numbness three weeks PO endoscopic carpal tunnel release

ohboy3x
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Hello,

Had single incision endoscopic carpal tunnel release three weeks ago. When my CT was diagnosed previously, my symptoms were numbness at night and periodically when working. After surgery my doctor told me he had to make several passes during the surgery to remove "significant adhesions and scar tissue". Now three weeks post op my middle finger and 1/2 of my ring finger are numb especially in the area between them and I have a burning sensation on the palm side of my fingers. Is this normal or is it possible there was some nerve damage done with all the scraping he needed to do? I didn't have the constant numbness before the surgery. Thanks for any input !

jeremydpbland
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That could be a description of injury to one of the palmar branches of the median nerve - or of the fascicles within the median nerve at the carpal tunnel which are to become that branch in the palm. It's very hard to be certain however. If there are good pre-operative nerve conduction studies available it might be possible to get some way towards an accurate diagnosis with careful post-operative studies and maybe high resolution ultrasound. However I would probably wait until at least 6 weeks post-op as there is a possibility that this is only a neuropraxia which may recover spontaneously. JB

ohboy3x
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Dr. Bland,

Thank you for your response. I had a nerve study and EMG test and will see my surgeon in a week for follow up and results. The neurologist who performed the test only said there seemed to be some "slowing" in the wrist area and that could be from swelling.

Unfortunately there are no prior tests to compare with. Because my surgeon needed to make several passes to remove adhesions and scar tissue scraping the tendon (in his words) and was close to opening up my wrist, would that have made nerve damage or irritation more probable?

I'm now 5 weeks PO and have absolutely no change in numbness of 1/2 of my middle finger and 1/2 of the ring finger. I can't feel anything particularly between the fingers. I have tingling on the tips of both fingers and I have some sensation on the palm side of both fingers but it feels uncomfortable and a burning feeling when I touch the palm side of both fingers. Two days ago I started getting a sporadic burning feeling in the center of my palm.

If after six weeks I have no improvement what would you recommend? Also what is the benefit of an ultrasound ... will it show nerve damage? If there is injury to the palmar branch, what is the treatment? I'm extremely uncomfortable and frustrated because my fingers were not numb before the surgery and I'm unable to work. I had an open CT release on my opposite hand along with a ulner nerve transposition 3 years ago and had immediate relief after the surgery so I'm a bit concerned with this outcome.

Once again thank you for your answers - this site has been extremely helpful.

Have a good day.

jeremydpbland
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It's a pity there are no pre-operative NCS for comparison. Did the person who did the new set try to test particularly the area affected by the new numbness (this is difficult but it can be done to some extent)? Ultrasound examination can do a few things. It is possible to check that the transverse carpal ligament has been satisfactorily divided and if you have a skilled operator with a high quality scanner it is possible to follow each branch of the median nerve all the way to the finger ends. Injury to the palmar branch which eventually supplies the adjacent sides of the ring and middle fingers will show up as a swelling of the nerve (a neuroma). However, there are very few people who are competent to do this. Endoscopic surgery probably does carry an increased risk of temporary neuropraxia. What to do beyond 6 weeks probably relies on a very careful examination of sensation in the affected area and on the exact findings of the NCS - not something one can do on the internet unfortunately. My guess is that this is in the USA? JB

ohboy3x
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I am hopeful the neurologist specifically did test the area - my referal noted the numb fingers. I was wondering if you can explain a little further about a neuroma. Does the entire palmar branch become swollen? Is there any treatment aside from waiting for it to heal and does it heal? At this point I'm so uncomfortable - in my perfect world we could surgically go back and open up my wrist to see what is going on but I'm assuming thats not practical nor would be of value?

As far as temporary neuropraxia, is there some sort of timeline as far as when feeling could come back or could this be longterm? My worry is that this will not resolve.

Your guess is correct - I am in the USA. I am set to see my surgeon in two days to discuss my EMG test results and hoping to get some kind of idea of what to expect going forward. Is there anything I should be specifically asking at that appointment?

