What should my next steps be?

Curtis Stevens
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Hi Doc,

I hope you can provide some words of wisdom as you really seem to know your stuff! To summarize, I've had CTS for several yrs now (at least since 2014). I have done various things and symptoms have gone up and down. I think I had many causes, one of them being my posture at my computer, which I have since adjusted and stopped doing Crossfit last yr, which is why my symptoms have changed I feel.

I saw a surgeon last yr, lets just say I didn't go back as I felt he was very condescending, then he shortly retires. I had an EMG done a few months ago (December 2016), but do not have a copy but sorta remember the results. I saw another surgeon yesterday and not sure if I want to go back as he didn't allow enough time for me to get all of my questions out. I feel more stressed out now than I did before the appointment. For the hands, I remember the numbers being 4 and 5 something. 4+ was for left, 5+ was for my dominant right. Not sure if it was both for sensory and motion, but he did say it was about a 30-40% reduction. Elbow was a 42, at least one of them. I don't remember if both elbows, I'm guessing so. Based on my moderate severity, he is recommending cts release and ulnar nerve decompression.

From what I can remember and what I was understanding he was saying is either my tunnel decreased in size over time, causing the pressure or my tendons enlarged, causing the pressure. I was not able to get it out, but if it is because your tendons have enlarged, is not possible to get them to shrink? Have you ever seen someone's EMG results with those kind of numbers ever go back to normal without surgical intervention? I guess this is the one question that I can't keep thinking about.

I have done so many things, but I didn't know about the ulnar nerve and now I'm wondering if most of my current symptoms (most of them) are from the ulnar and not median. And should I try wearing an elbow brace at night and see if that gets better and with that, it might just be possible that I have the EMG done in a month or two and everything could be better. That's what I would like to hope for, but don't know if that is just wishful thinking and I should just stop thinking that right now.

You are talking about cutting two different things on both arms. I could handle endoscopic CTS, but now both elbows? I financially support my family. I just want to make sure I can't make my symptoms go away and reverse the damage without surgery.

If all of that isn't enough, my wife is a teacher and she is off during the summer, which is so important to have her help me. You are talking about doing one side at a time, recovering between the two and we have some things going on this summer. So I need to get something figured out soon, but I need to at least get my symptoms to decrease as I'm just tired of dealing with it at this point. Too chronic. On top of that, my thought is can I still heal this without surgery if I start bracing my elbow and is there enough time to show results that would show up in an EMG test, all before I need to decide if I'm going to do the surgery. I would say first surgery needs to happen in June.

Thank you so much for any input you can provide and I understand anything you say, can only be based on what limited info I've shared. It has to be better than what I can find online and what's floating around in my head.

Curtis

jeremydpbland
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Quite a lot of questions! It's not really possible to make sense of those remembered comments on the NCS results so if you can get hold of a copy that would help a lot. Most surgical clinics are very tight for time so I'm not surprised you felt a bit pressured

Even quite severe CTS can resolve without any active treatment at all, though this is not common for the more severe grades but I have seen my grade 5 resolve without intervention. My preferred tactic when there is any doubt about which way it is going is to use serial nerve conduction studies to track it but in many healthcare systems that is not practical.

Personally I think that in most cases it is not the tendons that are enlarged, nor the tunnel which is narrowed, but an increase in the volume of the tendon sheaths, median nerve itself and miscellaneous packing tissue in the tunnel which increases the tunnel pressure. There clearly are some cases with different mechanisms, especially after things like wrist fractures but I think most cases of CTS fit the above description. The swelling of these tissues can be reduced by steroids, and possibly in early cases by rest/splinting but nothing else has been clearly shown to have an effect. Conventional surgery simply makes more space for the swollen tissue.

The best guide to which nerve is causing trouble is the distribution of the tingling and numbness. Pain is a much less reliable indicator so look for which fingers feel numb. If it is mainly the thumb, index and middle fingers then this is the CTS/median nerve, whereas if it is worst in the little finger that is the ulnar nerve. The ring finger is difficult because it gets part of its nerve supply from each nerve. If your symptoms are predominantly those of CTS rather than ulnar neuropathy at the elbow (UNE), then I would ignore the NCS results round the elbow and just treat the CTS. 

Local steroid injection at the wrist is a good short term fix for CTS and is also quite a good predictor of what you can expect from surgery for CTS so that is another good way of helping to distinguish whether the problem is really the wrist (CTS), the elbow (UNE), or both.

I'm not a fan of simultaneous bilateral surgery, especially not for both CTS and UNE at the same time. I like to take a more measured approach, treat one thing at a time, and re-evaluate the situation as we go along, but I appreciate that that does prolong the overall episode of illness in those cases where you do end up doing multiple procedures in the end anyway.JB

Curtis Stevens
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I did not realize you were not in the USA, which is where I reside. Thank you so much for your detailed response! That's pretty sad I'm getting more help from someone in the UK than in my own place of residence.

I just received my results from the doc. I have uploaded it to this website I found online that allows me to share the PDF with you. You can download the file directly using this link: https://www.keepandshare.com/doc11/20137/314164799-pdf-57k?da=y

I would upload it here but no way of doing that.

