orthopedics-toda...

Thank you

Johnny

Thanks for the link - looks as though that work was presented at a meeting. It's a fairly small series but interesting. They presumably chose to look specifically at opposition of the thumb because that's an important movement for function of the hand but it's not actually done by the muscle which they sampled with EMG to define their patient population. If they had actually tested abduction of the thumb I suspect they would have found a high incidence of detectable weakness in these patients. Quite a lot of surgeons like to use measures of grip and pinch strength as outcome measures for surgical studies of CTS but these measures do not seem to correlate very well with overall patient satisfaction so I tend to take them with a pinch of salt. I think the fact that you have already noticed some improvement is a good sign. If you happen to have your pre-operative NCS results we can try to get a more objective idea of what 'severe' means and have a better guess at likely recovery time. JB

I just emailed them requesting the report. Back when I get a hold of it.

Thanks again.

JL

This discussion has prompted me to take a further look at surgical outcomes in the most severe CTS and there is now enough data on the subject that I have added a dedicated page to the site discussing it. Dr Ebata tends to publish his interesting work only in abstract form and by giving presentations at meetings - of which I have found three altogether. There are clearly more findings that I can extract from the records held in Canterbury and we may do some work on this in the next year or two. JB

Just found this:

http://meeting.handsurgery.org/abstracts/2012/P26.cgi

Statistically consistent with that first one, is it not?

JL

I just read your page on severe CTS. Very nice, I applaud your efforts to bring understandable, compassionate advice to the internet.

JL

That one's a bit hard to follow and some of their methodology is a bit unclear - subjectively judged thenar atrophy is rather inconsistent - but I think their broad message is that about half of their cases recovered and that the recovery took place mostly between 3 and 6 months - which is indeed fairly consistent with other observations. JB

Thats what I got too.

Whew, now that my left has not had thenar atrophy as I first thought, I haven't used up my one in two chance :-)

Seriously though, so happens my neurologist wants me to come back now (a letter in the mail just today). Repeat the nerve test I presume. I've read this is too early, but he's the boss.

Ill have preoperative and two months post operative results to share soon.

It's hard to know what the 'correct' timing is for post-operative NCS. In cases where surgery has clearly been successful they are not done so we don't get a comprehensive picture of how they are expected to change after surgery - just a few research studies that have looked into the change at usually no more than one or two post-op time points. My best guess is that where there is serious doubt about whether an operation has been done correctly or not you can probably repeat the NCS as early as 2 weeks. In all except the most extreme cases I think you should be seeing some improvement by 6-8 weeks. There are surgeons around who completely misunderstand post-operative NCS - see the recent rapid responses to a BMJ review.JB

I am back.

I have the results of the first, pre-operative nerve conduction study. The repeat is not until right after Christmas.

Its a two page pdf document. What do you need to know?

JL

If you don't mind sharing it with me in full  then the easiest thing to do is email it to me (address in the contacts page) if you have it in electronic form anyway. I can then post back on here the relevant measurements with an explanation of what they are. There are many different formats for reporting NCS so it's probably easier for me to read directly than to explain what to look for. JB

Done. Sent 3:57am my time, Pacific Northwest, US.

On another note, I continue to feel better everyday. Im at 8 weeks and 3 days from my surgery.

Strength is returning. No thenar in my right hand. Pretty good sensation in my entire palm (both hands) which is an improvement. It had been absent on the median nerve side of the palm, so I believe nerve regeneration is occurring. Tingling is decreasing. It will subside one day.

I know now that the feelings I had during the first 8 weeks were the "explosion" of the surgery. Both the incision and the release of the nerve had things going crazy. Changes to these symptoms I have been confusing with nerve regeneration. They were not. However, now that I've more familiar with things, I do believe that I can detect changes (ability to sense pain) nto the palm of my hands, and they seem to be positive.

