A curious case
Hello, I have been having hand and wrist symptoms for a long time now. I would very much appreciate if you can provide any help.
*** History
- For the last three years I have been having worsening numbness at my index and thumb and pain at my wrist. These symptoms are worse on the right side.
- I first saw a doctor for my neck hernia(c5-6). On my right side there was neck and arm pain and some numbness in my fingers. After some time, I also started getting similar symptoms on my left side. Then, it became clear that most these symptoms was not due to hernia but to muscle spasms and bad posture. While I was seeing doctors for these problems a neurologist suspected CTS since I was waking up in the middle of the night with pain and numbness. She requested NCS which came out normal. But at the time of appointment I was almost symptom free. This was in 2013. I went to see the same doctor after two years, in 2015, because despite my neck and arm problems were resolved, on my right hand, I was having disturbing twitches on index finger and most of time I had numbness on my index and thumb. She requested another NCS which also came out normal. At the same time I started using splint for my right hand.
- Late 2015, I got started having pain on my right wrist in addition to numbness, which prevented me working normally. Also my left hand started to get tingling and numbness. I went to a hand surgeon which I think is quite experienced with CTS. He told me that I seem to have atypical CTS. He gave me a steroid injection on my right wrist. It made some difference after a couple of weeks. Pain was mostly gone in about a month. Numbness also got better. But all came back after two and a half months.
- On the follow up, he told me that that the injection helped to some extent shows there is problem at the wrist. But, given that I have very small amount of tingling and tingling is very typical in patients with CTS, the expected success rate of surgery is low. He told me that the success rate in my case is 50% and it is up to me whether to have it or not. Later, after some more talking, he told me that I might actually have a good chance.
- Right now, I am quite concerned since I might already have some persistent numbness on my right hand and I will start a new job soon which will increase my workload and stress levels. It is affecting my overall mood and my career, just like almost every CTS patient.
- The results of the last questionnaire from this site:
+ Probability of CTS: 17%
+ Symptom Severity Score: left: 1.3, right: 2.2
+ Functional Severity Score: left 1, right: 1.6
- I have very flexible hands and fingers, like the hyper-mobile people.
- My neck and back muscles are sensitive, I have occasional pain and I have lots of trigger points. But these respond to exercises, relaxation and medication.
*** Questions
- Should I have additional tests for more certain diagnosis? I never had an EMG and it's been more than a year since I had NCS last time.
- Should I try to get the detailed results for the NCS tests or they would be irrelevant since they are not recent, the recent one is older than a year?
- My left hand follows a similar path with my right, the symptoms get more frequent and I am sadly getting used to them. Should I go straight away with an injection there even though the symptoms are mostly mild for now? I don't want to be too late like I was for my right hand.
- What would be your recommendation as the next step for my right hand? Any estimation for the success rate of the surgery?
*** Personal
- Male
- 33 years old
- Normal weight
- Software engineer
- No family history of CTS
*** Symptoms
**** Common
1. Numbness on index and thumb. Both right and left. For right, it is there more than two years, some persistent loss of sensation compared to left. A feeling of swollen finger tips. For left, recently started, still comes and goes, but worsening. Numbness on both hands triggered by computer and phone use. Gets better if I stay away triggering activities.
2. Pain on wrist, affecting index and thumb occasionally. A feeling of swollen wrist. Mostly right hand. Increases with computer use, phone use, knife use and the swinging motion of my arm while walking. A couple of times, it was quite severe. Gets better if I stay away triggering activities. Also, when pain stays for longer, for example when I use my hand more, it becomes difficult to use my hand, a feeling of clumsiness.
**** Rare
1. Night time waking with pain, numbness and tingling. Mostly right hand. This has been rare with me compared to the amount that is typical of CTS. Sometimes it happens back to back for a couple of days, but on average it has been less than once a week. It is even rarer when I wear a splint. But, even with the splint, some mornings, I feel some numbness when I wake up.
2. Tingling at base, inner and outer sides of index and thumb. It is so in small amounts that tingling does not contribute to my disturbances. On the left hand tingling precedes numbness.
3. Twitching of index finger. Very rare, only happened for a period of a couple of weeks. Only right hand and only with flexed wrist.
4. Sharp shooting pain from wrist to forearm. Very rare but painful. Only right hand, happens when gripping something such as mouse or phone.
*** Tests
**** NCS
Two times, in 2013 and 2015. Both normal.
**** Phalen's test
Several times by therapists and doctors, none very distinctly positive.
For both hands, when I keep by wrists relaxed and flexed, I get slight tingling on index and thumb within 30 seconds.
**** Tinel's sign
Negative with tapping. Only had slight tingling when a constant pressure is applied at the base of the hand.
*** Treatments
**** Injection
February 2016, on right hand. It made some difference but not right away. It took more than three weeks. Pain was mostly gone in about a month. Numbness also got better, though, even at its best I had less feeling on the tips of index and thumb compared to the left hand. But pain and numbness all came back after two and a half months. I suspect the quick relapse is due to that, although they are not extreme, I have had the symptoms for a long time.
