Revision for scar tissue causing symptoms post CTS surgery?
I am 64 years old and was diagnosed with CTS in January 2016 after nerve conduction studies demonstrating motor latency across the wrist at 6.1 milliseconds (ms) on the right and 4.6 ms on the left. Sensory latencies measured 3.8 ms on the right and 3.9 ms on the left. The opinion of the neurologist was mild to moderate CTS on th right and mild on the left.
My hand surgeon recommended surgery on the right hand because my symptoms had been occurring for some time and he noted some atrophy in the the area muscle on the right. I had attribute my symptoms in both hands to cervical disc degeneration from which I would have symptoms from time to time that always resolved wtih physical therapy. However, I investigated the neck situation in November 2015 obtaining a new MRI and consulting a neurologist who was not impressed that they hand symptoms were coming from my neck. Thereafter I woke up one morning with pain in the joints of both thumbs and bilateral trigger thumb. My hand surgeon injected the left thumb joint in March and I proceeded with the surgery on the second hand on March 29, 2016. A trigger thumb release was also performed at the same time. There were no apparent complications from the surgery.
I had no symptoms (tingling, numbness, pain) immediately after the surgery. My thumb sutures were removed on April 14 and the hand incision checked, which had dissolvable sutures. All bandages off at that time. I still had no symptoms two weeks after the surgery. About three days later, I noticed a sharp feeling in the very tip of my index finger, and eventually in the tip of my middle finder, and then tip of my thumb. I also noticed within a short time period the tingling coming back in my fingers, thumb and hand in the areas of the median nerve distribution. The underside of my thumb became completely numb from the tip down to the first joint. My surgeon kept telling me it would resolve but I eventually asked him to send me to occupational therapy which he said I should not need. I had OT for a month, consisting of four visits wherein I was shown exercises with rubber bands and then did them at home. She only did one treatment wtih ultrasound. In a month my strength and grip did improve in my right hand, but the symptoms really did not.
I then had repeat nerve conduction studies with the same neurologist on July 29, 2016. At first, he could not even obtain a reading on the median nerve response but then concluded as stated in his report that "right median motor and sensory conduction showed very low amplitude motor responses at the APB in the 0.5 millivolt (mv) range whereas gen previous studies in January we're in the 5 MTV range. Sensory responses were comparable with stimulation in the Palm but with stimulation at the wrist and at the el one and conduction through the carpal tunnel gen amplitudes we're markedly de erased to absent. The motor latency through the carpal tunnel was delayed at 11.4 ms...and the sensory latency...at 5.1...". EMG was also performed on the right hand, forearm and cervical paraspinal muscles which "was significant for low amplitude fibrillation and positive sharp waves in the APB and large polyphasic motor units with volitional activation with a reduced interference pattern and otherwise normal." With regard to the conduction studies, the neurologist concluded there was "a significant mixed axonal and demyelination get process affecting the right median nerve at the carpal tunnel with the demyelinating process being favored by the drop off in the sensory responses proximal to the carpal tunnel and the axonal issues being shown by the similar amplitudes with stimulation of the median enervated muscles in ten barista and elbow and additional prolonged latency through the wrist. The EMG further substantiates this but th presence of large polyphasic motor units in the time frame since the surgery would also imply there had been axonal loss prior to the surgery as these large polyplastic motor units would not be expected to have fully formed in the last four months."
I last saw my surgeon on August 17 and still had symptoms of tingling and numbness continued. However, in mid October after I did some research online, I found a chiropractor who specializes in performing both Active Release Technique (ART) and Grastin Technique for soft tissue therapy, focused on breaking up scar tissue that may form as a result of sports injury or other trauma, including surgery. In addition to the typical spine adjustments, she has also adjusted my elbows and my hands, and after five Grastin treatments to my hand, my tingling has almost completely resolved. The numbness is still in only the very tips of my two fingers and the thumb numbness is a little improved. I also saw a new hand surgeon on October 26 for a second opinion and he currently recommends revision surgery to release the scar tissue from the median nerve which he feels is responsible for the symtoms that developed 17 days after the initial surgery. But he said the scar tissue can come back. I am thinking about it but am very hesitant to undergo a second surgery with no guarantees it will work. I am scheduled for repeat nerve conduction studies on November 15 and look forward to seeing if my right hand median nerve tests have improved. Then will discuss further with the surgeon. I have told him about my currrent conservative treatment.