I am grateful for your help and the info on this site has been the most comprehensive CTR advice on the internet, particularly when it comes to complications. Thank you again for your help!

jeremydpbland
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The whole point of the ultrasound exam is to try and get a look at what is going on without having to 'open it up' again! You can get surprisingly detailed images. Neuropraxia can last anything from a few hours to about 3 months and can be thought of as the nerve stopping working for a while, but retaining it's structural integrity. Nerves are like any other tissue - when you injure them you see swelling at the site of injury. An injury that does not break the nerve will produce a fusiform swelling in continuity but if you cut right through a nerve you see a swelling at the cut end. With endoscopic CTD, lesions in continuity are much commoner than nerve lacerations - though both have been reported. Which it is has implications for treatment - lesions in continuity are much more likely to recover and are usually left alone to heal. There is no concrete evidence for this but I suspect that an injury which is too mild to produce swelling visible on ultrasound probably has a better outlook.

You should be able to tell what the neurologist tested if you were paying attention during the test. NCS to test the sensory nerves in the USA are usually done 'antidromically' which means placing ring electrodes around the fingers and giving a shock at the wrist to stimulate the nerve (usually 14cm up the arm from the ring nearest the base of the finger - you may remember them measuring this). Doing this using the middle finger in your case might have given a relatively normal response however because they are recording from both the affected and unaffected sides of the finger - which are supplied by two different branches of the median nerve. To selectively test each branch you have to recod at the wrist and carefully stimulate each individual digital branch - so in that case the shocks are to the fingers, not the wrist, and usually need to be given with a small handheld stimulator. Even then it is difficult to stop the stimulus spreading to the 'normal' side of the finger but it can be done with care. JB

ohboy3x
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So I met with my doctor to go over my EMG/Nerve tests. My surgeon said because the test showed the right median distal motor latency was minimally prolonged and the right median sensory conductions were mildly slowed - he was of the opinion the nerve is just "irritated" and should recover although it could be up to 5 months to obtain complete healing and the feeling back in my fingers.

He felt because the radial nerve readings were normal there was no severe nerve damage such as a laceration. He is also of the opinion that I still have quite a bit of swelling in my wrist area and was going to do a cortisone shot to reduce the wrist inflammation but decided to wait on it. I asked him about doing an ultrasound but he didn't think it was of value at this time because of the test results. He also stressed that I should continue to "use" my hand even though my fingers become extremely sore and painful particularly after using the computer for a while. My hand "aches" at the end of the day and i continue to have trouble sleeping because of the finger numbness.
My test results were as follows:

Motor Nerve Conductions

Nerve Latency Amplitude Velocity Distance

Median 4.3 2.1 10
79 2.1 56 20

Ulner 3.4 5.4 10
7.1 5.4 62 23

Radial 4.3 2.1 20

Sensory Nerve Conductions

Nerve Latency Amplitude Velocity Distance (cm)

Median
(thumb) 2.1 44 38 8

Median
(ring) 4 12 40 16

Ulnar 1.5 39 53 8

Radial 1.6 38 56 9

The impression was the findings are consistent with mild to moderate residual Carpal Tunnel Syndrome

I'd appreciate your input and opinion on these test results and the wait and see approach my surgeon has suggested.

Thanks for your time ..

jeremydpbland
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It looks as though they did not make any special effort to test the territory in which you have the new numbness. It is quite striking in those results that the median sensory nerve potential ampitude for the ring finger seems to be 12 microV, compared to 44 microV for the median potential using the thumb and 39 for the ulnar (presumably little finger but this would be more significant if the ulnar one was also recorded using the ring finger). It therefore looks as though the median/ring recording is unusually small compared to the others but we don't know what the normal values are for that lab. Comparing with the other hand would be useful. At this point, whatever the diagnosis, there is probably little you can do in terms of treatment other than sitting tight and waiting I'm afraid. As you know I would do somewhat more extensive NCS and u/s examination here to try and figure out what the problem is but I have to admit that whatever I found it would be quite unlikely to lead to specific treatment. Let me know how it evolves though please. JB

ohboy3x
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One question I forgot to ask if I may ... because of my diagnosis of "residual carpal tunnel" is it worthwhile to wear my splint or is it better to keep moving and using my hand through the discomfort? Does it benefit nerve healing to splint my wrist?

