To have op or not ? Urgent, due Friday !
Help !
Hi.
Male 62, open heart surgery July 2011, replace bicupsid aortic valve.
Good recovery,, some problems with fluid on heart and an episode of emergency admission Hospital because of atrial fibrillation..
January 7th, feeling good, worked intensively in garden, woke up at night intense pain, numbness both hands.
Nerve conduction recorded 10. "Off the scale", said the person doing test.
At same time as carpal tunnel syndrome I had a flare up of psoriasis, swelling of feet.I have arthritis which can be troublesome, including in right thumb.
Had cortisone injections February 24th-,no pain from injections,- which IMMEDIATELY stopped the pain. (had been unable to sleep).
Hands getting slowly better. Still have numbness both hands but can tie shoelaces etc. Some weakness in right hand(Keen tennis player, coincidentally past captain,singles/doubles champion Canterbury LTC !).
Episode of suspected "gouty arthritis" in right foot, sufficient to get admitted to hospital 6 weeks or so ago.
Now, no swelling, psoriasis calmed down, feeling fine.
Due to have first op on Friday. Right hand.
QUESTIONS-
1- as my hands appear to be slowly getting better, should I have the op ? (Have been told that because of the severity of symptoms they will slowly get worse, and that op necessary to stop further damage).
2-If I have op on Friday should I get left hand done first because could then still play tennis and symptoms worse in that hand..
2-Will effects of cortisone slowly wear off or is my immune system getting stronger ?
Hope to get some advice !
Thanks in advance,
John Nickson
ps -sorry re dual posting as just realised no title, feel free to delete other post.
Many thanks for your prompt and informative reply, really helpful.
The tests were done at Hereford Hospital(I live near there now).
I will study the parts of the website dealing with causation, and will probably go ahead and start with non-dominant hand.
Again many thanks and well done for making this resource available, tremendous !
best wishes,
John
One more thing - that story of relatively sudden onset after a bout of strenuous gardening would make you wonder whether this might be a quickly reversible process. That would also fit in well with the good response to steroids. Good luck! JB
Thanks again, I will certainly give the matter more thought. Great to be able to speak with an expert. This seems a complex problem.
I had NO problems before this " attack", but recently playing in the final of Club Tournament felt a lack of power in hand, interestingly also left side of wrist.
thank you for your help.
John
Hi again,
Had the op on my left wrist Friday 8th June, all went well. After discussion with surgeon decided this best option as symptoms worse in that hand. He thought I should go ahead with op to stop further damage to nerve etc. Also thought more severe symptoms would return after effects of cortisone wears off. I had jabs on February 24th, which is nearly four months ago.
Interestingly, chatting to other five people having op, little pattern in how their symptoms developed. Also three or four (can't remember)out of six of us had problems with both hands. Only two of had had cortisone injections. Surgeon commented on how problem seems to be worse now, and more men.
However for me so far little or no improvement in numbness of fingers. Any idea when I might (or if) expect some improvement ?
At present I am due to have op on right wrist in next couple of months.
Once again, Thank you for your help.
John
Surgeons tend to have a slightly different mindset to us physicians and are often more confident in their predictions -hence the widely held conviction that CTS is inevitably progressive and that 'something must be done' to stop nerve damage progressing. All I can see is that some patients clearly recover from even quite severe carpal tunnel syndrome without any medical intervention at all. It's just very hard to predict which ones. We have some data coming up on what CTS is like at the time of recurrence after a first injection but I can't refer to it on here until it gets published except to say that it does not appear to be the case that it is worse when it comes back.
Bilateral involvement is common, indeed almost the rule - 4 out of six at the time of first operation is about par for the course and the other two are at greatly increased risk of getting it in the other hand later.
If you have actual loss of sensation in the fingers then that usually is a feature of fairly advanced CTS and is often due to death of the nerve fibres carrying sensation. These either take some time to re-grow or do not re-grow at all so this symptom can be slow to recover after surgery or can even persist indefinitely. Again, the pre-operative nerve conduction studies can help to predict this sort of thing if one has the measurements available.
I am always a little wary of deliberately planning the second hand because a few patients seem to get bilateral improvement in symptoms after operating on the first. This seems to be a very definite phenomenon but is not that common so it is quite likely that the second op will be appropriate - I just tend to defer making a final decision until the outcome of the first operation is known.
Thankyou for the update - one of the slightly frustrating things about running the site is not knowing what happened to those people who post a question and then simply disappear :-) JB
Many thanks for your thoughts and information, really helpful. It does seem there are a lot of different opinions about CTS and the best way to deal with it. I will certainly ponder your ideas. Surgeons seem, not surprisingly, pretty keen to operate.
On another occasion I saw a consultant rheumatologist about my arthritic feet, which were very bad at the time, and he said,"Don't let them near you with a knife"-advice I have followed. I had no choice about heart valve replacement(genetic bicupsid valve), but feel I do have a choice about CTS.
It must be frustrating not getting feedback, the interplay of your expertise informed by peoples experience can only be helpful to others.
Thanks again.
John
Update, uncertain how to proceed.
Now just over three weeks since op on left wrist. Little or no improvement in numbness in fingers.Right hand continues to improve and now have much of my strength back in this wrist.
Have got op date for right wrist end of this month,having outpatient appointment 16th this month.