I feel that my symptoms are resolving and am thankful that I really have had no pain, just maybe an uncomfortable achy feeling with overuse of my hand, but that was prior to my recent soft tissue treatment. I am reaching a point where I feel that I can tolerate my residual numbness in my thumb even if that never gets back to 100%. I realize that I will have to maintain some level of home or chiropractic treatments in this regard. But there are no guarantees with a second surgery and my hand could be much worse. I have read a lot of horror stories about post operative pain and I do not think I want to go there. I am also trying to do exercises to stretch and strengthen my thumb, which could have some degree of permanent damage due to the duration of symptoms prior to my surgery. The left hand CTS and trigger thumb symptoms have pretty much resolved over the last ten months wearing a wrist splint at night and also perhaps the one injection in March.
Sorry for this long dissertation. But wanted to summarize all the facts. Let me know if I have left out any relevant information.
I would appreciate Dr. Bland's perspective on this case and whether a second revision surgery at this point is a good or bad idea. Others' comments are also certainly appreciated.
Thank you.
Thank you Dr. Bland for your prompt response. Sorry about the “thenar" muscle typo. I was going to send another note to correct it but hoped you could decipher it. Will do a better job proofing this time.
Before my surgery on March 29, 2016, I had the typical tingling in my right hand. I had been wearing splints on both wrists since I was diagnosed in January and my left hand symptoms had subsided for the most part. My right hand had not. It was like the tingling would come in waves based on what I was doing with my hand (i.e., typing on my phone, iPad or computer) and the position of my hand that apparently caused more pressure on the median nerve. I could shake out my hand and the tingling would subside. (Interestingly, I could also change the position of my neck and they would subside. So, if I was looking down at my phone or iPad, my hands could start tingling. Hence I realted the tingling to my neck.) At least with wearing the splints I could sleep at night unlike before I started wearing them. I do not recall having any numbness in either hand before the surgery. Just that swollen and tight feeling, more noticeable in the morning, which some have described as "sausage fingers." I definitely did not have the numbness that developed in my two fingers and thumb like 17 days after the surgery. I was still experiencing trigger thumb in both hands up until my surgery. On March 23 when I returned to see my hand surgeon and told him my right hand CTS symptoms had not improved with wearing the splint at night since January, he thought I should proceed with the surgery. He also suggested that he release the trigger thumb at the same time. At that time, he also injected my left thumb to see if that would resolve the trigger thumb in that hand.
After the surgery, I felt absolutely no tingling when I moved my fingers or my hand. Of course I still had on my bandages and stitches in my right thumb. I wiggled my fingers and used my hand as much as I could and no symptoms. I returned two weeks post op and the bandages and thumb stitches were removed. My hand felt good. It was about three days later that I started to develop the numbness at the tips of my fingers, and then the tips of my thumb, and eventually more down the underside of my fingers and thumb, but much more pronounced on the thumb. About three days later I began to have an achy feeling in my arm (which did not last too long) and sort of a diffuse tingling feeling in my hand, in the approximately the same distribution (two fingers and thumb). Not the sort of waves of tingling that I would have before the surgery in response to a particular use of my hand. This felt more pervasive and more constant. I emailed my surgeon about it early the following week. But I was out of town and so could not get into see him until May 4. At that time he felt that I should give it some time for the numbness to resolve.
Eventually I asked him to order occupational therapy for me because neither the numbness nor the new tingling feeling improved. I started the therapy on June 28, 2016 and went for four visits. But basically I did exercises at home. The most prominent issue was the tripod pinch on the right, and right thumb laxity and joint instability in the right thumb CMC and MP joints. The strength improved by the last visit on July 19, but the thumb joint stability did not.
I saw the hand surgeon again on July 20. I mentioned again my previous cervical spine issues, which I had initially told him I had attributed my symptoms to, and he decided to do a cervical spine x-ray that day. He also then ordered the repeat nerve conduction studies, which were done on July 29. The neck x-ray showed “[m]oderate degenerative disc disease at C4-5, C5-6 and C6-7. Upper cervical facet arthropathy with slight anterolisthesis which reduces on extension.”