Lets assume I have an increase in the volume of the tendon sheaths, median nerve itself and miscellaneous packing tissue. Based on those test results you can see at the above link, in your professional opinion, do you think it is possible to have it stop progressing and reverse itself with natural methods like splinting? I have been wearing the custom made hand splint since Jan sometime. You said the swelling of those tendons can be reduced by steroids and possibly splinting, but is that permanent? I understand surgery just makes more room, but if you can't get what is swelled up to shrink in size and have that to be permanent, then it sounds like to me, your only choice is to make more room. Once you go the surgical route, does everything shrink in size because it has more room to breath and relax or are you basically making a bigger room for those fat tendons to move around in, but you can't make them go on a diet and lose weight after they have become fat?

Right now, I think my major symptom which is with me most of the time is a dull, very light feeling, not sure how to describe it, but maybe that sensation you get when your muscles are so tired, they ache. Maybe a very light tingling feeling, but it feels like it is the whole hand. If I start doing things like hold up a cell phone to my head, I start to get numbness. If I do a lot of work with finger dexterity, I get numbness too. I will be getting some elbow splits I purchased from Amazon tomorrow, I was hoping after wearing that for a few days to a week, that my symptoms may change enough for me to really pinpoint my discomfort and to know which nerve it is coming from.

I keep reading everything you said, trying to wrap my head around it all. Based on those results, do you think surgical intervention is probably my only path at this point? I know many patients probably just listens to the doctor and do what they say, but for me and my brain, I have to understand everything and convince myself I'm making the best decision as this isn't a light one to take.

Thanks again JB!!!

Curtis

jeremydpbland
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OK those NCS resuts show grade 3 bilateral CTS (you can read about the grading scheme, which runs from 1-6, on other pages of this site). I note that the person who reported that says that the ulnar abnormality is 'asymptomatic' so they did not think you have any ulnar nerve symptoms and that this is all CTS. The ulnar nerve conduction abnormality is very mild - the AANEM suggested criterion for abnormality in a 10cm segment of ulnar nerve around the elbow is <50 m/sec and yours are below that but you have no other ulnar nerve abnormalities and without ulnar symptoms I would be against operating on the elbow myself - just try to stop leaning on them or sleeping with the elbow flexed. Given four possible entrapments though one might wonder if you have some predisposition to this sort of thing - is there any family history of similar problems?

That leaves the CTS. Both surgery and steroid injection cause the tissues in the carpal tunnel to shrink interestingly. This can be most easily seen by looking at the size of the median nerve itself with ultrasound imaging. The nerve size reduces after treatment though it does not necessarily go back entirely to normal - this is also true of the nerve conduction studies.

Grade 3 is a good time to operate.... but many grade 3 cases do well with injection too so it's not mandatory to rush into surgery.

If you don't want to leave your NCS results visible to the rest of the world you can take them down from keepandshare now :-)  JB

Curtis Stevens
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You are so awesome! Do you by chance offer consulting services for a fee through skype?

My dad had CTS surgery like 10 yrs ago on both hands. He is a meat butcher, so I assumed occupation hazard, but he is right handed like me and his right was worse than his left.

I recently learned my brother, a dentist since 2006 has been having some mild symptoms as well. He said when it acts up, he wears a brace for a few weeks I think he said, and it goes away.

I've been trying to really pay attention to my symptoms since last week and it seems like I may be getting symptoms from both nerves. If I hold my cell phone up to my ear, I start to get numbness around the pinky and ring finger. I'm wondering, if it is anyway possible, the ulnar nerve is the one inflamed now and the median nerve isn't because I've been wearing the brace for a while now. But I'm getting symptoms from both because the ulnar nerve is the one crowding all the space in the tunnel, so if I get the ulnar nerve to come back down, everything else will magically get better? Does that even sound medically possible and realistic?

Injections - I'm a little confused. Everything I read basically says injections are not permanent for most people and there are some major possible, consequences from it. If cutting the ligament is a permanent fix for most, than why isn't the injections? If it shrinks everything and the injections normally always leads to surgery, then doesn't that mean you are doing something to make it continue to get worse and even surgery won't be permanent? Having a hard time wrapping my head around that.

Right now it seems like my symptoms have reached a point that it is bothering me enough that I'm ready to do something to just make them go away. It isn't painful per say, just chronic that gets annoying when you have a sensation that doesn't feel good, almost all the time.

Not sure what to do. I purchased an elbow brace for both elbows, arriving today. I was thinking I could wear that and hopefully my symptoms improve pretty quickly. Is that wishful thinking and I should just go get the injections? If so, I'm starting to think I should seek another doctor here based on what this first doctor was telling me and what you are saying, which is almost the polar opposite. He did check some muscular resistance exercises with my hands, push against him this way, cross my two fingers, etc.

Curtis

jeremydpbland
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No Skype consults I'm afraid - I don't think the ethics and legality of it are quite right between countries. What I offer on here is help with interpretation and what I hope is a fairly rational overview of the evidence on treatment. The site is also strictly non-commercial - I think money should be kept out of medicine as far as possible - though donations to a suitable charity are fine.

