Musicians and Carpal Tunnel Surgery

nofithsrgy
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Hello Dr. Bland, GREAT Site !!!
I'm a musician who has been playing for approximately 45 years. I play Bass, Guitar, & Shakuhachi (Japanese Bamboo Flute). Approximately 11 years ago I developed tingling and numbness in all the fingers of the right hand and was diagnosed with ulnar nerve entrapment at the elbow and CTS (I had a nerve study on 4-8-05, and neck MRI on 12-26-07. Additional nerve studies 10-17-08, 2-19-15,10-20-15 and neck MRI 11-14-14. These studies were done when the numbness and tingling flared up). I was able to get rid of the ulnar nerve entrapment myself. I didn't want surgery so I went to Barbara Paull (in November of 2007)who is a physiotherapist in Canada (I live in New York) who specializes in musicians. She said it was all in my neck.Barbara told me what to do to get rid of it and within a year and a half the numbness and tingling was 95 % gone. It wasn't
until June of 2015 after doing a lot of work around the house for two days that the numbness, tingling and pain (which I never had) got very intense and did not go away with shaking the hand. It was definitely in the wrist as I iced it down it got markedly better. Over the last 12 months it's gotten worse. I've tried many different modalities: physical therapy with TENS, ultrasound, and massage, ART(active release therapy), Medical/Deep tissue massage, Bowen Technique, Myotherapy, Apitherapy (bee sting therapy) along with accupuncture, Cold laser therapy (which made it worse), chiropractic adjustments of my neck and wrist, and a wrist brace when I sleep. Things have gotten some what worse over the last year. The last nerurologist who did my most recent nerve study (October 2015) said my CTS is moderate. About three years ago I saw her for a different problem and she did the physical tests for CTS and said at the time I didn't have CTS. I know a total of 18 people who've had CTS surgery . Of them only two were successful. Of these 18 people 3 of the people were musicians; two of them no longer play an one of them plays multiple instruments but no longer plays bass. I saw four of the top hand surgeons in New York. Three of them never had any problems (I asked a total of 33 plus questions) which of course is impossible being that perfection does not exist. All of them each practiced over 18 years. The fourth surgeon was more realistic. He admitted that some people loose grip strength as well as experiencing other types of chronic problems but said it was rare and overall most patients were glad they had the surgery (most people I talk to wish they never had the surgery). It would have to deify the third law of physics to think that you would have the same level of grip strength once a main support of the wrist is compromised. My grip strength of about 8 months ago was 100 lbs in both hands and pinch strength was 25 lbs. My right thumb does have a very slight muscle wasting that the neurologist and surgeon said was negligible (it's been like that for about six years). One of my questions is how long can I go before I must have surgery if at all (I was also diagnosed with diabetes in April of 2015 as well as the last three nerve studies indicating I have mild CTS in my left hand but I have no symptoms). All the doctors and neurologists say I will probably get CTS in the left hand in the near future, how likely is this? The CTS barely affects my ability to play the various instruments and it does not wake me up at night. My right hand fingers are always slightly numb but lights up any time I grip something whether it's as light as a piece of paper or heavier. My day job is as an electronic technician. I should mention that I consider CTS surgery more serious then if I had to have open heart surgery or if I had to have a lung removed due to cancer for example. Approximately how many musicians do you know who have had CTS surgery and can still play at the same level or better than before surgery? How many had to stop playing? Approximately how long is the recovery period before someone could play at the same level as before surgery? All the surgeons say that if I don't have surgery it will only get worse and after a period of time nothing will help, is this true? Sorry for the lengthy post but I could probably write a book. Thanks for your help and time. Be well, Bob.

jeremydpbland
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There's a lot in that an some of the answers are here on the website, in particular what I think are the best statistics available on the patient reported outcomes of carpal tunnel decompression which show the true figures to be, as you might expect, somewhere between the optimistic view expressed by some of the surgeons you have seen and the rather woeful success rate amongst your immediate acquaintances.

