Post-op concern

Clint
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Bilateral CTS for >10yrs. Dx NCS (L): severe; (R) moderate but 'complicated' by mild mid-line palmar paraesthesia over thenar / hypothenar eminences. Bilateral open CT release 3/52 previous. Both transverse ligs. demonstrated at surgery to be fully resected prox & dist. Underlying basis of problem: morphological. (R) required dissection through substantial thenar muscles that had crossed the midline. (?bleed) Prompt post-op bilateral resolution of nocturnal Sx. (a real delight!)

Recovery (L): v.nice healing, v.minimal swelling, some incisional tenderness. Grip, excellent; finger pince grip, excellent; wrist mobility and tendon glide full and excellent; mild paraesthesia as before over median distribution but absence of nocturnal sx. Anticipate continued good recovery.
Recovery (R): v.nice healing, mild swelling, incisional and thenar anaesthesia extending to volar pad and lateral aspect of thumb. Grip, poor/moderate; finger pince grip, moderate and weaker at 4&5 with pain in CT. Continual 'squeezing' neuralgic pain felt at wrist, and along course of median n. to medial arm and axilla. Intermittent sharp pain in the deep dorsum of the forearm and hand. Sx markedly > by activity, particularly more static tension eg. playing piano, which results in > neuralgia and profound anaesthesia/dysthesia in the thumb pad and odd swelling sensation. Relieved after a night's rest, though sleep may be disturbed.

I concede I may have been doing 'too much' - eg. mowing grass 2 days after surgery etc.. but based on the superb recovery of the diagnosed worse (L) side, which involved prolonged dissection to release a heavily compressed ribbon like nerve, and which presented no post-op difficulties at all, I pressed on. The (R) side is a frank cause of anxiety with the brachial neuralgia (median n.) varying from a persistent quiet throb to awe-inspiring. It may be brought on by keyboard work (within 1 min or playing piano, within 3 min). It has improved since surgery, when immediately afterward the neuralgia in the arm was truly severe and only relieved by staying completely still. In any event, these are entirely new (R) hand and limb sx since surgery.
Surgeon's comment at suture removal and post-op check was dismissive. He offered no explanation and less interest. I regard the surgery as 'successful' but the development of troublesome and new symptoms in the right extremity are personally concerning.
Due for 6/52 post-op follow-up end Jan.

I would deeply appreciate any insightful comment please. Clinicians make the worst px!
My own feeling is that a cutaneous branch of the (R) median n. may have been injured. This may explain the distribution of the anaesthesia. The (R) brachial neuralgia appears more difficult to explain. Could it have been associated with a bleed? A sense of prognosis (on the R) would also be helpful based on your extensive experience.
Many thanks in hopeful anticipation of your response.
Clint.

jeremydpbland
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The palmar cutaneous branch of the median nerve is certainly sometimes injured during surgery and usually supplies the skin over the thenar eminence and lateral half of the palm but not usually the border of the thumb so there is something a bit odd about that - though of course there is considerable variation in 'normal' human anatomy when it comes to the cutaenous distribution of small sensory nerves. This much pain after surgery is unusual, though it is at least, by the sound of it, improving somewhat. It probably is reasonable to review at 6 weeks as most of the immediate peri-operative inflammation should have settled by then. If it is still very problematic at that point I personally would want to repeat the NCS and look at the operation site with the ultrasound scanner to check that there really has been an improvement in nerve function and that there is nothing structurally untoward. If you have read the sections of this website on severity you will know that the terms 'moderate' and 'severe' can mean very different things to different people when it comes to CTS - do we have the actual NCS rescults from before surgery? JB

Clint
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Thank you kindly JB. Yes, I understand the subjective nature of descriptive terminology and have finally secured the NCS results, below.

Left MEDIAN MOTOR (thenar)
SD left median motor raw data
Distal motor latency 6.1 8.3 MARKED DELAY Lat Amp Area Dur Distance
Distal amplitude(mV) 9.8 0.6 WR 6.05 9.80 46.60 8.85
Distal area 46.6 1.8
Distal duration 8.9 2.5

Left MEDIAN SENSORY digit III - wrist
SD left median sensory raw data
CV onset 34 -6.4 MARKED SLOWING Los Lpk Amp o/p Amp pp Distance
CV peak 26 -7.9 MARKED SLOWING 3.70 4.85 1.70 1.20 124
Amplitude (μV) 1.7 -9.0 MARKED REDUCTION
duration 1.15 10.2