The family history is interesting as CTS is, to a large extent, genetic in origin. Symptoms in the ring and little finger do indeed indicate ulnar nerve problems but usually all you need to do to manage them to begin with is keep the elbow straight and stop leaning on it. The ulnar nerve does not go through the carpal tunnel so there is no question of it crowding out the space for the median nerve. The site of the problem with the ulnar nerve is usually at the elbow, well away from the wrist anyway - so two completely separate conditions which probably do not influence each other significantly.

Treatment of CTS by injection is widely criticised by surgeons and surgeons are responsible for most of the secondary care treatment of CTS in the USA so you hear a lot about their views. It's much the same here in the UK. A variety of objections are put forward - it's risky, it queers the pitch for surgery, it's always temporary, it only suppresses the symptoms, it's painful etc etc. I have been systematically studying these claims for the last few years and so far not one of them has proved to hold water when looked at objectively. You can draw your own conclusions. It IS the case that many patients relapse after injection. There are no adequate long-term prospective studies of this using a decent dose of steroids in a cohort of patients initially presenting with CTS (as opposed to those who make their way to surgical clinics, who are a highly selected bunch). However data from this clinic suggests that about half of the patients relapse within the first year after an initial injection and that about half of the remainder relapse in the second year - so that after 2 years you still have a quarter of the initial group whose symptoms are adequately controlled by just the one initial injection - which is not bad for something which is much safer, cheaper, and more convenient than surgery. In a study we have just published, only 41% of patients who started out with an injection had had surgery 8 years later.

I think the reason that the long term outcomes of the two treatments are different is that surgery leaves you with a trench instead of a tunnel. Once the surgeons have finished with you there is no longer any anatomical tunnel for the nerve to get trapped in. With injection however the basic anatomy stays the same and although injection can reduce the pressure in the tunnel and effectively treat the current episode of CTS it does not stop you getting another episode - because you still have an intact carpal tunnel.

Ulnar neuropathy at the elbow is a different kettle of fish entirely. It does not respond to steroid injection and the efect of bracing is unknown. There is a group in Ljubljana who are interested in ulnar neuropathy in the same way that I am interested in CTS and they think that there are essentially two common, but different, problems at the elbow - one a nerve entrapment a bit like the carpal tunnel and one which is much more due to external trauma to the nerve from being stretched when the elbow is bent and compressed when you lean on it. They think these should be treated differently. JB

Curtis Stevens
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If I understood the surgeon right, he was telling me that even if my symptoms go away, he has never seen NCS results like mine at this stage improve without surgical intervention. He almost was giving me the impression that if I find something that makes the symptoms go away, the actual problem could be getting worse and the likely hood of reversal decreases. Would you agree with that?

I completely understand you do want to give medical advice. I'm thinking I'll wear the elbow braces for a few weeks. If it doesn't start to improve drastically, then see another doc about injections for the CTS. My only fear is if I keep trying to find a solution for the symptoms and if I find something that does work, that the actual issue will continue to get worse. Then the only way to know for sure is to have NCS done again to confirm, which I'm all for, but not sure if insurance would cover it. However, that is only money, so I'm more concerned with it getting worse before I know it and then I have a lessor chance of it ever recovering once I get to the surgical route. Do those concerns have any merits?

I'm not opposed to surgery, I just want to make sure it is the right decision as I'm only 35 and have a long life ahead of me, hopefully. Would you not agree that it is in the patients best interest to avoid surgery if at all possibly if the patient is fairly young and they are able to eliminate the issue before the issue becomes to big and too late for even surgery to fix it? I understand if you can't really comment on that question.

Curtis

jeremydpbland
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I've seen plenty of people recover from grade 3 CTS without surgery. Change in subjective severity of symptoms is fairly well correlated with change in physiological impairment of the nerve - which essentially means that the condition is not going to creep up on you and become irreversibly bad without you knowing about it. If it feels as though it is getting better it probably is, and if it feels as though it is getting worse it probably is (with a few minor exceptions - it can be difficult to tell in diabetic patients for example). All this is a rather complicated way of saying no I do not agree (your first paragraph).

I do agree that it is worth trying to avoid surgery if that is possible without significant risks. The surgeon is proposing to destroy a structure that is a functioning part of the wrist joint - not a useless appendage like your appendix. In my view such an assault on the wrist should not be undertaken lightly - but sometimes it is necessary, just not as often as some surgeons seem to think. JB

Curtis Stevens
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Just an update. I was hoping I had good news. Saw another surgeon about a week or so ago. I kept wearing all of my splints hoping it would continue to get better and based on my various symptoms I was pretty convinced I had double crush. I could lay on my side in the bed and pretty quickly have symptons, like my hand was going asleep. I'm sold on the idea that I had multiple symptoms and multiple causes. One being on the computer for 20 yrs and poor posture being another big one. Now that I think I have fixed all that, still here because of other causes. I probably still have a narrow tunnel, but was hoping the problem was elsewhere in the shoulder or something and I was also feeling it in the tunnel because it was already hypersensitive and my tunnel is just narrow and always has been. When I saw this doc, he said I didn't have classic symptoms and wanted to refer me to someone else that can better help me. I went in wanting to get the shots a try as I think that is my last option at this point before surgery. That didn't happen, he referred me elsewhere. May 13th, I started doing a lot of meat cutting that day and then did more the following Saturday. I think I may have been doing more things with my hands as well since that day. Since then, it seems like my symptoms have changed and I've been paying attention to what I feel and I'm pretty confident it is always the median nerve now. I don't think I ever have feelings from the pinky now. So I think the ulnar nerve may be ok, at least seems like it for now.