Thanks again,

JL

Nothing's come through on email as yet. One interesting comment there though - if you are built to 'standard' human anatomy then CTS is not supposed to impair sensation in the palm of the hand because the palmar cutaneous branch of the median nerve passes outside the carpal tunnel. I have however long since learned not to be too surprised at the variation in patient experience of what seems, in a mechanistinc sense, to be the 'same' disease. JB

I sent it again and received a copy of it myself. It left anyway.

Junk Folder?

Both went off to Jeremy [dot] Bland [at] nhs [dot] net

I have never paid any attention to this until now, a crisis. Much of what Im putting together is based on assumptions on how I used to be. Not actual observation.

So, those diagrams you see. The median side of the hand a blue blob, and the ulcer side a red blob. Very general I guess...

I was going to send you another link, node 53, until I realized it was yours. That was the best source of information i have found.

From the stacked bar chart I took it that, from a probability perspective, I have a 25 percent probability of getting all the way "well", and another 25 percent probability of "much better", which I'll be satisfied with too.

So, I'll not bother to send you that link. :-)

Oh, Maybe its this....

Perhaps my misuse of medical terminology. Not the palm, per se, the part of the hand in which the scaphoid and trapezium bones (I looked this up) are located. Not the fingers, but where the fingers start.

Thats numb too and is changing. I think.

A surprisingly large number of the illustrations on the web have the sensory distribution of the median nerve in hand illustrated using the area that would be affected if you cut the nerve in the forearm rather than the area affected by carpal tunnel syndrome - ie many of them are wrong for CTS. However the whole picture is confused by the fact that relatively few patients seem to adhere to the standard textbook distribution of symptoms anyway.

Checked the junk folder and used a different email client to be sure too but still no email. NHS mail does have a limit on attachment sizes which may have something to do with it. I'll send you an alternate email address - sorry about the hassle. JB

I sent them separately.

My work email filters attachments coming from me (my personal email) and must be others.

I just tried the other email addresses

OK now we have some results to look at. It's quite an interesting set  It's probably easiest to start with the motor studies. You had an absent motor response from abductor pollicis brevis on the right side and apparently a very small and delayed response on the left (9.2 msec latency and 0.1mV amplitude in the left hand). Assuming that this is just CTS then those results alone would make the right hand grade 6 and the left probably grade 5 - I would need to see the recorded waveform to be sure whether the left was a 5 or a 6 but lets give it the benefit of the doubt and say grade 5. In the vast majority of grade 5/6 CTS cases the median sensory potentials are unrecordable unless you use sophisticated techniques like near nerve nerve needle recording and prolonged averaging runs so it is not surprising that your median sensory studies were unrecordable here.

I did say in that paragraph 'assuming that this is just CTS' - and that is where I think a little caution is perhaps warranted here. If you think about the right hand - all we have really shown so far is that the median nerve is electrically dead - it can look like this in very severe CTS but it would look exactly the same if you just cut it at the wrist - ie these results do not prove that the problem is specifically carpal tunnel syndrome. On the left side, if the reported motor potential is real, we have much better evidence of entrapment because the distal latency in the median nerve is greatly prolonged compared to the ulnar nerve in the same wrist (9.2 msec vs 3.0 msec).

We then look at the other recordings and it starts to look as though you have other nerve problems too. The right ulnar nerve shows relative slowing of motor conduction in the segment around the elbow (34 m/sec around the elbow vs 49 m/sec in the forearm segment), the left ulnar nerve seems generally a little slow - 42 m/sec where your lab's normal value is >53 m/sec, and both ulnar sensory potentials are a little on the slow side (38 and 37 m/sec)

I think there is probably a typo in some of the measurements incidentally as some are indicated as being done at about 21C (temperature) while others are 32-33C. There is no way there could be a 10C difference between the median and and ulnar sides of your hand

Finally we have the needle EMG findings which are all normal except for the median innervated thumb muscles. On the right side it appears that no definite electrical activity was recorded from the muscle at all while on the left there was some abnormal spontaneous activity suggesting that the nerve is currently degenerating at the time of the test. The comment 'remote' I think probably means that the examiner thought that what activity he did see when you tried to move the muscle was actually being picked up at a distance from other muscles. If this is right then seemingly you were unable to recruit any voluntary motor units in either thumb.