**** Splint
Prescribed first two years ago. Used it on and off until 6 months ago. For the last 6 months constantly using.
I think it helps with night time symptoms but, since my most disturbing symptoms are in daytime doing specific activities, splinting does not help much overall.
Thank you for your response,
I will obtain the actual NCS results.
I understand that ultrasound imaging would be again for diagnostic purposes. But what would be the second injection for? I mean, is it possible that it might last longer than the first one, which lasted shorter than two months, or would that also be for strengthening the diagnosis?
Also, I got the first shot about three months ago, how long do you think one should wait for a second shot to be safe? I read about limiting the number of shots to 3 or 4 times annually.
Thanks a lot.
Ultrasound is indeed diagnostic. There are several pages of this site showing how it can be used. Second injections are, on average, about as successful as first, but sometimes they work better and sometimes less well. They are diagnostically useful in that a response to injection helps to confirm that the problem really is CTS - your first one was a bit uncertain in response so I would be tempted to try again, making sure that an adequaate dose was used. Two can be given in quick succession, especially if a low dose was used the first time. The surgeons recommend a maximum of three injections per site but there is no evidence to support this recommendation and I think it is reasonable to give more than three under close supervision in some circumstances. We currently restrict them to not more than an average frequency of 1 every 6 months (which means you can have two quickly and then leave a longer gap).
I still have to go back over your original post, sorry! It's been a busy weekend but I'll get to it shortly. JB
OK I've had a bit of time to absorb that now. I think I pretty much agree with your surgeon's assessment that there is about a 50:50 chance that you will benefit significantly from carpal tunnel surgery, however there is also probably about a 10% chance of surgery making you worse.
The distribution of the symptoms into just thumb and index finger would fit with the original suggestion of C6 root problems. I have to say that I am a little sceptical of attribution of neurological symptoms to muscle imbalance/spasms. The persistent wrist pain is also a little odd. From the story it sounds to me as though there may be a local problem in the wrist which is itself painful and aggravated by use. It is then possible that this may in turn be producing intermittent pressure on the median nerve in the carpal tunnel and resulting in the occasional night-time CTS-like symptoms. If this is only intermittent and not producing any permanent physiological alteration in median nerve function that would account for two sets of normal NCS. I doubt if needle EMG will achieve anything other than giving you a sore thumb when the NCS are repeatedly normal. I wonder what your hand surgeon thinks about possible causes of wrist pain specifically - he has had the chance to see and X-ray/MRI the wrist or whatever so is in a much better position than I am to approach that question.
It's a little hard to judge the response to injection - a delay of 2 weeks before any effect and then 'some' relief is certainly not the dramatic and major improvement in symptoms within 48 hours that one usually takes as fairly clear confirmation that the problem is CTS and steroids will have a general anti-inflammatory effect around the area where they are injected which may benefit conditions other than CTS to some extent. If it is tried again I would be inclined to monitor the results with serial SSS/FSS scores JB
Dr. Bland, thank you for your responses.
I was able to obtain the NCS results at last. I am sending them to you by email. I would be glad if you can look at them to see if they were done throughly.
Regarding the C6 relation, I am inclined to think that if the root cause was C6 then I would not get symptoms aggrevated directly by wrist use. And my hernia is located at the right side which shouldn't cause any symptoms on the left, which I have.
Regarding a non-CTS condition, my hand surgeon didn't ask for any xray/mri but he checked my wrists. I think he just didn't suspect anything. I will ask him if any xray/mri imaging might also help.
I am trying to determine the next step. It could be to ask my hand surgeon if we can try another injection, perhaps for both wrists this time, and then I will record my SSS/FSS scores every day or every other day this time and get back to you.
Thanks a lot.
Oguz
Thanks for the NCS results.
They take an interesting approach - they went straight for the most sensitive tests for CTS and did three of them and when all those came back normal they did not pursue it any further. Both sets of studies are the same so this was an examination focussed very tightly on trying to confirm/exclude CTS. This combination of tests probably has a false negative rate of about 5% overall so there is still a possibility that at least part of your problem is CTS and as a couple of years have passed it may be worth repeating them again, perhaps with a few studies designed to look for more proximal median nerve problems or thoracic outlet syndrome and maybe with some ultrasound imaging as a double check. Some Americans would say you should have extensive needle EMG to look for evidence of the C6 radiculopathy but I am not a great fan of this approach.
The only thing I would definitely say about these results is that there is no need to rush into carpal tunnel surgery becasue of fear about irreversible median nerve damage at the wrist - your median nerve function was obviously pretty good in 2014.
If using the SSS/FSS to track symptoms, once every week or two is probably about right. JB
That's a long and complex tale. I'll go through it in more detail later but having quickly read through once I would say that it does sound as though there is a fair probability that part of your problem is CTS. I would like to see the NCS results to check that they really were done thoroughly and see if there was any change over time when comparing the two studies. In my own clinic I would also be considering ultrasound imaging and possibly a further trial of injection before taking the irrevocable step of surgery. JB