Numbness after CTS surgery and original symptons are worse

It ought to feel at least somewhat better by 2 weeks unless it was catastrophically severe before surgery. If it is still this bad when the stitches are removed I would think about organising a new set of nerve conduction studies for comparison with the pre-operative ones. Have a look at the graph for the usual pattern of improvement in symptoms that you can find in the surgery pages here. JB

Thank for your quick reply. Do you think the surgeon will want me to wait longer for more tests? What is the minimum time after the surgery would you suggest for more tests to be run?

Personally I think repeat tests are indicated if there is no improvement 6 weeks after surgery but most surgeons disagree with me it seems. Many surgeons are prepared to argue that we should not bother testing patients at all before surgery too but it is almost impossible to interpret post-operative tests if you don't know what they were like before surgery. JB

OK, 6 weeks. Better than the 3 months I was fearing. Thank you once again for your medical opinion.

Cheers, Jon

If you can obtain the pre-operative NCS then that would give us a better idea of how fast recovery should be proceding. I hope it does begin to improve. JB

Well, I would like to update on what has happened since I last posted. I had stitches removed by the surgeon and told him again about the symptoms. He did a couple of strength tests (I have never had any symptoms of reduced strength) and then simply said he was sorry. I asked if he had taken any notes during surgery and he said no he never does.

After this I went to see my Primary Care doctor and told him of my symptoms and we talked at length about his experience treating CT patients and what exactly is done during the surgery. He told me my new symptoms are in his opinion are a result of the unavoidable contact with the nerve during surgery and he expects a full recovery from the persistent numbness eventually, but healing may take months and progress slowly. He said all nerve injury's heal slowly and that NCS will lag far behind that (3 weeks or more) to show changes.

I asked him about injections in the area of the surgery and he says that they don't work and would "gunk up" the area around the surgery.

I asked for another NCS to be performed and I got an appointment for the 27th of this month.

He looked at the test results of the NCS performed before the surgery and said they were "moderate".

He asked me if I wanted to take a anti-inflammatory medication which I indicated yes. He prescribed Dexamethasome 4mg tablets taken a half a tablet twice a day.

The first 3 days after taking the above medication my symptoms decreased by %30 and I was hopeful of a quick healing and the numbness to disappear. However, after that I have had little to no decrease in persistent numbness that is the most concerning of my condition

I had a follow up appointment one week after and told him about my improvement and he said that was very encouraging and gave me refill that cut the dosage in half.

Yesterday I met again with my PC doctor and told him about my symptoms not improving and he said that was not any way alarming and that it will probably be around 4 months post op for the symptoms to fade away. He said that is when he would expect NCS to give reading that would be indicative of how successful the surgery was.

I asked about Ultrasound to help accessing the results of the surgery. He said an MRI might be option much later down the road if the symptoms don't get better, but dismissed Ultrasound as a viable diagnostic tool for nerves.

I have an appointment next week on the 11th with my PC doctor and will get a copy of the NCS performed before the surgery and will post the numbers then and any symptom changes.

I am still out of work and not sure when I want go back as repetitive use of the hand and certain wrist positions result in what I would describe as a "nerve stinger" which is quite uncomfortable and can even result in a jerking motion as I respond to the sensation. I am in the food service industry and this is my primary hand so I am concerned about performing my job duties while these symptoms are present.

I do think that the nerve has been fully released because the symptoms before the surgery were triggered in part by the position of my arm (holding the steering wheel of my car with my right hand would bring on the pins and needles numbness in my hand). Now I when I drive I haven't noticed that sensation.