Am seeing doctor tomorrow and wonder if I should ask to be referred for further nerve conduction tests prior to outpatient appointment.
As I have mentioned, the first test revealed very severe cts in both wrists. I then had cortisone injections which had an immediate positive effect, with the pain disappearing.
My feeling is to delay surgery, is this wise ? I have been told that-based on tests and apparent severity of symptoms-I probably have nerve damage and that my symptoms will return and my wrist get worse unless I have the op.
John
If I understand this correctly, so far the unoperated hand is doing rather better than the operated one. If that is really the case then I would definitely repeat the NCS before reaching a decision on surgery for the second side. JB
Interesting developments.
Saw the main consultant at Hereford Hospital on Monday.
Since my operation on my left wrist 5 weeks ago there has been little change in the numbness and the scar is yet to heal properly.
Both hands have continued to improve,albeit slowly,since my cortisone injections on 24/02/2012.
I have at present no pain or tingling and my right hand is almost normal.
The consultant thought that therefore I did NOT need an operation on my right wrist, which was due 31st July. He thought there was every chance I will make a full recovery.
When I asked the surgeon who did my first op whether it was necessary he said that it was to prevent further deterioration, and that I would need the second op on my right hand for the same reason.
There seems a variety of opinions about the best course of action ! I intend to see how it goes.
Incidentally, my consultant on Monday did not regard ncs as being necessarily the best guide to CTS.
My tennis is also getting back to normal.
Well your history certainly demonstrates quite a few of the observations about CTS which I have made over the years, notably the slow response of sensory loss to treatment, the fact that surgery is not always a perfect solution, the responsiveness to steroid injection and possibly improvement in the other hand after operation on one side.
5 weeks for a CTS scar to heal is quite a long time. It seems pretty clear that there is little urgency to operate on your right hand and it may well not be needed at all.
There are quite a few orthopaedic surgeons around who are sceptical about NCS. The president of the British Society for Surgery of the hand said a few years ago that NCS should not be done in CTS because they only confused the surgeon. I am afraid that I think this is nonsense. Your surgeon is right in one sense only - that NCS are not the only guide to CTS - and no-one should make treatment decisions based purely on the lab results. However I cannot condone the wilful ignorance of doctors who deliberately deprive themselves of knowledge of the physiological state of the median nerve when making a decision about surgical treatment of an organ as vital as the hand, and I have met far too many patients who have told me that they wish they had never had their carpal tunnel decompressed to be entirely happy with surgeons who advocate routine surgery for every case as a precautionary measure.
As always, thankyou for the update and I hope both hands continue to improve. JB
Thanks again for your time and interesting comments. My wound is now almost healed, although I am keeping it covered to stop it getting bashed.
Fingers still improving, although I still feel my wrist strength is not what it was.
Hopefully I will be able to report more improvement !
If sensation in the fingers is definitely improving at this point then one might guess it would take about 6 months to return fully. Slight weakness after surgery is thought to be mostly a direct mechanical result of cutting the transverse carpal ligament but is not usually a major problem. JB
Update.
I now have almost no numbness in my right fingers and am able to play tennis far better. My wife says I am playing "properly" now !
Left hand now very little numbness. I don't think this is due to the op.
Operation scar still very tender and sensitive. Don't want to put much weight on it. The scar also has three small nodules on it. I wonder if there are remains of stitches there ?
JN
So if I understand correctly the hand which has only been injected is rather better than the one which has been operated overall, though the CTS symptoms have improved in both. I take it you are not rushing into surgery on the second hand.
You would be best asking a surgeon about the state of the scar - that's their territory rather than mine and in any case you really need to see it to comment. Peristent tenderness after surgery is quite common unfortunately. JB
Yes,
"the hand which has only been injected is rather better than the one which has been operated overall, though the CTS symptoms have improved in both. "
No rush for surgery, surgeon thought best to see how it goes.
Will investigate scar.
If tenderness is common it is a very important point, as if I had had my right wrist operated upon I would really struggle to play tennis.
Once again. thank you for your reply.
JN
Massage of the scar area, aided with a little aqueous cream or similar is generally felt to help with post-operative scar tenderness though I am not aware of any formal trial. If it's bad enough to impair your use of the hand then your local hand therapists may have a view on this. I could not formally recommend a treatment here for a specific patient I have never met or examined though. JB
thanks again, will do as you suggest. My left hand is not very bad, but it is inconvenient not being able to use it normally.(for eg, when riding a bike I have to just use the fingers of my left hand to hold the handlebars. Washing up is difficult etc.).
JN
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If it is greatly improved after injection there may be some grounds for deferring surgery but a lot depends on the clinical examination and NCS results. '10' does not mean a lot unfortunately - where were they done? If there is weakness of the muscles at the base of the thumb that would encourage one to proceed with surgery. Ideally one would repeat the NCS to see if there really has been an imrovement after the injections of course. I presume you have moved away from Canterbury however so that may not be an easy option.
Choice of hand again rather depends on how symmetrical the problem was to start off with but if they were about the same then it might be safer to start with the non-dominant hand.
Steroids wearing off /immune system - I don't think it's anything to do with the immune system (see the parts of this website discussing causation). There is a high chance of relapse after injection but it is not inevitable. JB