But it has been really pissed off since then. Not sure if I have ever had this much discomfort, but I can't just sit around the house and not work waiting around. I have bills to pay. This referred doc isn't available until June 12. Having as much discomfort that I do during the day now, I don't want to wait that long and afraid I'm causing too much irreversible damage. I was hoping that the shots may be answer but starting to feel like that is a pipe dream and I should just go ahead and prepare myself mentally for surgery. Is it even a wise idea to hope that the shots could be my answer? Based on everything I have read on your site about shots, I don't have much confidence that it will do anything. I don't know what else I can do. I'm wearing my hand splits during the day today just to help limit the discomfort. It immobilize your hand so I think it helps. Hard to do much and slows you down, but I think it helps. I did a lot of work with my hands over the weekend and was wearing my splints most of that time hoping that it helps.

I have tried various things hoping the issue might be in my neck, like stretches. Unless it may take days or weeks to know, I don't think it is making a difference. I really want surgery to be the last answer, but not sure if there are any other plausible options for me at this point. Is it hard to really rule out any issues that might be present in the neck or anywhere between the head and your tunnel that may be the culprit? Like can an MRI show something? I guess I'm hoping for some magical answer that will fix my issue and prevent me from having to do surgery and destroying that structure.

Curtis

Curtis Stevens
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I can't remember my symptoms ever being this bothersome before. All I can think of is get someone to do the shots. The Dr I saw before reaching out to you, said I needed surgery on elbows & cts and I'm guessing believes injections would be a waste of time, but his nurse is going to confirm if he is ok doing it still. I have an appt to see him next Monday. If he isn't, should hear back tomorrow. The other doc I was referred to by the new guy, my appt isn't until June 12th, so I'm hoping I can get by until Monday. It just makes me feel like I'm doing a lot of damage or it's getting a lot worse, but is that even possible, within a few days or even a week or two? I would like to think the nerve can take a lot of beating before it's dead and I'm already a grade 3, so I don't want to get worse before it can get better.

I've been wearing my splint most of the day today. It's very hard to do many things! But it seems like it may help it recover than just wearing it at night. Is that just wishful thinking?

If you were to put your hand in a cast for a few months, would your body not naturally heal itself, just as much as an injection would do? That was my thinking, if I had the splint on most of the time, sleeping, during the day, I'm giving my body as much time to heal itself and not piss off the nerve so much during the day that it can't recover at night.

jeremydpbland
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Some cases do respond to just a splint but yours doesn't sound like one of them I'm afraid. If one doctor there thinks it's 'atypical' but you clearly have abnormal NCS and at least some symptoms which are consistent with CTS then, in my view at least, that is all the more reason to try injecting it and that is almost certainly what we would do here. It's a good diagnostic 'test' as welll as occasionally being all you need to treat it. You have about an 80% chance of a quick solution to the current symptoms from something that can be done in the office in 5 minutes with you going straight back to work afterwards and the risk of a serious complication is very small if it is done by someone competent. Finding someone to do it seems to be the main issue. Studies that have shown good results have usually used a dose of 40mg methyprednisolone or equivalent to get this sort of success rate. Many people add a local anaesthetic to the injection but it's not really necessary and just leaves the patient with a numb hand for hours afterwards. If symptoms do then recur some months after injection you can proceed to surgery with more confidence that CTS really is the problem.

It's not very likely, in purely statistical terms, to suddenly jump from grade 3 to grade 5 in a few days unless you do something such as break the wrist to really aggravate it, but it is very variable in progression rate. The most worrying evolution in symptoms is a change from tingling and pain to numbness - that usually does mean that nerve function is deteriorating significantly. JB

Curtis Stevens
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Thank you! From everything I can read, injection if anything is a good test to find out if you will respond well to surgery. One doc was quoted on Webmd saying he never does surgery without trying injection first for that reason. If the symptoms don't go away for more than a week or two, what does that mean? Do injections ever not last more than a few days or weeks?

40 MG, do I go in asking for this? What you say makes me want to say this is what I want, but I doubt that will go very well. I truly respect your opinion, you seem to know your stuff. Hopefully, they use that or equivalent...

I have had tingling for as long as I can remember. Numbness, I assume you refer to the sensation that it is going asleep kind of feeling, I have been having that for a while. I think it has been more prominent lately and I think that may be because of my actions lately, doing too much with my hands. I know you can't say, but your comments worry the heck out of me. I'm hoping that one doc will do my injection on Monday and it will be ok waiting until then. I'm not someone that wants to act stupid and put something off until it is too late, but I have been trying so much to avoid surgery as I don't think surgery is the answer for many things, even though our society rushes to it. Honestly, I wish I came across your site a lot sooner. So I have been trying so many things since the start a few yrs ago.

My symptoms have changed since I saw that one doc a week or two ago saying I'm not atypical. I think he would say I more classic cts now. My symptoms are all median nerve now and much more prominent now, never had to resort wearing a splint during the day just to get through it.

