Stabbing pain worse after CTR op
Again thank you for such a complete and well laid out CTS Website. I had been in touch about my CTS but had not posted on the forum before. I have suffered from CTS for over a year in my right hand (I am left handed). Ultrasound scan revealed a bifid nerve with a persistent median artery and I had a steroid injection on 25 April before having carpal tunnel release op on 11 July as advised by rheumatologist and traumatologist / hand surgeon. After the anesthetic wore off, pain and slight numbness I have been experiencing over the last few months came back. Then on 14 July stabbing pain got more intense along the distribution (thumb, index, middle, ring), worse than it had been for weeks before the op. This pain is keeping me awake at night. My plaster splint and dressing are all still on so have not seen the area or the stitches yet. I seem to be healing rather quickly though, very little pain from scar (been put on ibuprofen every 8 hours, no effect on nerve pain). I can move my fingers and thumb and nearly touch type again in less than a week with dressing and splint on. (I only started to try touch typing 6 days after the op.) I am sticking to the rules I was given by surgeon though, hand in sling for the first 72 hours and never using it for anything requiring even the smallest amount of strength. I had been told by my surgeon that CTS symptoms would go away immediately and that is why I am concerned. I will be seeing him on 19 July but texted him before and he said this could be from the nerve entrapment having been really bad. He said I should just hang on and prescribed more painkillers which do not target nerve pain so still awake at night. Again I would be very grateful for any insight at this point and many thanks for going through this.
Thank you very much for replying so quickly and for the guidelines which I will follow. I will post back an update mid next week.
Again thank you so much for your comments. Stabbing pain went on especially at night and kept getting less than 3 hours' sleep each night. Also BP went up. However on Saturday I started to improve slightly, also haematoma in palm started to fade. Symptoms started fluctuating, pain will go away then come back although a bit less intense, a bit like before having the op. Hand use steadily improving, 70-80pc normal as I type, just avoid holding heavier objects and pulling.
I saw the surgeon yesterday, he said your analysis was perfect and was thankful for it and did an ultrasound scan of the median nerve in the carpal tunnel saying it still looked 'irritated'. Then he scanned the nerve starting at wrist up to the elbow, told me to move my thumb and / or my fingers looking for pronator teres syndrome or anterior interosseous syndrome (possibly another condition as well I cannot remember) explaining what they were, how symptoms differed from my 'purer' lingering CTS symptoms, and showing why he could not see evidence of any. He told me to hold on in the hope things will improve naturally but will see me again on 9 August. I will report back by then or of course before.
Pronator syndrome, and especially problems with the anterior interosseous nerve, are notoriously difficult to diagnose on ultrasound but I'm impressed that he took a look. I would expect the median nerve at the wrist still to be enlarged at this point, I'm not sure whether 'irritated' is the right word or not. Some people use colour power doppler imaging to try and detect increased blood flow in the nerve as a sign of inflammation but it seems to be a very operator and machine dependent technique. Glad to hear things are improving somewhat anyway. JB
My apologies for not writing before due to a problem with my browser. I am so grateful for your comments. Stabbing pain has decreased a bit since I last wrote and it will still interfere with sleep, which seems to be the only way I have of measuring progress at the moment.
3 1/2 weeks after the op sleep went up to 4+ hours. 4 weeks and 3 days after the op (ie now) up to 4-5+ hours. Hand use 80-90pc back to normal, I am driving and moving stuff around as long as it is not too heavy and 'feels right'. I will get the occasional but very mild shooting pain now and then whilst using my hand. Lump around the scar area gradually disappearing, just a bit of it left on the wrist side.
On 9 August the surgeon said any improvement was a good sign. I mentioned colour power doppler imaging to detect blood flow in the nerve, he promised to do it next time I see him by the end of September as by then the area will be clear of debris from the op.
I thought I would mention I also have some rather mild CTS symptoms in my 'good', unoperated hand. Never had pins and needles (whereas my now operated hand started with intense pins and needles), just dull discomfort / burning / pain. The surgeon thinks they could start to go away as soon as my operated hand has healed properly.