Thank you !

jeremydpbland
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I don't think anyone really knows the answer to that one. In practical terms, if you think the splint helps control symptoms then use it - they are pretty harmless. It is unlikely to inflluence the process of nerve recovery either for better or worse after surgery I think. Nerves either regenerate or they don't and there are very few things that we have control over that make much difference to the process. The issue of whether to try and 'work through pain' in rehabilitation is a dificult one and not my speciality. I would suspect that there is a lot of individual variation in this from one patient to the next and that only someone very closely familiar with both the patient and the particular injury should really advise. JB

ohboy3x
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Thank you for all of your quick responses, Your advice has been extremely helpful as I go through this process. Hopefully this will resolve at some point and the feeling in my fingers will return .. I'll keep you posted !

ohboy3x
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Hi there,

Just a follow up @ about 15 weeks post op. I've had no change in symptoms that occurred after my surgery with the exception of my middle and ring finger get "cold" when the rest of my fingers and hand are warm - I also have constant burning sensation on the palm side of both fingers which wasn't there in the early weeks after my surgery. I continue to have no sensation particularly at the web space between my middle and ring finger as previously mentioned.

At todays appt. with my surgeon, It was his opinion that I have a compression at the carpal tunnel area resulting from scar tissue and swelling from the surgery and he doesn't recommend anything other than nuerontin for pain and waiting 6 mos. to see if feeling comes back. He told me nerve irritation is one of the risks that can occur with CTR surgery and with the results of my last EMG nerve study the nerve was not severed. He did a Tinel test and I felt the zapping feeling on the palm side between my ring and middle finger - he said that was a good sign. My concern since I continue to have zero change is that if there was some kind of nerve damage and I wait too long (6 months) if something could be done do I run the risk of not being able to repair or address an injury that could be repaired.

I've scheduled an appointment with a hand specialist for a second opinion and was wondering if you could suggest questions I should be asking also I have another Nerve study scheduled and would love some feedback on what I should look for or ask at this second test.

I am so uncomfortable all the time with my fingers its hard not too think or focus on anything else. They are a constant source of discomfort even holding the steering wheel when I drive. I guess I'm hoping for answers that may not be out there but I will feel better with a second opinion at this point. If you can offer any other suggestions I'd appreciate it.

Thanks again for your time and expertise.

jeremydpbland
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I guess the key question is "could this be an intra-operative injury to the palmar branch of the median nerve which supplies the middle and ring fingers?". The other thing is to enquire whether you have anyone in the immediate area who is really good at nerve ultrasound imaging. There are several people in the US who are very good but it's a big country and they are scattered around. In the nerve test ask them to try and do sensory tests on all the fingers and compare with the other side. They could also try to stimulate just the individual digital nerves of the affected fingers and record at the wrist, again comparing with the other side. This is difficult because of spread of the stimulus to the opposite side of the finger but with careful comparisons with the other side it is possible to make something of the results. JB

ohboy3x
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Hello Dr. Bland,

Just wanted to check in with an update from my endoscopic CTR done 3/3/17. Unfortunately I have had no improvement in the continued tingling and numbness on 1/2 of my middle finger and ring finger and have a burning sensation in my palm almost in the center below the two fingers. I have seen two hand specialists who both say there is nothing to be done.

I can tap at the wrist area and illicit a slight tingling sensation at the point between the middle and ring fingers on my palm side. Pressing down on my palm about one inch from where the release was done - not the actual scar which is above on my wrist, is tender and burns. I was just checking to see if you had any new input regarding my continued symptoms or if this is something that may or may not resolve. I'm still hoping for answer.

Appreciate your time!