Left MEDIAN SENSORY antidromic digit III
SD
Amp palm-III 12.5 AXONAL LOSS left median antidromic raw data
Amp ratio wr/palm 0.69 -1.3 Los Lpk Amp o/p Amp pp Distance
dispersion 122% -0.7 pa 1.25 2.15 7.10 12.50 67
CV palm - III 54 wr 5.25 6.35 4.00 8.60 85
CV carpal tunnel 21 -8.1
CV diff (normal >-7) -32 -10.0 MARKED SLOWING

Left ULNAR SENSORY digit V - wrist
SD left ulnar sensory raw data
CV onset 59 -0.3 Los Lpk Amp o/p Amp pp Distance
CV peak 42 -1.5 1.85 2.60 5.90 9.60 110
Amplitude (μV) 9.6 -0.4
duration 0.75 3.9

Right MEDIAN MOTOR (thenar)
SD right median motor raw data
Distal motor latency 4.4 3.7 MILD DELAY Lat Amp Area Dur Distance
Distal amplitude(mV) 9.5 0.5 WR 4.35 9.50 37.80 6.70
Distal area 37.8 1.0
Distal duration 6.7 0.7

Right MEDIAN SENSORY digit III - wrist
SD right median sensory raw data
CV onset 40 -4.4 MODERATE SLOWING Los Lpk Amp o/p Amp pp Distance
CV peak 33 -5.3 MODERATE SLOWING 3.10 3.80 1.80 2.00 125
Amplitude (μV) 2.0 -8.5 MARKED REDUCTION
duration 0.70 3.0

Right MEDIAN SENSORY antidromic III

Amp palm-III 25.8 right median antidromic raw data
Amp ratio wr/palm 0.43 -3.2 CONDUCTION BLOCK Los Lpk Amp o/p Amp pp Distance
dispersion 100% -1.5 pa 1.35 2.10 20.70 25.80 70
CV palm - III 52 wr 4.15 4.90 6.50 11.00 83
CV carpal tunnel 30 -6.2
CV diff (normal >-7) -22 -7.0 MODERATE SLOWING

Right ULNAR SENSORY digit V - wrist
SD right ulnar sensory raw data
CV onset 55 -1.5 Los Lpk Amp o/p Amp pp Distance
CV peak 43 -1.4 2.10 2.70 3.20 6.30 115
Amplitude (μV) 6.3 -1.8
duration 0.60 1.6

OTHER RELEVANT INFORMATION: symptoms have been quite marked and unusually seem to include the median palmar cutaneous distribution as well as digital nerve involvement.

PRINCIPAL FINDINGS: marked left median nerve compression at the wrist with moderate involvement on the right.

DETAILS: median sensory amplitudes were markedly reduced bilaterally. This was shown to be due to axonal loss on the left and conduction block on the right. Marked focal slowing was found through the left carpal tunnel in both motor and sensory axons. Mild (motor) to moderate (sensory( slowing was present through the right carpal tunnel. Normal ulnar sensory action potentials were present bilaterally.

jeremydpbland
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If I am interpreting which number is which correctly those show grade 3 left and grade 1 right CTS - on my scale from 1(mildest) to 6 (worst), you might push the right side to grade 2 depending on the local normal values for that lab which are not given. The really key figure is the distal motor latency to APB which I take to be 6.1 msec on the left and 4.4 msec on the right.

From grade 3 you would expect rapid resolution of symptoms after surgery and more or less complete recovery as long as you escape the complications of cutting the ligament, so that side is going according to plan.

With grade 1 changes it is sometimes hard to be sure that the abnormality you are finding on NCS is actually anything to do with the symptoms and a significant number of people with grade 1 do poorly with surgery, probably in at least some cases because CTS was not really the main problem. Our preference is to try grade 1 with splints and steroids first and to be very wary of surgery on patients who show no symptomatic response to steroids. The comment on involvement of the median palmar branch territory is interesting though they did not say which side they were talking about. Anatomically CTS should in theory spare the palmar branch so I would keep an open mind about whether the problem was CTS on the right, though if it felt the same subjectively as the left that is pretty strong evidence. It's also slightly unusual for this to be worse in the left hand unless you are left handed or there is some specific reason for it like an old wrist fracture.

If the right hand problems do persist then repeating the NCS and ultrasound imaging between 6-12 weeks post surgery may throw some light upon it but is not guaranteed to I'm afraid. The palmar cutaneous branch can be imaged as it leaves the median nerve and usually as far as the heel of the hand over the transverse carpal ligament but gets a bit difficult after that. An American colleague has published a paper describing imaging of the recurrent motor branch too but I have had little success with this myself so far. If there has been damage to that branch it should be evident from needle EMG however. That's about as far as I can speculate at this stage. JB

Clint
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My grateful thanks once again for your reply. I will bear your helpful comments in mind and simultaneously hope that with the passage of time the incremental improvement continues.

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