Advice re surgery


I have had CTS diagnosed by NCT and given levels of 4 on left and 5 on right. Symptoms have been severe for last two months. I started wearing night splints two months ago. In spite of these splints symptoms progressed from numbness at night and pain in wrists and hands to constant tingling/ numbness all day and night which never recovers. The pain caused weakness in that it was so painful to grip my grip had no strength. When I saw the surgeon last week he booked me for surgery on the right and gave an injection in the left. I still have constant numbness/ tingling in both hands which never recovers but the pain is much improved. I can now make a fist and grip pretty much without pain in both although it takes a while to be able to grip first thing in the morning. I have stopped playing golf and I do want to go back to that without delay. I did try having time off but it didn't improve it at all. I also tried exercises, pain killers, cold therapy.
I am booked for surgery on Friday but do you think this is too early ? I pushed for it due to the pain and results from NCT and am paying privately but I'm now wondering if I've rushed into it. Or do you think going ahead is wise because I still have the constant numbness and results from NCT shows nerve compression.
Any advice would help.


If that is my grading scheme they are using then surgery is a good choice for grade 5. You really do not want it to reach grade 6, at which point much of the nerve damage is often irreversible. The presence of constant daytime symptoms is correlated with severe CTS so the grading would make sense clinically too. A couple of other questions are of interest. How far back do symptoms go in total, ie how long is it since you noticed the earliest symptoms of CTS, as opposed to it just being severe for the last 2 months? Secondly, did both hands improve after injection to one side only? JB


Carpal tunnel symptoms have only come to my notice in last two months but now I think about it I have had some symptoms for a couple of years including needing to change hands when holding the phone and hands going dead at night ( I thought I had slept on them). It was when it became more frequent I started to realise that's what it was.
I immediately got night splints. But in spite of everything symptoms rapidly progressed and became in both hands and severe pain. Two weeks ago I was having to frequently use ice and iced water to get any relief in the day or night. This severe pain seems to have gone but I'm left with the constant tingling/ numb feeling. The injection in the left cured the pain and the numbness is still reducing( Its a week ago now since injection). The right pain had started to reduce but has improved since injection in the left. But I'm not sure if it was in an improving path anyway.
On the grading it was explained that grade 1-2 was splints. 3-4 injection and 4 and over probably needs surgery. He said over 7 was unlikely to be improved by surgery as would be too late.
No one has ever said this can improve, I've only been told it will get gradually worse. And that injections for my stage will only delay the surgery. If this is so I will go ahead and I'm thinking that I will get the right done anyway and see how the left goes.
Thank you for your interest and can you offer any explanation why the pain has gone ?
Another question - are you of the opinion that golf can cause this ? I am a low handicap golfer playing a few times a week and I have no idea why this has come on. I am fit, slim and tall and age 57. No previous injuries etc. It was suggested that gardening , DIY, and previously being a physio are all factors for me.
All interesting stuff.


Most of the answers to those questions are in the main pages of this site however:

I know of only one person who uses a grading that goes above 6 - there is a proposal for a 1-10 grading. Even I think that is a bit over the top (mine goes from 1-6) and most of the world only recognises three 'degrees of severity' for CTS. Now that the possibility of grade 7 has been raised we would need to see your actual results to figure out what they really represent. 

I do not think that treatment options should be slavishly dictated by the NCS result alone but I do think it is unwise to rush into surgery in patients who have a short history and either normal, or only mildly abnormal, NCS results.

No-one actually knows whether it is better to use steroids as early as possible or only after splinting has failed so a rule such as grade 1-2 = splint, 3-4 = steroid, is not really evidence based and is effectively just the personal opinion of the doctor quoting it. Even really extreme cases can sometimes benefit from surgery - the chances are just not as good as they are with less severely damaged nerves. Overall I think what you have been told there (or at least what you heard and understood, which I have to admit is not always the same thing) is a bit dogmatic and implies much more certainty than is justified by what we know about CTS. It can certainly improve without surgery, indeed without any treatment at all - some people get an episode of CTS which clears up spontaneously but what evidence we do have about the natural history of CTS suggests that it is more likely to stay the same or get worse than it is to improve without treatment.

The common idea put about by surgeons that 'injection will only delay surgery' is certainly something you can argue with. We have just published a paper demonstrating that only 41% of patients initially treated with injection in our clinic had ended up with surgery 8 years later. Another group in Scotland found broadly similar results so it's not just us. 

Pain in CTS is a very puzzling topic - so much so that we are having a conference session devoted to it in Sweden in June. Some patients get lots of pain, some none, and it is poorly correlated with the degree of nerve damage and often not confined to the anatomical territory you would expect from the anatomy of the median nerve. The bottom line is that I cannot suggest any clear reason why the pain may have improved in an individual patient. it might mean the problem is getting worse or that it getting better, or it could be entirely random, or relate to some other problem than CTS such as tenosynovitis - sorry!

It's not particularly common in golfers. The known risk factors are covered in detail in the 'causes' pages. The only recognisable risk in you from the information you have given is age - the incidence rises quite markedly in the 50s. JB

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