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 supporesses 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

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