Personally I would probably have done more nerve conduction studies and less EMG sampling but that's very much a transatlantic difference. Extensive needle EMG is widely used in the USA to try to detect evidence of problems further up the arm. In patients with an absent median motor potential from abductor pollicis brevis it is often possible to record a median motor potential from the lumbrical muscle which allows confirmation of slowing across the carpal tunnel, and given the ulnar nerve abnormalities too I might have been tempted to measure some other nerves, including some in your feet, to make sure there was not a more widespread underlying problem. The doctor did indeed suggest checking you out for diabetes - which would be the commonest cause of widespread nerve problems in both the UK and USA and is often undiagnosed - and I suspect the lack of further NCS measurements here is perhaps more related to insurance and billing procedures in the USA than the doctor in this case not thinking about doing them. Another way of helping to clarify what is happening to to a nerve from which you can record nothing electrically is to do the ultrasound imaging but not everyone has a scanner to hand and again there are insurance/funding issues in the USA.

Overall then you probably had grade 6 right and grade 5 left CTS with a remaining questionmark over whether there might be an underlying generalised nerve problem. I would expect recovery of the CTS to take some time and quite possibly to be incomplete, not only because of the severity of the median nerve abnormalities but also because of the suspicion of underlying nerve problems.

I share your neurologists scepticism about thoracic outlet syndrome diagnosed by therapists of various types. Thoracic outlet syndrome does exist in both vascular and neurogenic forms and can be quite easily demonstrated with vascular, neurophysiological and imaging investigations. Classical neurogenic TOS has quite a recognisable neurophysiologcal and imaging profile and it has to be said that the majority of patients whose therapists make diagnoses of TOS show no evidence of it when investigated. It seems fairly clear from your story that someone at least suspected CTS at a much earlier stage and it is indeed a pity that it was not picked up earlier with NCS. It's interesting that the neurologist is planning to check you out again - I suspect this is not routine practice and that many of the same thoughts about these results have gone through his/her head.

FInally, a warning/disclaimer. I've thought quite hard about how much detail to go into with these comments. The above is quite a technical description of the issues so I hope I've judged correctly that you are able to handle that. In the process of diagnosis we are taught to consider all the possible explanations for the evidence in front of us - but not necessarily to discuss them all at length with the patient, and sometimes there are good reasons for that. Your neurologist is clearly on top of this and has already mentioned some of it to you so hopefully I am not springing anything unexpected on you via the medium of an internet forum. JB

Very good. Thank you so much, I do follow a lot of this. Im a chemical engineer and fledging self-taught, internet neurologist.

I had immediately gone to my general practitioner and we have ruled out diabetes. The numbers that indicate that were very normal. So, if not diabetes, what are the other possibilities? There is no way CTS can cause all this?

So, the repeat NCS is a good next step, perhaps supplemented with a more global view of the problem. It should show progress in my hands (but if there are other issues, they should still visible), the question being how long and far will healing occur from the CTS

I should work with these guys to try and determine any other issues.

I do have another question though. Why don't we heal completely from treatment of severe CTS? Seems that the body wants to. Any way to encourage this?

So, you essential concur with the others: It is at least a case of severe CTS, there may be more to it (additional NCS is the place to begin and maybe that imaging device you refer to), I have a 50:50 probability of my left thenar recovering (the soonest time being 3 to 6 months), it may take at least 12 months for this process to reach the end (perhaps up to 24), and I may not heal completely (although the Carpal Tunnel.net data says I have a 25 percent probability of complete recovery, and another 25 percent to be "much better"). I appreciate your previous comments regarding the definition of "successful" surgery. I think I stand a chance of becoming "very well". Although, my left has a better chance than my right.

Close?