The neurologist who performed both nerve conduction studies decided to do an EMG of the right hand, forearm, upper arm and neck muscles on the July 29, which he had not done previously. He also looked at the report from my November 2, 2015 MRI of the cervical spine. He also was impressed that the findings of that MRI were enough to cause any compromise of the nerves from C5-6 or C6-7, although the report of that MRI clearly states that there “may be compromise” of the exiting right C6 and C7 nerve roots. But nonetheless, the EMG studies did not show evidence of cervical nerve root involvement. Following the results of that testing, I saw the hand surgeon once more and he did not recommend further exploration of the carpal tunnel. I even asked for an ultrasound to see what was going on in there (after I had read this website and the “what to do when CTS surgery fails,” and your recommendations to others on this forum) and he felt it would not show anything. He said to be patient and essentially do nothing.
Finally, after feeling no improvement in my right hand symptoms by mid September, I decided to see the second hand surgeon for a second opinion. In the meantime, I was researching other conservative treatments and found the ART and Grastin Techniques and then sought out this chiropractor that I am still seeing. I started seeing her on October 20. I have seen her twice a week and she has performed techniques. The ART from my neck down, and the Grastin focused on the scar tissue in the palm of my hand around the incision and around my thumb incision. I am also doing other exercises to stretch and increase the range of motion of my thumb, which is still a little tight at the incision, and massaging at home.
The numbness in the fingers has essentially resolved except the very tips. The thumb numbness seems to be starting to get a little better with the therapy. The tingling is better. Some days my hand feels great and I hardly notice anything. Other days are not as good but not too bad, and certainly not as bad as it felt from May through September. Sometimes I wonder if what I am feeling as tingling is really from the feeling of numbness. (The entire tip of my thumb feels like I burnt it on a hot stove, but I am beginning to feel that feeling subside a little.) It is more like a pins and needles sensation rather than waves or pulsations of pins and needles like before the surgery. Not sure if that makes any sense or not.
My third set of nerve conduction studies are on November 17 (not the 15th s in my initial summary). My new hand surgeon actually called the neurologist to discuss the findings of both sets of testing and they came to the conclusion that further testing was warranted. However, I also asked the new hand surgeon if an ultrasound would be beneficial and he said no. So I guess the US surgeons are not as on board with this test as you are in the UK for diagnosing carpal tunnel surgery complications. But the new surgeon also does not believe it is a failed division of the carpal tunnel ligament. He believes it was a completed division and done properly, but that the resulting scar tissue is again compromising the median nerve. If that is true, then it seems to make more sense that the conservative treatment focused on breaking up that scar tissue or at least attempting to break it away from the nerve is perhaps working. It may take a few more treatments and it may also require maintenance at some level, but would that not be better than a second surgery and the risk of more scar tissue?
I will let you know the outcome of the next testing.
Thank you for your comments and expertise.
VHunt
That detailed analysis of how the symptoms evolved over time is certainly very useful and it does sound as though something developed after surgery to cause new compromise of the median nerve. The third set of NCS are definitely a good idea - if they show improvement compared to the second set then one can indeed afford to defer further intervention and await developments. I can sympathise with the surgeons/neurologists over ultrasound. There are perhaps only a dozen or so places in the USA (I am assuming this is the USA) that are really expert in peripheral nerve ultrasound, though expertise is spreading, so most neurologists and surgeons have not yet had the opportunity to learn how useful this technique is. JB
Thanks Dr. Bland. I will let you know how the tests go on November 17. I am in Northern New Mexico. Hand my surgery at the University of New Mexico Medical Center, a teaching institution, and where I worked as a health law attorney for five years. My new hand surgeon is in Santa Fe. I will try to research peripheral nerve ultrasound to see what I can find out and if there are any providers in the area who provide that service. VHunt
I think there is someone with an interest in nerve ultrasound in Albuquerque but I'm struggling to remember the name at present. If it comes to me I'll let you know though probably by email rather than publicly here. JB
Hi Dr. Bland. Sorry for the delay in getting back to you but it has been a very busy month. I had a third set of NCS on November 17 and the results were disappointing to say the least. The Interpretaton stated: Right median motor conduction did not produce a response at the APB. Right median sensory conduction showed a prolongation of the motor latency across the wrist at 4.7 msec., normal being 3.8 msec. Pre-surgical sensory latency was 3.8 msec. and previous post-surgical latency was 5.1 msec. Right median to radial sensory comparisons showed 2.7 msec. median delay and median to ulnar a 2.6 msec. delay, normal being less than 0.5 msec. delay. Right ulnar motor and sensory conduction were normal. EMG of the right FDI was again normal while the APB showed low amplitude fibrillations and single unit activation of a polyphasic motor unit. The Impression/Plan stated: These results show modest improvement in the right median sensory conduction through the carpal tunnel, but the comparison studies still place it in hte too moderate severity. The motor conduction showed worsening of the motor conduction and activation of the APB.