In the particular circumstances of musicians I know a handful who have had surgery, various instruments, varying levels of competence, varying status from occasional amateur to full time professional, but I can't extract their outcomes alone from the outcome data because we do not specifically record that bit of information in the database. We are therefore dependent on my very fallible memory. At present I know one virtuosic bluegrass fiddle/mandolin player who has successfully managed to continue playing despite his CTS with the aid of steroid injections but who has been contemplating surgery for some time - I'm not sure whether he has eventually gone ahead with it or not.

For the questions about progression, and the interestingly definite answers you have received from local professionals, the truth so far as I can tell is that we do not really know. There are no scientifically satisfactory studies of what happens to untreated CTS. The little data that does exist is handicapped by biassed samples, short follow up and confounding variables. We do know that some cases do deteriorate and some will progress from unilateral to bilateral symptoms, but we also know that some will spontaneously remit without treatment and some will persist for long periods, often with rather fluctuating severity, with no overall deterioration. We have very few clues as to how to predict what will happen in the individual case.

If you have access to them I would quite like to see your most recent NCS so that we can put a grade to your CTS - then we know just how serious a nerve problem we are talking about. The English language words people use to describe these things in reports are notoriously vague and inconsistent from one lab to another so it is impossible to know what the comment of 'moderate' actually means. JB

nofithsrgy
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Hello Dr. Bland: Thanks for the AMAZINGLY speedy reply !!! I'm going to list the data for my right hand as well as my left hand.

left median motor (abd poll brev)
wrist onset=3.8ms, spec <4.0ms o-p amp=14.5mv spec >5
elbow onset=8.9ms o-p amp=15.3mv spec> 5
site 1 elbow, site 2 wrist delta-0=5.1ms dist=26.0cm vel=51m/s spec vel > 50m/s

Right median motor(abd poll brev)
wrist onset=5.0**ms spec < 4.0 ms o-p amp=14.6mv spec > 5
elbow onset=10.9 ms o-p amp=6.9mv spec >5
site 1 elbow, site 2 wrist delta-0=5.9ms dist=26.0cm vel=44m/s** spec vel >50m/s

left ulnar seg motor (abd dig minimi)
wrist onset= 2.8ms spec <3ms o-p amp=10.1mv spec>5
B elbow onset=6.9ms o-p amp=9.1mv spec>5
A elbow onset=9.5ms o-p amp= 8.8mv spec>5
site1 Belbow site2 wrist delta-o=4.1ms dist=26.0cm vel=63m/s spec = >50m/s
site1 Aelbow site2 Belbow delta-o=2.6ms dist=10.0cm vel=38m/s** spec>50m/s

right ulnar seg motor (abd dig minimi)
wrist onset=2.5ms spec <3ms o-p =9.7mv spec >5mv
Belbow onset=7.0ms o-p amp=8.9mv spec>5mv
Aelbow onset=9.5ms o-p amp=8.5mv spec>5mv
site 1 Belbow site 2 wrist delta-0=4.5ms dist=26.0cm vel=58m/s spec >50m/s
site 1 Aelbow site2 wrist delta-0=2.5ms dist=10.0cm vel=40m/s** spec >50m/s

sensory data to come, couldn't take typing any more and didn't want to lose data.
Thanks beyond what words can express and be well, Bob..

nofithsrgy
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Hello again Dr. Bland: I'll try and finish up the data.

left median D2 sensory (2nd digit)
wrist onset=3.7ms** spec <2.5ms o-p amp=15.7 uv spec >10
palm onset=1.4ms o-p amp=22.5uv spec >10
site1 wrist site2 2nd digit delta-0=3.7ms dist=16.0cm vel=43m/s** spec >50
site 1 palm site2 2nd digit delta-0=1.4ms dist=8.0cm vel=57m/s spec >50
site 1 wrist site2 palm delta-0=2.3ms dist=8.0cm vel=35m/s** spec >50

right median D2 sensor (2nd digit)
wrist onset=4.8ms** spec< 2.5ms o-p amp=4.6uv** spec>10
pam onset=1.5ms o-p amp=7.4uv** spec>10
site1 wrist site2 2nd digit delta-0=4.8ms dist=16.0cm o-p=33m/s** spec>50
site1 palm site2 2nd digit delta-0=1.5ms dist= 8.0 cm o-p=53m/s spec>50
site1 wrist site2 palm delta-0=3.3ms dist=8.0cm vel=24m/s** spec>50