I will report back by the end of September or before if any significant changes. Thank you very, very much for your help and support.
It does sound as though it is settling down slowly. CTS is usually bilateral, often worse in the dominant hand, and the less affected hand does sometimes improve after operating on the more affected one. It is not uncommon however for patients to present with the non-dominant hand CTS several years after surgery on the dominant one. JB
I am very sorry I am coming back so late. I hope you will excuse me. My poor father passed away in the last few days and had been very poorly over a few weeks which put a lot of stress on me, and time has been tight.
Stabbing pain in the usual fingers and thumb continued to trouble me since I last wrote (14 August). My right hand (the one operated on) would be painful and there would be some discomfort in my left hand (again, median distribution) as well. This was not really an issue during the day but would still trouble me at night. I would sleep well and then it would come back the next night either stopping me from falling asleep or flaring up a few minutes after waking up in the middle of the night.
I tried hard to relate the pain to the stress I was under, coupled to the few hours' sleep I was getting, but as usual could not draw any conclusions. (I have not suffered from pins and needles for weeks now. Also, the Tinel's has consistently been very low to nonexistent on both hands, even more so in my operated hand).
I saw the surgeon end of September who did an ultrasound and said everything looked 'normal now although there is still some debris around' and reckoned I was healing rather slowly. He also admitted he had wondered whether I would be affected by complex regional pain syndrome after the op and was happy this had not happened. I am very sorry I managed to forget to ask him for the doppler ultrasound to detect increased blood flow in the nerve as you suggested. I asked him for a copy of the US and he only sent me a couple of screenshots without the parameter legend but I thought I would put them in the email in case you may find them of interest.
Then starting 18 October I spent ten days helping customers and standing all day. I was away from my desk, did not drive or read or use my mobile device much either. Some four to five days into the new activity I was rather surprised - the stabbing pain seemed to be not as bad in bed. I was still under a lot of stress at the time.
From about 23 October onwards I have been trying to keep my neck straight through the day as opposed to bending it for minutes or even an hour at a time when reading, using mobile devices, or working at my desk. (I am now 49 and have spent easily 30 years with a forward head posture, exacerbated by my love of reading and handheld devices.)
I still feel the (now diminished) stabbing pain in the median distribution in both hands, not ulnar; no tingling or Tinel's to speak of; no pain, numbness or tingling anywhere else.
Strangely enough stabbing pain has not seriously interfered with my sleep for about two weeks now. The discomfort is still there but milder in bed, mostly noticeable during the day if I try to take a short nap in my chair (discomfort will last for 5-10 minutes which is what I would like the nap to last for!). Also I am now under much less stress and since my poor father passed away, I am getting 6+ hours' sleep thanks to very little interference from stabbing pain as well.
Thank you ever so much for going through such a long post. It would be fantastic to know what you think and as always your advice would be invaluable.
Quite nice pictures from that GE scanner. He didn't measure the nerve cross sectional area, or at least not on those images, and it looks as though you probably have two branches to the median nerve at that point, possibly even with a small median artery between them - hard to be sure without seeing the live images. I can't remember was that noted previously when the rheumatologist was looking at it?
Overall it sounds as though post surgical inflammation in and around the carpal tunnel is gradually settling. It's a rather more prolonged recovery phase than one would like to see ideally but at least it's going in the right direction. I wonder how much the NCS have improved by this point - should I ever end up haveing carpal tunnel decompression myself I'll be tracking the evolution of the NCS daily but so far I've managed to avoid the condition. JB
I am extremely grateful for your quick reply and your views. Yes the rheumatologist noted a bifid nerve with a persistent median artery in my CTS wrist. I have more images complete with parameter legends and a short video of the live US she did back in April (those would be pre op). I will be delighted to send them to you if you wish.
I have not had any NCS done after the op. Sensitivity in fingers does seem to have improved, especially over the last two weeks. The tips of my middle and ring fingers used to feel numb (never completely though) and they feel nearly back to normal now.
Do you think forward head posture may have been playing a role at all in stabbing pain felt in both hands? Again thank you very much.