This was perplexing at best because my hand symptoms have continued to improve with my continued chiropractic treatment, including ultrasound and the Graston Technique. See https://www.ncbi.nlm.nih.gov/pubmed/17224356. Specifically the diffuse tingling sensation has resolved for the most part and the loss of sensation in the thumb, index and middle fingers has improved to the point where I feel that I can live with the residual and hope for further improvement. Nonetheless, at your recommendation for ultrasound studies, I contacted Francis Walker, MD, at Wake Forest, who coauthored an article on the use of peripheral nerve ultrasound to diagnose complications of carpal tunnel surgery. He referred me to a neurologist at UNM who trained under him at Wake Forest and he believed she was doing ultrasound for carpal tunnel at UNM. I contacted her and unfortunately she responded that she wasn't not yet doing it as they had no ultrasound equipment and she was therefore not really focusing on carpal tunnel. She did not know anyone else in New Mexico who did the ultrasound but suggested I gptry to get an MRI. In an effort to obtain a referral to her before she said she could not help me, I contacted my orthopedic surgeon who did the surgery at UNM and he suggested I see another's neurologist at UNM for further evaluation of my thumb function. I saw my surgeon on November 30 and then the neurologist at UNM on December 8.
In the meantime, I had seen a physician assistant to the hand surgeon in Santa Fe I had seen in late October for a second opinion (and who ordered the third set of NCS) to discuss the results of the NCS of November 17. I brought up the possibility of ultrasound and he basically said he never heard of it for this purpose. I also asked about getting an MRI and he agreed to see if he could get authorization from my insurance company if I wanted to get one. He got the authorization and I had the wrist MRI on November 26. The results of her MRI were not very specific and did not really address whether there was any scar tissue present that could be impinging the medial nerve even though that was supposedly reason the MRI was requested. However, the report of the MRI stated with regard to soft tissues: Mild dorsal ulnar subcutaneous edema. Median and ulnar nerves are within normal limits. Mild thickening and volar bowing of the flexor retinaculum which can be seen with carpal tunnel syndrome. No mass or cyst in the metacarpal total is seen. Tiny ganglion/synovial cyst along the volar aspect of the radiocarpal joint, proximal to the carpal tunnel. Also significant in the findings were degeneration and thinning of the triangular fibrocartilage and scarred scapholunate ligament.