left radial sensory (base 1st digit)
wrist onset=2.3ms spec<2.5ms o-p=15.6uv spec>10.0 site1wrist site2base 1st digit=2.3ms dist=12.0cm vel=52m/s spec> 50

right radial sensory (base 1st digit)
wrist onset=2.0ms spec<2.5ms o-p=16.7uv spec>10.0 site1wrist site2base 1st digit=2.0ms dist=10.0cm vel=50m/s** spec>50

left ulnar sensory (5th digit)
wrist onset=2.3ms spec<3 o-p=34.8uv spec>10 site1wrist site2 5thdigit delta-0=2.3ms dist=12.0cm vel=52m/s spec>50

right ulnar sensory (5th digit)
wrist onset=2.3ms spec<3 o-p=17.1 spec>10m site1wrist site2 5thdigit delta-0=2.3ms dist=11.5cm vel=50m/s** spec>50

One question if you don't mind; all the doctors tell me that the onset of diabetes has nothing to do with my CTS, I find this hard to believe, is this true?
I appreciate this beyond what you could imagine. All the best, Bob.

jeremydpbland
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OK that's grade 3 right and grade 2 left CTS, not bad enough to demand immediate surgery certainly and there is little danger of irreversible nerve damage in the immediate future. Here we would manage the majority of cases like this with splints and steroid injection initially though if people want to go straight for surgery with grade 3 we do let them. There is also a hint of ulnar nerve trouble at both elbows, at least by that lab's normal values, but I would view this as relatively trivial compared to the CTS.

The issue of diabetes and CTS is complicated. There is moderately good evidence suggesting that CTS is commoner in diabetic individuals. However, if the CTS preceded the diabetes then one would be talking about whether pre-diabetes (the disturbed metabolic state before diabetes is diagnosed) might predispose to CTS - I have seen only one study of this and the conclusion was 'probably not'. On top of this there is the question of whether the presence of diabetes prejudices the outcome of treatment for CTS - verdict still open, and I have a personal conviction that diabetes modifies the way in which CTS presents, leading to later presentation with somewhat atypical symptoms. Lastly, some diabetics have peripheral neuropathy and some do not and these two groups might be different subcategories from the point of view of CTS too. JB

nofithsrgy
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Hi Dr. Bland: Thanks so much for the info.
What I gathered from the information you supplied, the posts on the forum, & the people I've met at some point in time I will need surgery. Would that time be when I start having pain, loss of strength, coordination & wasting of the thenar muscle (at that time I would assume a nerve study would show a grade 5 level of CTS)? If surgery is done at a relatively early point (say within one year) of grade 5 what are the odds I'd have some relief of symptoms? If I wait too long what are the odds of permanent nerve damage? In either case I would assume due to lack of grip strength (one study on this forum stated that out of 89 patients 66 of them still had as much as 50% loss of grip strength after ten months), coordination, dexterity, & bow stringing as well as possible pain in the palm and/or pain when moving fingers due to possible tendon constriction it would be impossible to play various instruments at a very high level, Am I correct. Sorry for so many questions. I realize most of these are almost impossible to answer but I thank you immensely for trying. If there's such a thing as karma you will undoubtedly have earned an immense amount of good karma with all the good you do by helping to put peoples minds at ease and offering some hope. Be Well, Bob.

jeremydpbland
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I would be more inclined to go for surgery if your CTS gets to grade 4 rather than waiting for grade 5, which is a bit late. Alternatively we generally resort to surgery when it stops responding adequately to steroids, even at lower grades. I'm not really a fan of the 'grin and bear it' approach to managing CTS when effective tresatment is available. JB

nofithsrgy
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Hi Dr. Bland: From your last post I assume that your saying that I should possibly try steroids which from what I read for most people is a short term band aid, therefore it looks like your saying I should go for surgery sooner than later. From what I've read at this site and many others my overall odds are that I'll have a 90% chance of some level of positive improvement or at worse remain the same and that I'll have a 10% chance of making things worse. As far as recovery goes it would cover the full spectrum to having a hand that is useful for only minor tasks all the way up to being able to do a large number of things that I do but there will be some amount of compromise in my ability to play multiple musical instruments. Am I correct in my analysis?
I can't thank you enough, Bob.