Head position might be putting a bit of extra stretch on the brachial plexus perhaps. It's hard to see how one would conclusively prove or disprove the idea though, especially in the dynamic period after carpal tunnel surgery when the neurological status of the arm will be changing anyway. JB
Again my apologies for replying so late. Hopefully this time I have some good news.
My right ('bad', operated) hand did not improve at all over the next few weeks after I last wrote, keeping me awake at night (2-4 hours sleep, occasionally 4+). Hand functionality continued to be good. I am sorry I have been putting off writing as typing often exacerbates my condition and try to keep computer work to a minimum.
I saw a few physiotherapists for no gain but end of January I was recommended a very good one who graduated from Southampton in '99. He wondered whether forward head posture may have been causing TOS or some other sort of double crush issue. He suggested I raise the monitor so that I need to look up slightly when on the computer. He also gave me several stretches to do at home and in the office. I gradually started to feel better about three weeks later. Hand pain went down easily 70pc and it was no longer keeping me awake.
I have been stretching 2-3 minutes at a time, three times a day. Working on the computer, reading, and moving heavy objects with my operated hand usually brings the pain back (as does being under stress!) but when I stretch regularly I seem to be able to keep the pain at bay over 70pc of the time.
A few days ago I tried keeping away from the computer and my books for a week, using both hands but avoiding heavy objects, and stretching once a day or not at all, and my hand has been mostly pain free. I've been getting more sleep (6+ hours) and felt this was helping.
Swimming seems to help as well.
I wonder whether at the time of my operation my CTS had actually started to resolve and new issue to creep in (TOS / double crush / something else?) but I am only a layman of course. It would be fantastic to hear your view on this and any advice on what else to do. In particular I would love to go back to my books too as I used to be an avid reader.
Thank you so much for going through all this.
Did we ever have any pre- or post- operative nerve conductioon studies for this - I can't remember offhand and I can''t see any mention scanning quickly back through the thread. It's always hard to know whether 'ergonomic' or exercise interventions have really made a difference to something in the individual case becase it is so common for things to improve spontaneously anyway - even after long periods of apparently being fairly constant. Nevertheless, if it seems to be helping I would be inclined to continue. Physiotherapists tend to be much more enthusiasic about diagnoses of thoracic outlet syndrome and double crush than neurologists - I don't know that either side has conclusive proof to rely on. JB
Thank you. Only NCS was in 2015 months before the operation which I sent you by email at the time. I will continue and report back sooner this time. Again thanks so much.
Ah. got them now, grade 5 CTS, and there was some response to pre-operative injection with 20mg triamcinolone (had to find that in my email trail). By this time I would be thinking of repeating the NCS in someone who still has significant symptoms after surgery to see how much the nerve has improved but that is not always possible in less well resourced areas (I am given a pretty free hand by the local purchasers here to test people as I think is appropriate). Starting from grade 5 this could still be a matter of the nerve very slowly recovering from the CTS and the wrist slowly recovering from surgery... but of course there is no law against patients having neck and shoulder problems too. JB
Thank you. Great news. I've just got back to playing music on my keyboards and am not too bad which hopefully means the nerve has improved. I should have mentioned the injection sorry! I decided to have one thanks to your advice. Your support has been, and is, vital to me, and so much appreciated.
I should have also mentioned I've been trying different things and keeping a log. On average, on days when I spend a few hours on the computer and / or lift heavy objects, and intentionally don't stretch, my hand is more painful at night, which is why I keep stretching. It feels as if completely stopping the stretches could bring back pain that's more constant.
I think the conventional advice to vary the things you do during the day and take breaks is probably fairly sound even though it's not exactly evidence based medicine. We didn't evolve as an animal that sat at a bench/desk doing the same thing for hour after hour every day so we probably aren't ideally adapted to that. JB
CTS symptoms do usually resolve immediately after surgery, at least in cases below my grade 4 in severity, however a fair number of people do seem to experience this sort of symptom in the early stages after surgery, perhaps related to the release of inflammatory mediators by the trauma of surgery. I start to worry if problems persist beyond about two weeks and by 6 weeks I would normally be aiming to check the NCS results if things feel as bad as they did before surgery or worse. JB