When I saw the neurologist at UNM, he examined my hand and fingers and felt that there was severe atrophy of the thenar muscle of the thumb which will likely not improve. Atrophy had been noted prior to surgery and post surgery the primary effect of this is in the pinch function of the thumb. However, when this neurologist started performing yet another (partial) NCT, he also could not elicit a response of the right median motor latency stimulating at the wrist and recording at the APB. When stimulating at the elbow, there was only what is probably an ulnar response which is minimal or a volume conducted response. He then recorded from the 2nd lumbrical in the palm and found a median motor response at 4.6 msec. with an amplitude of 1.2 millivolts. When recording from the same muscle and stimulating the ulnar nerve there was a latency of 2.8 msec. and amplitude of 3.2 millivolts. The difference in distal latencies over the same 8 cm distance was 1.8 msec. which is beyond the normal of 0.5 msec. And deomonstrates a delay of the median nerve cross the carpal tunnel. Right median sensory recording at the index finger with mid-palm stimulation produced a response at 1.2 msec. with an amplitude of 15 millivolts was concluded to be "probably somewhat reduced." However, when stimulating the right median nerve at the wrist proximal to the carpal tunnel and recording at the index finger, there was no response. The conclusion of the studies was that there is a continued delay across the carpal tunnel. His report also stated "I believe there are technical explanations for why the electrodiagnostic studies have been so confusing. I did note when stimulating the median nerve at the wrist and recording from the APB that a
5-microvolt _____ potential was obtained but it had an initial positive or downward deflection which along with ulnar stimulation recording from the same site suggests that this was overstimulation of the median nerve leading to unexpected stimulation of the ulnar nerve and a 'pseudo' median response."
The neurologist was admittedly baffled about the results of the testing and consulted with a colleague in the clinic who turned out to be the same neurologist that Dr. Walker from Wake Forest had referred me to. She came into the room and actually discussed and assisted the other neurologist in completing the testing. They both then took my wrist MRI to review with the UNM Chair of Radiology who is also a hand specialist. I waited and the neurologist who conducted the exam and testing returned and showed me the images that led the radiologist to conclude that there appears to be scar tissue beneath the site of the carpal tunnel release scar that "essentially reestablishing the flexor retinaculum and presumably compressing the nerve at the site."
The next day, I again saw the physician assistant for the Santa Fe hand surgeon (December 9) to review the MRI results and I showed him the images that reflected what I was shown by the UNM neurologist and concluded to be scar tissue that may be affecting the median nerve. He was going to discuss the images with Tehran surgeon and another radiologist in Santa Fe who they rely upon for special expertise in hand cases. My follow up appointment with the hand surgeon in Santa Fe is January 5. He is the one who initially opined that my new symptoms developing 17 days after the surgery were likely due to the development of scar tissue and hence he recommended revision surgery.
But, my hand feels almost normal again and I am very hesitant to have surgery if I don't really have any symptoms, other than the residual loss of sensation in my thumb (first digit dorsal side) and the very tips of the other two fingers. Again, this feels to have improved over the months and I have read many many others on this forum who have had these identical symptoms developing a short time after carpal tunnel surgery, and in some cases these symptoms also resolved eventually. In reading the submissions to this forum, I feel somewhat fortunate that I have not had any pain or other debilitating symptoms as others have reported and consider myself fortunate. Nonetheless it has been an interesting nine months since my surgery, mostly looking for answers to my new symptoms.
Finally, I saw my UNM hand surgeon again for follow up on December 14 and he had reviewed the report and findings of the UNM neurologist. Curiously, he had also reviewed (or re-reviewed) the MRI of my cervical spine done a year ago on November 2, 2015, and in the office showed me images from that MRI which demonstrate degeneration of the C5-6 and C6-7 discs. He then told me that he suspects that likely I have a "double crush" injury and that some of the residual hand symptoms may be contributed to by a nerve root compression at that C6-7 level, the distribution of which is to the thumb, index and middle fingers. He said that he had also spoken about this issue to my neurosurgeon at UNM (who I saw on November 5, 2015, and who concluded that he did not believe my hand symptoms were from my neck) and that the neurosurgeon wanted to see me again.
I am therefore seeing the UNM neurosurgeon on December 29 to discuss this with him. Although I am not convinced at this point that my residual symptoms are being contributed to by my neck, I am still pursuing chiropractic treatment and my chiropractor also looked at my cervical spine MRI and said that my spine actually "zigzags" at the C5-6 and C6-7 disc levels as a result of the degeneration. She even wondered if this could have been due to some type of trauma at some point. She is hopeful she can assist me I need this regard to open up and realign those disc spaces. We will see what my neurosurgeon says about this. I have definitely had an ongoing cervical spine issue and undergone multiple regimens of physical therapy and chiropractic treatment for actue flare ups over then past eleven years.
So that is the update and I apologize that this is so long. I would be happy to email you any of the reports if you are interested further. But I would appreciate your thoughts on this fairly factually complex case.