jeremydpbland
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As I said I would generally inject first. It's a bit of a gamble but one with hardly any downside. The risk of serious consequences is less than 1:1000, a much better bet than surgery, and far from 'always being a temporary sticking plaster' in some patients it provides lasting benefit. It's also useful in helping to predict how you will respond to surgery. Those patients who do well with injection tend to do well with surgery too, and vice versa. In this case I would not speculate further about the likely results of surgery until I know how it responded to steroids. JB

nofithsrgy
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Hi Dr. Bland: Again your help is much appreciated!!! Thanks for all your help and time!!! Be well, Bob.

nofithsrgy
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Hi Dr. Bland - Just checking in with an update. On Jan. 11, 2017 I tried hydrodiscetion therapy under the guidance of ultra sound. Watching the procedure I realised it would be of no value for my conditon but thought why don't they just stretch the ligament the same way they stretch an artery using angioplasty. Fortunately they do which I may have actually read on your web site called "Balloon Carpal Tunnelplasty". I had the balloon carpal tunnelplasty surgery on Monday Feb. 13, 2017. From what I've read and people I've met this is a far superior method for correcting carpal tunnel nerve entrapment, the other two methods should be outlawed. I was able to take the bandages off on the fourth day after surgery as opposed two 10 to 14 days if i had the other type of surgery done. I started playing bass that evening and started playing shakuhachi (flute) & guitar on Saturday. The pain from the nerve compression went away completely. The numbness and tingling also went away completely on the thumb, index and ring finger. The middle finger was actually slightly worse than before the surgery when I played bass with respect to numbness and pain. It's a little over 9 weeks and the middle finger is substantially better but not yet 100% (I'm told by the surgeon that it will take a little more time but should recover completely). It's hard to say what the long term results are due to lack of studies but I'm told that unlike open incision or endoscopic cutting of the ligament the symptoms will not return over time. As far as playing any of the instruments all out I took my time. After four weeks I had no problems playing with other people I just took it easy. After eight weeks I could play all out for a half hour straight probably more if I had too but the situation didn't warrant it. All in all I would highly recommend it (I am extremely picky, I went to a total of four top New York surgeons, three of them were perfect so I was going to call the fourth surgeon who was honest and also did one of the few surgeries that was successful but fortunately I found this method). I used Dr. John L. Berger in Fairfield New Jersey. As far as I know he was the creator of this procedure( I could be wrong) and has been doing this for approximately 23 years. You may want to leave this information out, I don't know if you want to mention the doctor's name. I can't thank you enough for all your help. Hopefully this info will help other people who want an alternative method. Thanks and be well, Bob.

nofithsrgy
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HI Dr. Bland - Here's some information that might be of interest to you. The ultrasound measurements of the nerve in my right mid forearm was .82. The measurement of the nerve at the wrist was 1.46. According to the doctor who did the test anything over 25% is an indication f carpal tunnel syndrome, mine being 78%.

jeremydpbland
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Dr Berger first published the technique of balloon carpal tunnel plasty in 1992 but it took him until 2006 to get around to publishing another paper with a more formal evaluation of it's success rate in 81 patients randomly allocated to to either open CTD or the balloon procedure. The follow-up period for this study was only 24 weeks so there is no published evidence to justify the claim that recurrence does not happen with the balloon though it does with OCTD. (Recurrence after OCTD is rare and generally takes 10-20 years so generally surgeons know nothing about their recurrence rates because they do not see the patients)  Both procedures were pretty much equally effective in that small study. No-one else seems to have published anything on it, at least that I have found, so it should still be considered an 'experimental' technique. From a theoretical point of view I would worry about the pressures on the median nerve exerted during the procedure. Even though Dr Berger's device has a 'protector' built in to try and stop the balloon damaging the nerve as much as it damages the ligament the pressure in the tunnel will undoubtedly become very high indeed during the procedure. It's also worth noting that the TCL is a really tough structure so that 'stretching' it is not an easy proposition but does require considerable force - far more than needed to dilate an artery.

