CT release post op problems

If it was very severe before surgery it can take a long time for numbness to improve, and in the worst cases it can be permanent. The only way to reliably assess the severity is the nerve conduction studies so if you have any pre-operative nerve condcution studies we can try to figure out whether a slow recovery is expected in your case or whether it indicates a possible problem. JB

I am pretty sure they do not do NCS here and so that would mean travelling overseas to get a test.

It is difficult to say how severe it was before because 'mild' to one person is 'severe' to another but it got to the point where simple tasks became difficult or impossible and often grasping something was tricky.and the thumb and main fingers were totally numb.

The OS said the tunnel was badly contracted and the nerve that was hit with the injection was badly scared.

The mobility is back but no feeling. Is there a test I can do to check the nerve like feel a pin prick or sense different heat levels so it can be compared with others? Is there any data base for comparison studies.

I thought about going back to physio who has an ultrasound and interferrential machine - do you think this is a good idea.

Really appreciate your time.

Linda

There are very few parts of the world where you cannot get NCS done - where are you? Obviously they did not test before surgery which makes it very difficult to assess the situation now. Surgeons always say things like 'the tunnel was very tight', 'the nerve looked very bad/scarred/wasted', in much the same way that abdominal surgeons nerver take aout a normal looking appendix, so I am afraid I put little weight on what the surgeon thought he saw at surgery, nor is it possible to be sure whether one nerve was accidentally injected or not - some steroid injections (thankfully few) can be very painful without the needle touching the nerve.

You are absolutely right - describing the severity of CTS by the symptoms is notoriously subjective. That is why the nerve conduction studies are indispensable to get a concrete idea of just how much functional impairment of the nerve there is. You can try measuring two point discrimination on the fingertips with a pair of compasses. Get someone else to do this while you keep your eyes closed - try to discriminate whether you feel one compasspoint or two at varying separations of the points and compare with a normal finger - usually the little which is supplied by the ulnar nerve - that's about the only semi-objective test which can be done by an amateur without specialised equipment.

I have no idea whether physiotherapy interventions help after surgery I am afraid - we are still trying to find out whether they are useful before surgery, nerver mind afterwards. They are probably mostly harmless though. JB

The two point discrimination test is a great idea. It is probably something that could be added to your questionaire about symptoms.

We did a whole range of tests and it is very interesting.

At 8mm apart all fingers and thumbs had a perfect score.

At 6mm apart it was 95% success rate with random 1 point and 2 point touches. The control is the little finger.

At 5 mm apart we see about 85 to 90% for most fingers and 75% for the worst thumb.

At 4mm it was down to 50 to 60% ie mostly could not tell a 1 or 2 point touch apart. Sort of 50/50 but the control finger was still 95%.

Then we tried various pressures and very light (just a feather light touch) was more difficult and scores fell down quite a lot especially with 4 or 5 mm tests.

Medium pressure (a 1 to 2 mm indentation) was better with scores being much higher.

Strong pressure and scores were almost 100% except for 4mm. So pressure has a lot to do with sensation and feather to medium pressure seems to give a better indication.

Perhaps testing on a daily basis for a while can be used to show improvement - it is more scientific than just subjective feeling which is difficult as one tends to flow feelings from day to day.

This is a most useful test indeed. Do you have any more - maybe temperature or surface detection like smooth or rough.

Many thanks

Linda

Well that's certainly a fairly convincing impairment of two point discrimination. Other quantifed sensory testing pretty much all needs specialised equipment - such as Semmes Weinstein monofilaments which give an indication of how sensitive you are to touch/pressure. 2-point discrimnation is a fair way to monitor progress though, maybe repeated once every 1-2 weeks. Are both hands the same or is there a difference between sides?

Thankyou for letting me know your location by email - I've replied that way too. JB

The 2 point method is good and I will get a monitering schedule going over the future days. Should be interesting to see the results.

Boths hands are about the same - given daily fluctuations.

Probably the onset was caused by a microbiocide in a paint, maybe setting off the inflamtion and now it seems any excessive hands in water or water and soap make the symptoms worse especially chilli or bleach. Of course I avoid this as much as possible but one has to get on with daily chores.

That is a guess of course and no real evidence except affter those incidents the hands become worse, maybe a circulation problem allowing the chemicals to cause more damage than normal. That would presume CTS also causes circulation problems? is that possible or known.

CTS has minor effects on circulation. The nerves control the muscular walls of small arteries to enable your body to redirect blood flow. Thus you can reduce the blood flow in your extremities when you need to conserve heat and increase it when the muscles need more oxygen. CTS affects all of the nerve fibres in the median nerve so it can impair this ability to control the circulation in the hand and thermographic studies have shown slight differences in the temperature of the median innervated bits of the hand in CTS, though they are only slight and not really reliable enough to make a good diagnostic test.