Curtis

Curtis Stevens
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The new doc has an opening and now see him next Tuesday. I don't know what else I can do to calm it down, I almost want to go lay down and watch TV until then because it is too bothersome, but I have a business to take care of. Will taking Advil help at all? Short term, I was told it is ok to take the max Advil dose of 4 pills every 6 hrs. If it helps with the symptoms, I guess that is good, but it won't prevent it from degrading right? I guess I'm just a little freaked out as it seems to have become more severe overnight. It may just because of the work I was doing over the weekend, a lot of hand work, but I was doing it with my splints on as it seemed to help with the discomfort. Maybe I just really irritated it and that's why I'm feeling so much now and not because it has degraded so much overnight. Thoughts?

Thanks for listening to my millions of posts.

Curtis

Curtis Stevens
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One more thing If I may. Lets say I respond well to injections but it comes back. Do you think it is even worth getting a 2nd, 3rd and 4th shot, hoping eventually it will fix it permanently? Would you consider doing that if it was you? The risk of complications compared to surgery, makes me say why would you not, as long as the issue isn't degrading further.

Curtis Stevens
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Read all of your replies again.

Quote: Treatment of CTS by injection is widely criticized by surgeons and surgeons are responsible for most of the secondary care treatment of CTS in the USA so you hear a lot about their views. A variety of objections are put forward - it's risky, it queers the pitch for surgery, it's always temporary, it only suppresses the symptoms, it's painful etc etc.

In your opinion, it suppresses the symptoms but could the problem continue to get worse even though you are symptom free or those two go hand in hand? If injections are turning out to only be temporary for a patient, why would a patient not continue to get them instead of doing surgery? Even if it is once every 6 months, are there any studies about long term side effects? I guess you could argue the risk of injections is very small compared to surgery, but if you continue to get the shots time and time again, that risk will continue to climb?

Did I read it right, that you personally have recovered from grade 5 without surgery? If so, what's your treatment history?

I need to read your injection page all over again...

Curtis

jeremydpbland
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Sorry if I misled you there - I've managed to escape CTS myself so far but I have had two patients who recovered spontaneously from grade 5 without treatment. I do know a rheumatology professor with CST who regularly injects his own CTS and has done so many times. That quote is a quick summary of all the objections made by surgeons to injection as a treatment - you see these arguments all over the place. My own view is that injection does more than 'suppress the symptoms' So far as I can see it cures the disease - but only temporarily. Think of it as like getting flu twice (though CTS is not infectious). You might have had flu in Winter 2010 and again in Winter 2013. That doesn't mean you actually had 'hidden flu' all the way through 2011 and 2012.

A lot of research needs doing into treatment by repeated injections over time but it's difficult to do, primarily because of the long timescales involved. Patients attending my clinic take an average of about 3-5 years to reach their third injection so to follow up a cohort of patients to see how successful treatment by repeated injections is will take many years, and that akes it very expensive, and funding bodies want 'quick returns'. We've recently published a paper in which only 41% of patients treated with repeated injection were found to have needed surgery 8 years later. In the 3/5 patient who had not had surgery, the average number of injections given during the 8 years was 2 - though one patient had got as far as number 10.

We're just working on a detailed study of risks and side effects and essentially they do not seem to change greatly with repeated injection - it remains a pretty safe procedure, though we try not to give them more than once every 6 months on average. JB

jeremydpbland
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Advil - or ibuprofen to give it its proper chemical name is not known to help CTS I'm afraid. Sorry. JB

jeremydpbland
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You might indeed get a cold reception if you go in demanding a particular treatment :-) It certainly gets my back up when patients do that to me, though I try not to get obviously annoyed. What you can do though, once a decision has been made to inject, is to ask the perfecty reasonable question "exactly what are you going to inject?" and the doctor should be perpared to justify their choice, even if the best they can come up with is "This is what I've always used" or "This is what we happen to have in stock". At the very least you should come away knowing exactly what has been given and we can then interpret the response in the light of that. Symptoms recurring very fast, or not responding at all, is not necessariy a major cause for concern but it is true that patients who respond poorly to steroid do have a somewhat poorer chance of a good outcome with surgery too so it makes you pause and think for a few minutes about whether there could be any other problem contributing to the symptoms before plunging in with the knife. JB

Curtis Stevens
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For your own treatment, have you done injections and if so how many?

I'm hoping I come home on Tuesday with an injection. If it doesn't last more than a days to 6 weeks, not close to 6 months, what would your thoughts be then as you generally try to avoid giving one more often than every 6 months.

I took 4 ibuprofen 3 hrs ago and maybe it is just in my head, but it seems like it has helped some. I will know throughout the day as I continue to take it every 6 hrs. It was becoming so bothersome, I needed to do something in the interim. I assume it isn't doing anything for my CTS, but just blocking the discomfort signals that are going to my brain?

Curtis Stevens
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Thank you for that insight on how you would feel if a patient came in demanding a particular treatment. I hope I'm not wasting my time with this guy. I will let him do his thing, I need relief and need it now, so either it has to be an injection or surgery. Hopefully he recommends injection and this is a mute point. I will tread cautiously and point out that I want to take one step at a time, I have multiple issues going on here and want to take baby steps before doing surgery because it just isn't he media nerve.