Hydrodissection - a controversial topic. All published reports of this have carried out the procedure with an injectate which consists of a large dose of steroids. I think all they are showing is the effect of steroid injection and that the 'hydrodissection' is irrelevant. I would be very interested to know whether whoever did yours was sufficiently confident in the procedure to use only saline.

The ultrasound results are odd. Most of us in the nerve ultrasound community now measure the cross sectional area of the median nerve and those measurements are usually in the range of about 5-20 mmsq in normal individuals and patients with CTS - in my lab the normal range is 4-10 mmsq at the wrist and most patients with CTS are >10 mmsq at the wrist - figures of 0.82 and 1.46 are therefore obviously not cross sectional area measurements in mmsq as they are too small. If they were CSA measurements in cmsq they would be much too big. They might be a diameter for the nerve in cm but they actually look a bit large for that, unless they are long axis of a very flattened oval - you can see what I mean about the difficulties of choosing a measurement to make on the ultrasound imaging pages of this site. Whatever they were measuring it obviously does suggest that there is some relative swelling of the nerve at the wrist compared to the forearm - which is typical of CTS. There is a bit of debate over whether one should make these measurements relative to the forearm area (The Duke Univeristy group likes that method), or just compare the absolute value at the wrist to a normal range. I find that the latter approach actually gives very good diagnostic sensitivity for CTS anyway and I only usually bother formally comparing with the forearm as a ratio maeasurement in unusual situations, such as a very small individual with generally very small nerves (I once had to image an infant of 3 months!)

Please let me know how it turns out long-term. You are the only individual I know of who has had this particular procedure so it's really useful anecdotal experience. JB

nofithsrgy
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Hi Dr. Bland - Sorry for the long delay the last few weeks were very hectic. I saw Dr. Berger on May 25, 2017. He would be more than happy to discuss the procedure with you. He's affiiltated with "Orthopedic Associates" of Fair Lawn, NJ 07410, USA.
phone: 201-794-6008, fax: 201-794-6190. Two web sites people on the forum might be interested in are: IBMEDICALUSA.COM
& " ballooncarpaltunnelplasty.com". The numbness in my middle finger is almost gone. I would think that in a few more weeks it should disappear and I would consider my hand at 100%. I haven't pushed myself but I can easily lift 20 lbs.and hang from a chinning bar. I can play all instruments with no problems with the pain, numbness and tingling gone. I can finally play with a guitar pick again no problem. Last Saturday I got together with a friend of mine and played two pieces for 35 minutes and one for 25 minutes effortlessly. I've been back to work for two weeks and thankfully no problems(I am an electronic technician and use my hands all day). I will definitely keep you informed with updates as long as your interested. Be well and again thanks you are surely a godsend to many people, Bob.

P.S. as far as the hydrodissection therapy the doctor was very confident but when I saw what was happening on the ultra sound screen I realized that in my case it would be of no value.

jeremydpbland
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Thanks for the update and I'm glad it's doing OK. If Dr Berger wants to come on here and debate his procedure he would be very welcome but I wish he and his colleagues would publish some systematically collected long-term outcome data in a peer reviewed journal. I really want to know what the recurrence rate is after the balloon procedure 10-20 years later. He's been doing this since 1992 but I suspect has long since lost touch with most of the patients operated in the 90s. It would be very unusual indeed for a surgeon to attempt follow-up over that sort of duration. We do however know that some patients develop true recurrent CTS 10-20 years after traditional surgery and one would wonder whether the rate after the balloon procedure might be higher or lower. Even a 2-3 year follow-up study would be very useful however.

The LBMEDICALUSA.COM address and ballooncarpaltunnelplasty.com are very close to advertising and I'm in two minds as to whether they should stay on here. I try to keep the site rigorously non-commercial and evidence based as far as I can make it. Those sites are essentially touting for business for a group of orthopaedic surgeons carrying out this procedure which, as I said, I would still consider to be 'experimental'. It this were a drug I do not think it would have been licenced for general use on the strength of the two published papers I have seen so I would prefer to see this method used only in a careful prospective research study, though I agree with Dr Berger on principle - it is a promising technique that deserves proper testing and evaluation of the results. On the other side of the argument your experience of the procedure is a useful anecdote and other patients might want to find out more about it so one could argue for keeping the link in for the benefit of others, albeit probably only those in Florida and New Jersey - I'm not aware of anywhere else that this is available. The procedure has the advantage of a very google search friendly name and just looking for "balloon carpal tunnel" - takes you straight to several appropriate sites so it's not too dificult to find out about it. (The 6th hit on my test search now was one of Dr Berger's articles and adding 'Berger' to the search makes it even more specific - we have already mentioned him several times and there is a link to one of his papers from the surgery section of my site anyway). What do you think?