Thanks again so very much

JL

Pretty fair summary of the outlook, and no you can't blame it all on CTS which is, by definition, a local bit of pathology at the wrist. 'Other possibilities' is a pretty wide field - if you want to get a glimpse of just how wide you could start at the University of Washington neuromuscular website (from the links page). As regards incomplete healing from severe CTS it doesn't just apply to CTS, any nerve injury will do less well in terms of recovery the more severe it is and the longer it has been present. Although nerve fibres can regenerate they do not seem to have an infinite capacity to overcome adversity and if they have to navigate through dense fibrous or scar tissue they may not make it. Beyond a certain point the end organs (muscle cells etc) may have atrophied completely and be unable to resume function even if the nerve endings get back to them. Furthermore, regenerated nerve fibres myelinate differently to those which you had originally with shorter internodes and slower conduction - one of the reasons there are often residual nerve conduction abnormalities after the treatment of even moderately severe CTS. JB

Ive got a couple of miscellaneous questions regarding CTS:

I continue to heal, i feel better month to month. I notice changes every other week. Today i pinched my left, index finger with a tool. Definitely have a sense of pain. If anything, it may be exaggerated, I'm not going to repeat that any time soon to check it.

Ive got two more questions:

1) Ive read repeatedly that nerves grow about an inch per month. What dies that mean exactly? My symptoms seem to be changing very deliberately, improving. Does healing eventually slow?

I envision that the nerves are similar to a circular hairbrush. A center, main trunk (the median nerve), with zillions of hairs branching off. As I'm healing, the truck is growing and the density off the hairs is growing and thats why my sense of feeling grows more acute. Its starts out a weak sensation and slowly gets more “normal”. Too simple?

If this is correct, it means that in a month, the median nerve moves another inch along my finger and that the associated network grows with it. Thats not how it feels though.

2) The term “incomplete” is used a lot, typically in conjunction with the idea of degree of healing. How close to normal will one return. I take it complete means recovery thats at a minimum a return to pre-carpal tunnel conditions. Since we don't have normal NCS numbers for me, we will never know for sure, correct? I guess there are normal ranges to compare to.

Point here is, I think there may be a pretty big range of incomplete that will feel like complete. Unless I’m “very” incomplete, this wont make much sense one day. Rather, I am certain I am healing now. The issue will be how much healing occurs and how efficient the new nerve network is.

I think I’m trying to associate the sensations I feel with the reality, whats happening in there for curiosities sake. The better I understand, the better I feel.

Thanks,

People quote all sorts of figures for nerve regrowth in terms of distance per time 'x'. I think such figures encourage too deterministic a way of thinking about it. In reality nerve regrowth rates are highly variable depending on age, nerve involved, type of injury, other coincident pathology etc and I generally find it more useful just to quote an upper time limite after which it is unlikely there will be further significant change - which is usually about 2 years.

The hairbrush image is not quite right - more like a tree - there are not many (if any) small terminal branches and leaves coming off the trunk, nor off the major divisions. It's not until you get out to the small branches and twigs in the periphery that you start to get to the functional bits. What is different from the tree is that, in a nerve, single cells extend from the spinal cord all the way out to a nerve terminal on a muscle (for movement) or in the skin (for sensation). If these long cellular extensions are cut or otherwise broken they have to regrow from the point of damage back out to where they used to terminate and it is the regeneration of these 'axons' which you are waiting for.

Complete recovery is not a technical medical term - we are just using it in it's ordinary English sense here. Complete subjective recovery may not be the same thing as complete neurophysiological recovery - I may still be able to detect residual evidence of nerve injury in people who are completely asymptomatic once they have recovered, and conversely, people whose NCS have returned within the normal range (yes we have 'normal' ranges) can still have troublesome symptoms despite that. JB

Since my surgery(s) my index fingers have felt ice cold. The do seem colder than the other digits. Normal in color.

Is this typical?

It can be hard to distinguish a sensation of being cold from actually being cold without checking with a surface thermometer, nerve abnormalties can play tricks with your normal perception. Both disturbances of temperature regularion and of perception are possible, as is a mixture of both. Such sensations do occur sometimes in CTS though I am aware of no wholly reliable figures to say how common they are. JB

Its been sometime since I checked in, so I thought I'd post an update.