Curtis Stevens
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I was thinking my issue my be a double crush case and have watched enough videos from these two PT guys: https://www.youtube.com/user/physicaltherapyvideo, so sometime last week I started doing more stretches hoping to alleviate it since my symptoms were becoming more pronounced since I've been doing so much hand work these past few weeks.

I've been doing various neck and arm stretches and they make the comment about not over stretching as you can irritate the nerve and it may take it a few days to calm down. Now I'm wondering if it is as bad as it is because of me over doing those stretches, self inflicted... None of the stretches had anything to do with the hands though. I started stretching the neck using this exercise: https://youtu.be/n26CXK6xZek?t=364 and then started doing these exercises from Egoscue: https://www.youtube.com/watch?v=0Pn5qtU_nvI. When I do this one exercise, https://www.youtube.com/watch?v=0Pn5qtU_nvI&feature=youtu.be&t=176 it really irritates it, even if I have my hand splints on and not even doing the modified golfers grip. I don't get why that would irritate it.

jeremydpbland
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There's a whole page of this site devoted to double crush syndrome. I'm not a huge fan of the concept but it's hugely popular with physiotherapists and the like. I'm also not very impressed with any of the various physical interventions for CTS but that is perhaps partly because of the sheer difficulty of doing randomised, double blind trial for an intervention where it is perfectly obvious to both the therapist and the patient what is being done. The scientific literture on this is a mess and the best that can be said is that most recommended exercises are probably harmless - but if they obviously hurt or seem to aggravate the CTS symptoms I think you should give up on them fairly promptly. I don't hold with the concept of 'work through the pain'.

We've done approaching 10,000 injections for patients attending my clinic so we have quite a bot of experience with them. We routinely follow people up 6 weeks after injection. If there has been no response then and we are still convincned it is CTS we would usually proceed to surgery. However one or two patients have asked if they can try a second injection and we let them do that if they wish. Some of them have done better with a second attempt than with a first. Again this is a topic that deserves a dedicated research study (are you beginning the see a theme here?)

All I can say about ibuprofen is that the only randomised trial found it to be no better than placebo - so for all we know you might also feel the same benefit from taking any other tablet, active or not - on the other hand if you feel better you feel better, there;s no arguing with that. Ibuprofen can be a stomach irritant but most people tolerate it fairly well. JB

Curtis Stevens
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Tuesday cannot come soon enough! Should I not be surprised if the shot does nothing for me? Such as it doesn't give me relief for more than a day or two? I'm really banking on it working and for at least a few months, but don't know what is realistic. If the symptoms don't magically improve, either give it another shot and see or mentally prepare myself for surgery?

Should I notice some improvement that day or will most likely have to suffer through a few more days before it gets better?

I guess the quick progression of my symptoms have me worried that it has degraded significantly and quickly. It feels like doing all that knife cutting that one weekend is what started it all, like pushed it over the edge and it can't recover. Even worse as of late maybe because of the stretches I've been doing has been irritating it even more. The wall stretches would really bother it when I did them but worked "through the pain". If I have indeed pissed it off more so because of these exercises, should it naturally calm down on its own in a few days? All of this makes me worry that the shot isn't going to work now. Of my entire history no one has given me one and I'm wishing I had one a long time ago.

Curtis

jeremydpbland
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Provided they use an adequate dose, you have about an 80% chance of feeling much better within 48 hours and a 50% chance of that lasting a year. Those are the figures I quote people in Canterbury and it's pretty much what we get. I'm working on a predictive model which will help us to say which people are more or less likely to respond well to injection but it isn't ready yet. We do know that people with grade 5/6 are less likely to do well and that people with very high symptom scores are less likely to do well but it needs a lot more work doing on it yet. At grade 3 (IIRC) your chances are pretty good. JB

Curtis Stevens
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I am crossing my fingers. I assume what I do afterwards may determine how long it lasts? If I go back to working my hands alot, it may not last near as long? Next weekend I'm supposed to work a consumer show selling my seasoning product and that means cooking and cutting up a lot of steak. Should I worry about that or just do what I normally would as my daily actions can't really affect how long it will last. Such as if it is going to only last a few weeks, then me cutting a bunch of steaks isn't going to be the cause of it only last a few weeks compared to a month or two if I had not.

jeremydpbland
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My best guess is that one of the main determinants of time to relapse after injection is indeed some aspect of what you do with your hands. I think it probably takes some 'trigger factor' to set off another attack of CTS and such factors might include a bout of strenuous work, or even something as mundane as just falling heavily alseep in an awkward position one night so if you are lucky enough to avoid triggers for a long time you can have a long remission,

How easy it is to trigger a new attack will depend on how strong your underlying predisposition to CTS is, markers of which might include age at the first onset of symptoms, presence of a family history, and seveirty of NCS at first diagnosis - there is some evidence to suggest that people with the most severe CTS relapse more quickly (grade 5/6). My other two guesses there (age at onset and family history - and they are guesses) need studying when I manage to get around to it - this can be  looked at in my patient records. I just need to find time to do it. JB

Curtis Stevens
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I submitted a reply but the site went down and lost my message. I received my shot today and I tried really hard to remember the drug name. I think it started with a c or an s. It wasn't an easy word to grasp, to me. He said it is the most soulable of the other ones he mentioned to me, one reason why he likes it more than a couple others he spit off. He did say it was synthetic. So I can't tell you which one exactly or the dosage as he didn't offer that up either.

