Advice requested

lenp
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Having constant severe numbness in thumb, index and middle finger.

Had EMG done 9/29/16 with result being "Severe entrapment of the left median nerve at the wrist, i.e., severe carpal tunnel syndrome. There were no needle EMG findings of denervation in the more proximally innervated pronator teres muscle suggesting that a more proximal nerve injury in the shoulder or cervical spine is much less likely. There does appear to be some ulnar sensory prolongation which could also suggest that in addition to the median neuropathy at the wrist there may be some ulnar irritation at the wrist as well."

Some additional background:
9/11/97 - MRI Cervical Spine showed a grade 1 spondylolisthesis, (reverse) involving C5 upon C6. The spondylolisthesis is causing high grade spinal stenosis with narrowing of the spinal cord at C5-6. C5-6 shows the spondylolisthesis with associated disc protrusion and high grade spinal stenosis as well as high grade lateral recess stenosis. The spinal cord is thinned at the C5-6 level.

April/1998 - Surgery performed for spondylolisthesis at C5 upon C6 with bone implant, plate and screws.

4/1/15 - MRI Left Shoulder showed diffuse degeneration of the supraspinatus and distal subscapularis tendons. A full thickness tear of the supraspinatus tendon is present measuring approx. 1.6 cm in diameter.

4/1/15 - MRI Cervical Spine showed anterior fusion at C5-6. Moderate to advanced degenerative disc disease is present abpove and below the fusion at CV3-4, C4-5 and most prominently at C6-7. There is foraminal stenosis bilaterally at all three levels, most prominently at C6-7 bilaterally and at C3-4 on the right side. Disc material and degenerative changes result in spinal canal stenosis at all three levels. There may be slight impingement of the cord at C3-4 and C6-7.

6/10/16 - Left rotator cuff surgery repair with anchors and sutures. Nerve block was administered along with general anesthesia. Post-op was in a sling for 6 weeks. During that time my left forearm and left hand were extremely swollen for several weeks. Began physical therapy at the post op 7 week period. Numbness in left hand began at the end of the six week sling period and progressively got worse during the PT time frame.

9/29/16 - EMG left side performed.

10/13/16 - Orthopaedic surgeon who performed the left rotator cuff surgery strongly suggested Carpal Tunnel Release.

There is a lot here but wanted you to know all the history involved. I had absolutely no symptoms of CTS prior to the left rotator cuff surgery and being in the sling. I believe my CTS may have been the result of being in the sling. I'm also concerned that my hand numbness may be caused by the issues with C6-7.

I am very hesitant in having the surgery for CTS after reading possible complications. But I am also concerned with possible long term problems if surgery is not performed.

Any thoughts?

Thank you!

jeremydpbland
Online

The local swelling of the hand during that period in a sling could well have been the trigger factor for CTS. The symptoms and NCS results are certainly consistent with CTS though I am wary of other doctors use of the term 'severe' which has widely varying meanings for different people - do you have the actual NCS results? JB

lenp
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I do. Previously only listed the interpretation.

Here's the remaining:

Clinical data and indications for study: Patient with numbness and tingling in thumb and first two digits of his left hand. He had recent rotator cuff surgery and symptoms began after that.

Findings: Accordingly, nerve conduction studies and EMG were performed. The left median distal motor latency was markedly prolonged at 7.9 ms. Amplitudes were very low proximally and distally in the 0.7 millivolt range and conduction velocity was normal at 54.1 meters per second. The left ulnar distal motor latency was normal at 3.0 ms. Amplitudes were normal. Conduction velocities were normal at 59.4 m/sec. The left median palmar sensory response was unobtainable. Left ulnar palmar sensory was prolonged at 2.6 ms. Left radial sensory was normal at 2.6 ms. Needle EMG was done evaluating the left deltoid, biceps, pronator teres, abductor pollicis brevis, first dorsal interosseous. The abductor pollicis brevis muscle demonstrated 2+ positive sharp waves and fibrillations with normal recruitment. The remainder of the muscles demonstrated normal insertional activity without evidence of abnormal spontaneous activity, normal motor unit morphology, and recruitment pattern.

jeremydpbland
Online

OK in my terms that's a grade 5 left CTS. I'm less impressed with the ulnar nerve abnormalities which are trivial by comparison. The statistics suggest that your best bet with a grade 5 is indeed to go for surgery but that does not preclude giving it a dose of steroids first by injection - George Phalen said that every patient with CTS should be given one chance with steroid injection. Ideally one would have caught it earlier than this but you have to deal with what's in front of you. JB

lenp
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Thank you very much JB! I greatly appreciate your advice!

I failed to mention that I had a steroid injection and I felt no change. Even the splint that I wear constantly doesn't help.

I'm guessing, as you mentioned previously, that my time in the sling caused/contributed to the onset of CTS.

I also developed trigger finger in my middle finger simultaneously with CTS.

Thank you again!
Len

jeremydpbland
Online

Trigger digit and CTS are closely associated - see the page of this site - 'The triad'. I'm not too surprised to see grade 5 not responding dramatically to steroids but it didn't do any harm to try. Good luck with getting it fixed. JB

lenp
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Thank you again for your advice! It is very assuring to know that I'm not electing a non necessary surgery.
Thank you!

lenp
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Update: I had the carpal tunnel release open surgery and trigger finger middle digit done 12/7/16. To date, 12/12/16 I feel no improvements to numbness in my thumb and first 2 digits. How long does it normally take for the numbness to be relieved?
Also, my middle finger is very tight and swollen. I can't extend it all the way. Is this normal?
Thank you for your help!

jeremydpbland
Online

From grade 5 recovery of numbness and weakness can be be very slow and sometimes incomplete. I'm assuming from the posting dates that 12/7/16 is American date format and 7th December so this is less than a week post-op and I would not worry yet. Tingling and pain, if present to start off with, should resolve faster. The stiff middle finger, is less likely to be directly related to the CTS and more likely to be a consequence of the trigger digit surgery - a subject about which I know less, though again 5 days post op is probably too early to make judgements. What did the surgeons advise re post-operative care? JB

lenp
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I have an appointment 19 December to remove the stitches. Have not received any other Post-Op advise to date. Len

jeremydpbland
Online

Probably worth asking specifically about after-care at that stitch removal visit then. Most of the people in the field now feel that hands should be mobilised pretty quickly after surgery but that view is not universal and you should generally be guided by your own surgeon. JB

lenp
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Thank you JB. I will definitely do that today.

lenp
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Update:
Stitches out 19 Dec., post op 21 days. 1st 3 digits still numb with difficulty squeezing/holding/ items. No PT prescribed. Re-visit 1 month. Is this normal?

Thanks JB!

Len

jeremydpbland
Online

Many surgeons here do not see CTS patients again after stitch removal - some don't even see them for stitch removal, using a resorbable suture or getting someone else to remove them, so a planned review in a month is either thorough or they are somewhat concerned about progress I guess. We would consider hand therapy for someone with marked stiffness and difficulty using the hand at this stage but it's arguable whether it really makes any difference or not, as compared to simply telling the patient to keep working at it. Is there any detectable improvement in the numbness yet? Starting out from grade 5, I would be thinking about repeating the NCS sometime between 6-12 weeks if there was no symptomatic improvement at all, almost always with an ultrasound examination as well nowadays - but few places wil have the resources to do that I think. JB

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