Chemicals could certainly be upsetting the scar while it is healing but I wouldn't expect external things to be having any real impact on nerve function unless you were using something really toxic such as organophosphate insecticides - and poisons like that cause severe acute illness rather than CTS (and are generally pretty restricted nowadays). For information on the known contributing factors to developing CTS in the first place the information pages of this site are fairly comprehensive. JB

It has been about 3 weeks now since we spoke. The surgery is healing well and looks like it may well heal fully with very little scar.

Feeling is returning slowly which is a huge benefit and mobility is normal although strength still needs to come back. The hands are usable again - great.

The physio suggested a regime of moves and some strength exercises with a 1Kg weight which seems to help.

I am using some night 'splints' which we made Blue Peter style from a plastic bottle, some foam and velcro and these really work well to stop sleeping on bent wrists. I would recomend these to anyone and I can send a photo if you wish. So simple yet effective.

The muscles of the thumb are however taking a long time to recover an very hard around the surgery and quite paifull still, is that normal? I know these muscle are very sensitive especially when knocked or bruised.

Last is some comments on water and chemicals.

I understand the theory that is on the site about how CTS may form and any chemical that one has on ones hands may cause some swelling of the tissues which in turn can aggrevate an underlying CTS. Certainly with CTS there seems to be a slower 'flushing' of any absorbed chemical from the tissues and the result is sore and swollen (a bit) hands.
Water alone would also affect the hands when CTS was there and it took hours to recover them from a simple washing session. However now the effect is very small and washing sessions do not leave the hands soggy for any time at all..

Certainly 3 weeks ago any mild chemical would cause a regression in symptoms and bleach was a bad one. Hot and spicy chicken wings with chilli and ginger are the absolute worst and really cause a relapse - dont eat chicken wings with CTS seems an appropriate motto here.

Avoiding any chemicals including mild soaps has helped to see a stable improvement.

Any comments you have regarding the muscle repair would be interesting.

Best
Linda

Like impairment of two point discrimination, wasting and weakness of the median innervated muscles at the base of the thumb is an indicator of nerve fibre degeneration and symptoms and signs which are due to loss of nerve fibres take much longer to resolve than those which are due to irritation of structurally intact nerve fibres. Once there is severe wasting of the muscles (like the illustration on the site here) they in fact rarely recover fully.

A sensation 'hardness' and local tenderness either side of the scar, usually more prominent to the thumb side, is not uncommon after surgery and my guess is that it represents inflammation around the 'cut end' of the ligament, although in reality the transverse carpal ligament is a bit more complex structurally than the mental image that that phrase tends to conjure up. It's also worth remembering that severing the ligament results in quite marked changes to the structure and shape of the wrist joint which may have mechanical consequences on the way the hand works too.

As regards chemical exposures, normally the epidermis is a fairly effective barrier stopping things getting into the deeper tissues but some things can penetrate it, especially when it's integrity is compromised by being soaked in water for long periods. Capsaicin - the 'hot' component of chili - is one of the things that definitely can cross the epidermis and capsaicin cream is sometimes used as a 'counter-irritant' by pain clinics. 

Glad it's improving, from the way it's going I would think it probably was quite severe before surgery - perhaps grade 4 or 5 and if that is right it will continue to progress for anything up to 2 years after surgery. JB

JB - you must be complemented in the highest terms for your help. It is so important for CTS sufferers to have a qualified opinion on symptoms and effects and it helps to know these things that occur after surgery are normal. Especially as you are diagnosing without sight or any tests of the subject.

The muscle was not wasted as it was only a few months after onset the surgery was done but even in that short time loss of strength in the hands came quite quickly and also returns quite quickly so that is most promising.

Perhaps you could explain the mechanical consequences of the surgery just so I know what to expect.

Really appreciate your support.

Linda

Thankyou! I try to be cautious about definitive diagnosis on the forum, though we have now validated the website questionnaire as being roughly as accurate as it says it is - ie 9 out of 10 patients with a score of 90% do indeed turn out to have evidence of CTS when tested - which is probably as good or better than I can manage myself clinically with the patient in front of me. Judging what is 'normal' after surgery is quite tricky, as can be seen from several case histories here on the site where some quite extraordinary symptoms have been written off as normal consequences of surgery by the surgeons involved.

The best review of the biomechanical consequences of surgery is found in Brooks 2003 I have this in pdf form and can send you a copy for personal use only if you are not able to access it locally. JB