It's amazing how the first doc was saying do surgery on all, and the last two were the complete opposite! This last doc says most cubital can be cured with bracing, habit changes, etc.

I tried to find a list of the possible drugs to say which one it sounded like, but can't find such list.

Curtis

jeremydpbland
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There is a list of steroids on this site but it only shows the drug names, not the various trade names they are sold under worldwide. How are the symptoms doing? JB

Curtis Stevens
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Not sure yet, I'm going to give it a few days, will keep you posted! I feel optimistic, but too many things have let me down too.

Curtis Stevens
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Well, this past week, I really put it through the test, not by choice. Before Friday, I was saying it wasn't looking good and interesting enough, it got a lot better pretty quick as it didn't bother me Friday-Sunday with all of the stuff I was doing.

It seems to be about the same now, maybe slightly worse, can't tell. Don't know if it will be a slow healing process or not as it seemed to get a lot better really quickly last week.

I'm just hoping it lasts. I'm still having mild symptoms in my elbow, not sure how to explain them. Will keep wearing my elbow splints and see how that goes. Afraid that will end up needing surgery, but we'll see.

jeremydpbland
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The rapid change is likely to be steroid effect and I wouldn't generally expect very much further change over the next few weeks - especially if you take to using the hand very intensively. In Spain one group there would consider giving a second injection after two weeks if there were any residual symptoms at all at that point, but this strategy has never been seriously tested to see if it is actually a good idea.Thanks for the update. Pity we don't know exactly what was injected. JB

Curtis Stevens
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So having a rapid change isn't a good thing? I'm not sure if you would say I was using it intensively or not. It's things that would bother me a lot a week ago. Lifting tubs, slicing meat, etc. I was hoping the rapid change was a good sign, that I was the 80% that responds and how long, only time will tell.

jeremydpbland
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The response to steroids is usualy pretty fast. We find the majority of patients get a marked improvement within 48 hours but there do seem to be a few who are slower to improve, up to about 6 weeks occasionally. The one thing I don't see is - 50% better in the first 48 hours, several weeks with no change, suddenly 50% better again. JB

Curtis Stevens
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:( I'm not sure just yet, but it seems like it has stopped improving and has started to go back where it was. I am still wearing my splints at night. I don't understand how a shot could provide such relief that can quickly dissipate. What is it doing to relieve the pressure so quickly for that pressure to then be there again overnight to create the symptoms again. If it is decreasing inflammation, how is that inflammation coming back so quickly, I thought that was a slow process... I could understand if it simply masked the pain/symptoms like medicine blocking your pain receptors.

Assuming my relief doesn't last long, what would you personally do? Try another shot so quickly? Could you say your disease was so far along, that one shot isn't enough to completely heal it per say, so good chance it just needs a 2nd one?

Would I be off to assume that it sounds like I am most likely going to have to do surgery and I need to prepare myself for that outcome? It is starting to feel like it is unenviable and I am out of options.

Curtis

jeremydpbland
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For grade 3 I might try a second injection if symptoms relapsed quickly but a lot depends here on what dose they used here. If it was 20mg of hydrocortisone then I would definitely try again. If it was a decent dose (40my methyprednisolone or triamcinolone) then one would start thinking about surgery. 

We don't really understand qute what steroids do in CTS but it is unlikely to be a simple anti-inflammatory action. They seem to improve every measurement that indicates CTS. Personally I think the local effect of the steroid is all over by a few days after the injection and the time to relapse then depends on how long it is before you encounter somel stressor that triggers the problem again. JB

Curtis Stevens
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Hi JB,

What I was able to get out of the doc's staff is Depomedrol, 1 CC.

Does that tell you what you need to know?

Curtis

jeremydpbland
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That's progress. The drug's real name is methylprednisolone - sold as Depo-medrol in the US and Depo-medrone in the UK. Unfortunately it comes in three concentrations 20mg, 40 mg or 80mg in one millilitre. I hope they used 40, which is roughly the equivalent of what we would use here. JB

Curtis Stevens
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So the amount they used wouldn't say what concentration they used right? So it could be 20, 40 or 80 mg right? So no way to say if it would be a good idea to get a 2nd one real soon or not?

I'm going to give a tad bit more time to see how it progresses. I don't mind the expensive of a 2nd shot because I've met my deductible finally, so insurance will pay 75%. I hesitate if there is a good chance of doing more harm than good. Or if I'm just wasting my time and money on false hope.

Not sure if your answer is the same, lets say they used 40mg or even 80 mg, would it be a big deal to get a 2nd shot in a week or two after the first? I'm talking about just a 2nd shot, not a 3 or 4th, etc.

Should I not get my hopes too high with an additional shot?