jeremydpbland
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I'm sorry to hear that but not entirely surprised I'm afraid. On the assumption that this is a relatively minor nerve injury that is leading to persistent irritative symptoms then the hand therapists will offer a variety of massage, exercise, desenstisation and odd techniques such laser or ultrasound application but I have to say that there is no concrete evidence that any of these things help. They do at least allow you to feel that something is being tried though. Surgically there are procedures such as interposition of a fat pad between the nerve and the skin which have been attempted for problems after carpal tunnel surgery but again evidence of efficacy is thin on the ground and some surgeons who used to do these have given them up. A further set of NCS to check that the nerve is not deteriorating since the first post-operative set can sometimes be useful, but not often with this particular pattern of symptoms. In my own clinic I would still be trying to identify the exact site of the injury but that's not something I can do via the net I'm afraid. The point at which you can elicit tenderness in the palm is the obvious site to look as post-traumatic neuromas are often painful on pressure. JB

ohboy3x
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I initially met with a hand therapist a few times and then stopped. It hurt too much and my feeling at the time was I didn't want to further irritate the nerve. I am scheduled to see my surgeon again in a few weeks and will request a new NCS to compare with the post op NCS. Can you give me more info on a neuroma? In regard to the palm tenderness to pressure and burning sensation what are other symptoms of post - traumatic neuromas? You mention that you would try to identify the exact site of injury - how would you do that?

Lastly are there any questions you would suggest to ask specifically when meeting with my surgeon at this point?

Thank you for your time and expertise!

jeremydpbland
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A neuroma is simpy the swelling formed at a site of nerve injury - they are often pressure sensitive. I would be using a mixture of detailed nerve conduction studies and ultrasound imaging to try and identify the site of any such problem but that's pretty much a research level application of the techniques at present and not necessarily something that you would expect the average jobbing neurophysiologist or musculoskeltal ultrasonographer to have in their repertoire. There are a few people in the USA who would probably take it on but the odds of you being near to one of them are slim and even if you do identify a small post-traumatic neuroma that doesn't necessarily tell you what to do about it - treating them is not that easy. I would definitely ask your surgeon what he thinks the cause of the persisting symptoms is and you might enquire what he thinks about fat pads and similar interventions for post-carpal tunnel decompression symptoms of this type. JB

ohboy3x
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One more question ....

One more question if I may - when I tap on the area right below my wrist, where I assume the release was done I get an electric shock feeling at the exact spot between the middle and ring fingers inside palm area. Is this a good sign ? There is no shock feeling throughout my palm just at the base of my two numb fingers. It may be nothing but I thought it might be worth mentioning.

jeremydpbland
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That is technically known as Tinel's sign and indicates the mechanical sensitivity of nerve fibres either at a site of injury or where new nerve fibres are regenerating. Tapping causes the nerve fibres to fire off action potentials which are interpreted by the brain as that tingling/shock like sensation (The word originally used by TInel, who was french, was 'fourmillement' - the sensation of ants crawling on the skin, which is very vivid). Exactly where you feel this depends on which nerve fibres are sending the signal. The brain has no way of knowing where a signal comes from other than past experience - you feel a pin stuck in your finger in the finger because the brain has learnt that that particular set of nerve fibres are connected to the finger so they have become mapped onto the bit of sensory cortex for the finger. When you then generate a spurious set of impulses, halfway along the route from finger to brain, the brain still interprets that as originating in the finger, so that is where you feel it, even though the signals may have started out at the elbow. Mis-interpretations of incoming signals like this are quite common. They underlie the phenomenon of 'phantom limb pain' when someone can still 'feel' an amputated limb and I've recently seen a man who had the nerves cut at the shoulder and re-connected to the wrong stumps so that now when you touch the little finger he feels that in the thumb. In your case I wouldn't interpret it as either good or bad. JB

ohboy3x
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Hi Dr. Bland - I'm hoping to get your opinion once again as I had a second NCS study last week and am now nine months post op from my surgery and continue to have no change in symptoms.
My second nerve study shows no improvement and my surgeon has proposed surgically opening up my wrist to for a second look to see if there is any scar tissue etc. and to look a the nerve branches? He also wants to do a fat transfer. Is it possible to send you my current NCS studies as well as the study done in March following my surgery? I would appreciate you taking a look at them and letting me know what you think about the recommended surgery. I'm not opposed to another surgery if there is a chance I can get some feeling back and some relief from the constant discomfort but would also like to hear what you think. Let me know how you prefer to get my NCS studies. Again thank you for your expertise and knowledge.

jeremydpbland
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Happy to look at them - probably best sent by email (my nhs email address is in the contacts section of the site) - JB

jeremydpbland
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Thanks for the NCS. I've replied in detail by email but essentially not much change compared with the previous set. JB

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