My last visit to my neurosurgeon (12/29/14) did not result in a new NCS. We met and he wanted to know how I felt. I will have a new NCS on 3/3/15.

I learned more about his concerns regarding the other neuropathy situation. He was pushing and pulling on me and I'm markedly weak resisting my elbows being pushed down when extended at my shoulders. My ability to push over my head is low.

I think I know why. A couple of years ago I had a weight lifting accident. Dumbell bench pressing, I lost control and the weight went from vertical to horizontal, over my head. I felt a distinct tear. If I didn't tear the rotator cuff, I don't want to know what that feels like. I was crumpled up on the gym floor for 20 minutes, and sore as the dickens for weeks. I had to have partially torn it. I was in physical therapy for a while, and the pain has diminished. Id forgotten all about it, I've regained complete range of motion. However, I think I'm left with some weakness I need to undo with (carefully) weight training.

He's ordered a muscle enzyme test and other blood work to follow up, but once I tell him this story, maybe his plans change.

Back to my hands though. I am making great progress.

My left hand has feeling everywhere, a bit vague, but it feels. Its is better than before the surgery. I picked up a little figurine last week and could discern details on it by touch. I can sense temperature.

My left hand lags a bit of course. The big news there is my thenar is recovering. I noticed it on January 9, which is 3 months, and one week after my surgery. Its been consistently building mass and strength, pretty much daily. A couple more weeks and It will appear healthy. The thenar internet links above talk about patients being tested at three months having no appreciable change in grip strength, and at six months a distinct improvement in grip strength. The researchers conclusion is that it happens between 3 and 6 months for about 50 percent of the patients.

Based on that paper, and my experience, I believe that the fastest it can happen is 3 months, and I have experienced above average recovery. I think this is also indicative of the possibility of other neuropathies, meaning I think it says my nervous system is pretty healthy if it is healing this fast.

I am still pretty numb on the right hand first and second fingers, although i believe my sense of pain is moving slowly up my index finger (pretty well absent on the distal joint). I can detect temperature with this hand as well, and I don't recall if this is new or not. It can't deliver the same ability to discern detail as the left, although it is very functional now. I'm much less clumsy, although I don't think I can yet button a shirt (I really want that skill back).

If progress stopped here, Id call the surgery a success as you pointed out earlier in this thread, doctor. I'm optimistic though, if things are going this well now, and continue for another friggin nine months then I anticipate being very well.

Point of all this is I was in a deep hole. Even this early I can say to the other severe cases out there, you can get significantly better following surgery, but it is slow. I think you have to accumulate a lot of healing before you notice a change. Patience is key and this is very frustrating.

Ill be back again in March. Thanks for the support doctor.

~J

Thanks for the update. I assume that the  'left' in the 8th paragraph should be 'right'. It sounds as though the right median nerve is starting to re-innervate your thumb muscles. There's a lot of confusing literature about grip strength in the journals which doesn't make a lot of sense because power grip in particular is mostly a function of muscles which lie proximal to the carpal tunnel. It's actually the movement of abduction of the thumb which is most affected by CTS. So far it sounds as though things are going more or less to plan with the neurophysiologically milder side improving faster and the time course of recovery being relatively slow because of the overall severity of the CTS. It will be interesting to see how it eventually turns out and whether anything other underlying problem is detected or not. JB

Correct. Right. Right hand.

So, What I have not been able to resolve is that the right hand appears to be stronger than the left, throughout this.

Measured by my "calibrated" strength squeezer. But I can do more repetitions with the right than left.

So, maybe it is stronger. I was not sure what the deal was. Absent a muscle and still in the lead.

Interesting...

It's just that grip is powered by muscles in the forearm which are not affected by CTS. The wasted muscle at the base of the thumb has little to do with grip, it is there to control the fine positioning of the thumb in delicate manipulative tasks mostly. JB