Thank you.
I've just had a quick skim through that on coming in tonight. There's a lot in there and I need to go back over the previous studies and history too to get it all straight in my mind. It's almost midnight at present here so I'll look at it in detail tomorrow. JB
Thank you Dr. Bland. Let me know if you want the actual reports or any other information.
OK I've just had a read through that again. Lots of opinions and I'm a little wary of adding even more confusion to the mix with mine so I'll confine myself to two main observations I think.
1) Median motor function is clearly very poor. Everyone agrees you have thenar wasting and the median motor studies (at least from APB) have clearly deteriorated over the course of the treatment so somewhere you have severe damage to the motor fibres innervating APB - this may be in the neck, at the wrist, the recurrent motor branch of the median nerve, or some combination of these. Notwithstanding that pretty objective fact, the damage to these fibres does not seem to be bothering you very much functionally and this degree of muscle loss is unlikely to improve with revision carpal tunnel surgery anyway so there is no point in re-operating to treat this abnormality. If you are bothered by the weakness of thumb abduction then the usual approach to this at this stage would be an opponensplasty.
2) Sensory conduction seems better, though one person was unable to stimulate at wrist and record from finger. Ideally I would like to see all the nerve conduction recordings to comment further but few people include waveforms in their reports. This seems to tally fairly well with your symptoms which now seem to amount to only slight sensory deficits - again there seems, to me at least, to be relatively little to be gained by treating this with further surgery?
It appears that you did manage to make contact indirectly with the person I was thinking of at UNM but that she does not yet have the necessary equipment in place to look at this. The Wake Forest team are very good but rather a long way from you. I'm not too surprised at MRI not being especially conclusive - MRI pictures of the wrist are, in my experience, much harder to assses than ultrasound, though there are others with far more experience of MRI than me who may manage better with this modality - though I have to say that if that is the case then they haven't been publishing much about it.
Have a good Xmas. JB
Thank you Dr. Bland for taking the time to read my histories and provide your comments. I really appreciate what you have said and find it very helpful.
I will email you all of the NCS reports, the first three have wave recordings with the report. I will see if the UNM neurologist included them in the report but I did not see them when I found the report on my patient portal. But I will send you that report as well. He really did not conduct a complete NCS.
As for the MRI, I do actually have some literature that I will send you the citations for. I am skeptical though because when the neurologist showed it to me, I saw what they concluded was scar tissue but I did not really see evidence of it compromising the median nerve which I could also see on the images, and I could not tell it had grown down into the retinaculum. I got the impression they were trying to find a reason to explain the return of symptoms 17 days after my surgery and were not really focusing on the current state of my resolving symptoms and sensory improvement. If it was scar tissue impingement, maybe my deep tissue massage therapy has softened some of it up. Who knows! But I must say however that my original surgeon is of the impression that I should have no more tests and no more surgery which suits me. Ha! Ha!
In reading through the forum, I feel that you are doing a great service to those of us who are a bit overwhelmed with all of the opinions as you say and are really helping us to make sense of it all. If for some reason my hand does not continue to improve or gets worse, I will definitely pursue the ultrasound. Dr. Walker at Wake Forest also gave me the names of physicians in Phoenix and Tucson which are a little closer than Wake Forest.
Merry Christmas to you as well and a Happy New Year!
With that change in nerve conduction results from before to after surgery my first assumption would usually be that there had only been partial division of the transverse carpal ligament. You say you had 'no' symptoms immediately after the surgery but it's not altogether clear what the symptoms were just before surgery. I'm not sure what to make of the 'honeymoon' period of two weeks or so immdiately after surgery but by the time your NCS were repeated there had obviously been a marked deterioration in median nerve function - that was grade 3 before surgery and grade 5 after surgery. At that point I would generally concur with your new hand surgeon that re-exploration was indicated but then we are faced with the fact that you seem to be improving. I think repeating the NCS would be a good idea to see if this is true in physiological as well as subjective terms and an ultrasound examination of the wrist would be useful if you have an expert in nerve ultrasound locally.
Don't you love auto text correction in modern software - it took me a minute to figure out that 'ten barista' meant 'the wrist' :-) JB