There is one interesting abstract linked to Dr Berger's web pages which I've copied here:

Zong-Ming Li, Jie Tang, Matthew Chakan, Rodrigo Kaz

This study investigated the expansion of the carpal tunnel resulting from the application of palmarly directed forces to the transverse carpal ligament (TCL) from inside the carpal tunnel. Ten fresh-frozen cadaveric hands were dissected to evacuate the carpal tunnel, and thus to expose the TCL. A custom lever device was built to apply forces, ranging from 10 N to 200 N, to the TCL. Without force application, the carpal tunnel area was 148.4+/-36.8 mm(2). The force application caused the TCL to form arches with an increase in cross-sectional areas of 33.3+/-5.6 mm(2) at 10 N and 48.7+/-11.4 mm(2) at 200 N, representing respective increases of 22.4% and 32.8% relative to the initial carpal tunnel area. The TCL length remained constant under the applied forces. It was found that the TCL arch formation was due to the narrowing of the arch width, which resulted from the migration of the bony insertion sites of the TCL. A geometrical model of the carpal tunnel was then developed to elucidate the relationships among the arch width, TCL length, arch height, and arch area. The model illustrated the effectiveness of carpal tunnel expansion by TCL elongation or arch width narrowing. 

This group applied quite a lot of force to the transverse carpal ligament - 200 Newtons is roughly equivalent to 45 pounds and I think this little experiment demonstrates just how tough the ligament is - it did not stretch even under this kind of force application. All that happened was that the carpal tunnel became more circular rather than oval - thus increasing it's cross sectional area. In a living wrist it would fairly quickly return to it's normal shape once you took the distorting force away. This is what makes me a little sceptical about any of the various ways that have been described of 'stretching' the ligament - not just Dr Berger's technique. There are chiropractors who believe they can do this by manipulation and several mechanical devices on the market which attempt to do it without surgery.

Until we see some carefully collected long-term results published all we will have for this technique is anecdotes so I would very much like to hear how your hand is doing once a year or so please - and if anyone else happens to come across this discussion and has had the same procedure years ago I would like to hear from them too.

One other question - how long did the balloon procedure take - the web video of this procedure rather skips over this aspect but describes three inflations of the balloon.... and was it done with a tourniquet around the upper arm? JB

nofithsrgy
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HI Dr. Bland: The balloon procedure took 15 minutes according to Dr. Berger. I'm not sure which video you saw on the procedure but Dr. Berger also weakens the ligament. From what I understand he uses an instrument with a hook at the end and scrapes the ligament thereby weakening the ligament. I did contact Dr. Berger's office and left a message to contact me about commenting on his method but never received a reply, but I have no idea if he ever received the message. In any case it's been six months since my surgery. I still have a slight numbness at the tip of my middle finger but it has improved since my last post. Whether it's residual from the surgery or just due to my having waited so long before having surgery is an unknown. As I mentioned before my middle finger was somewhat worse after surgery but is now better than before the surgery. I'd say my middle finger is approximately 90 % better and my other fingers are 100% better. I have full strength in my hand as well as having no problem putting my full weight on my hand. Once in a while if I move my hand in an unusual position I'll get a sharp pain in my thumb muscle or in the lower portion of the muscle of the palm underneath the pinky/ring finger. I have no problem playing any of my instruments, it's nice not having my hand go numb when i use a pick to play guitar or bass. All in all I feel extremely lucky to have had the outcome that I've had. I can't say it enough, "THANKS for all your help". Be well, Bob.

jeremydpbland
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Glad to hear it's doing OK. Interesting that Dr B has taken to 'weakening' the ligament as well as using his balloon - this isn't described as being necessary in the published descriptions of the technique. If we're lucky he will come on here and explain. JB

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