Curtis

jeremydpbland
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I think a second attempt within a couple of weeks is probaby safe if they used 20 or 40mg. I doubt if I would repeat it after an 80mg dose. Only one trial has used an 80 mg dose and although patients in that arm of the trial did well (at least by my standards), doubling that up quickly would be a pretty high dose of steroid. JB

Curtis Stevens
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Update: I gave it more time. Not sure if It got better or not, but it did level off to the point where it isn't 100% gone, but I don't have symptoms while sleeping, doesn't keep me awake, don't have tingling in the hands while I type, etc. Depending on what I do during the day, I can feel it but it's mild unless I do something that shoots off a sharp pain like lifting something heavy and twisting it just right.

I'm not sure if it is gradually get worse or not. I was thinking about calling the doc and seeing if he will do a 2nd shot. Hoping it wasn't 80 mg before. Lately, I feel more fatigue in my elbows while typing during the day, like it is telling me it doesn't like being bent so much during the day. Still wearing those splints at night. Not sure where the elbows are going to go.

Curtis

Curtis Stevens
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I called the insurance company. I was injected 20 mg methylprednisolone. Glad to know the facts now.

I have an ppt for June 13. Front desk said I have to wait 4-6 weeks for another injection.

Based on what the front desk was saying, it sounds like he also does injections for cubital as well. If this is true, does that make any sense? Would it not do the same thing like CTS? We don't know why it works for CTS, so maybe it would help with cubital too?

Would it hurt anything if he injected that area too, not much risk so why not? Finally met my deductible so it won't cost me much.

Curtis

jeremydpbland
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If they only used 20mg then there should be no problem in repeating that. There is just a single randomised controlled trial, that I know of, of injection for ulnar neuropathy at the elbow and it was no better than placebo. The mechanism of ulnar neuropathy at the elbow is probably quite different to that of CTS. You are probably right that injecting at the elbow is likely to be fairly low risk however. Overall it sounds as though you are reasonably improved at present - is that fair? JB

Curtis Stevens
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I for some reason don't always get notification emails when you respond.

I have always lightly closed my hand to make a fist and then I would move my hand in a circle, gently making the biggest circle I can. So as you come towards you, it puts pressure on the nerve as you past the palm side of your wrist. Does this makes sense? I have always done this to judge how well it is doing or hurting.

With that said.

Well, the type of discomfort when performing that test had been consistent for a while now and after I posted my message, I started wearing these again since I had some left: https://www.mycarpaltunnel.com. After the first night, I swore I could feel less pain when I did the test as describe above and then I wore it again last night. I'm not sure if you could say that could just be placebo or not. it seems to be helping some, at least right now. I've worn those bands before and everything I've done, seem to help for a period of time. The argument is it gently stretches those muscles overnight. As you know, anything to get the ligament to stop putting pressure on the nerve is working. Question if this will be short lived or not. Nonetheless, I feel a lot better as if I improved this much so far, then if and when I have to do surgery, should be a success! My elbows don't seem to be getting better though, so that's stressful as I feel much more comfortable with the CTS than cubital surgery. I don't know how to describe the sensation, but it feels like I get fatigue type feeling or something like that in the elbows when I'm typing on the computer. I'm constantly giving myself breaks, don't rest my elbows on anything when sitting, driving, etc. I will say I can sleep during the night without any issues at all, from the elbows or hands! So that should be a big sign of improvement at least...

Just to confirm, if your symptoms go away and not because you have just gone too far and killed the nerve, which we know is not the case with me, then I shouldn't be concerned about things getting worse right, even though my symptoms have improved or gone away? I would like to think those go hand in hand. I just didn't want to think I'm cured if I didn't have symptoms anymore and then find out later, the nerve is dead, etc.

Curtis

jeremydpbland
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In your case I would be fairly confident (so far as one can be in a web conversation) that improvement in the symptoms really does indicate improvement in nerve function. The movement you describe is really a version of Phalen's test which is one of the standard things to do when examining the hand for possible CTS. I'm not convinced that the 'carpal solution' stretches the ligament (which is a pretty tough structure). I think it's more likely that it just contributes to keeping the wrist straight at night. The predominant effect at present is most likely to be the steroids, even from a fairly low dose.

Not sure what would stop reminder emails getting through - it's a hard thing for me to test systematically. I'm usuallly fairly quick replying however so it's generally worth checking back 24h later anyway. Only occasionally am I so busy with other things that I forget to check here for a day or two. JB

Curtis Stevens
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I looked in my gmail spam folder and there were 4 notification emails, but some have gone through without issue.

I have been wearing my custom hand splints since January, non-stop. I just started wearing those band things a couple nights ago, in addition to the splints. I was thinking of the muscles it is pulling on if there are some there. Could it just be giving it a tad more room to breath and heal at night than without it? I don't know what the explanation is but seems like it is doing something. I'm going to give it a couple weeks and see. Those things are too damn expensive.

I have a feeling most consumers would have just had the surgery by now and not gone to the extent I have done. I am starting to feel like I'm just hard headed and being silly for trying so many things.

jeremydpbland
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Mnay people with CTS are not offered anything other than surgery and do not have the resources to go looking for other alternatives. My best estimate at present however is that probably only 2 out of every 5 patients with CTS actually NEED surgery. JB

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