Thank you for your time,
Jon

You seem to have been told several things there that are contrary to the published evidence I'm afraid but beyond saying that I'm not going to get into third party arguments with my colleagues. We can have a more serious think about this once we see the pre-operative NCS results - someone describing them as 'moderate' unfortunately means nothing. JB

You can view my pre-operative NCS here https://ibb.co/k8ag9a

Thanks. They show a grade 3 CTS (out of 6) so this should show prompt improvement after surgery and if it's feeling worse now then something is amiss and they should be repeated. They also show a small ulnar motor potential with a delayed ulnar distal motor latency but no ulnar sensory nerve deficit - was this commented on? JB

The only comments can be seen here: http://tinypic.com/view.php?pic=28k0s9s&s=9#.WWgO-bieZiU Next NCS will be July 27th. Will report back when I get those results. If I have any significant change in my condition I will come back here to update. The persistent numbness of the inner two fingers (and the stiffness of these two fingers) is the most concerning symptom still bothering me.

Looks like they didn't notice the ulnar result. Whether it means anything is hard to say - one thing I would do is compare with the other side. Your description of the worst affected fingers has changed a bit from the first posting to now - can we clarify exactly where the numbness is worst? It can be hard to be sure what people mean when talking about fingers as people use different terms for different digits. Personally I like the terms  thumb-index-middle-ring-little - in order across the hand as the majority of people seem to agree about which ones those are. JB

The persistent numbness is the right side of the middle finger and the left side of the ring finger on the right hand. The numbness is not that bad on the right side of the middle finger. The area that is the worst is the left side of the ring finger near the tip of the finger. Also both fingers feel stiff when I bend them. When I use my right hand I get pins and needles numbness in the same area and sometimes a nerve "stinger" in the palm of my hand. This symptom is about what I was experiencing before the surgery. I said before that some of the symptoms were better than before the surgery, let me clarify I no longer experience the pins and needles numbness while driving, but general use of the hand still causes the pins and needles numbness as before but now with the occasional added nerve stingers.

I did request NCS test to be performed on both hands in my upcoming July 27th appointment. This will be performed by the same doctor who performed all my NCS tests.

As more time goes by and my symptoms still seam pretty much the same as right after my surgery I am beginning to suspect maybe there was not a complete division of the tendon and maybe some part is still applying pressure on the nerve. What my real fear is that there is some sort of permanent damage to the nerve that will not heal completely and the numbness never goes away. I am also concerned that if there was an incomplete division, could permanent damage to the nerve happen if left too long before a possible second surgery to fix it?

Cheers, Jon

I think that means the adjacent sides of the middle and ring fingers are affected (left and right depend on which way up you are looking at the hand). If that's right then it would make anatomical sense as that corresponds to a single branch of the median nerve. Careful neurophysiology might be able to pick up whether that particular branch is performing less well than the others but it can be difficult. If it's the non-adjacent sides of those fingers then that is anatomically odd. When the ligament is incompletely divided at surgery most patients seem to feel that the symptoms are actually worse afterwards but, as with everything in medicine, that is not an absolute rule. Apart from incomplete release it is possible to traumatise individual nerve branches during the operation. The most useful thing here is going to be comparison of the before and after NCS results (at least in my view). Sometimes ultrasound imaging can also help but few people have the expertise with ultrasound in this particular clinical situation I'm afraid. JB

You are correct, it is adjacent sides of the middle and ring fingers. Yes the symptoms are worse, before the surgery this persistent numbness was not present at all.

OK Looks like the next thing is the follow up NCS then. JB

OK here are the NCS results and surgery notes. http://www.dumpt.com/img/viewer.php?file=sh24vnkntroxti1qkaar.jpg http://www.dumpt.com/img/viewer.php?file=x3y0p07hbzjt8f4ie4za.jpg http://www.dumpt.com/img/viewer.php?file=2k2v2wnjxjjsfqpmhjoa.jpg http://www.dumpt.com/img/viewer.php?file=7wgjz8rv8oqprhoejg7a.jpg

Symptoms have pretty much stayed the same with no substantial improvement. My primary care doctor advised me that nerve damage heals very slowly. He said that the results of the NCS tests show that there was basically no change from the NCS test before the surgery. He thinks that the damage to the nerve were severe enough that the surgery only will ensure no more damage is done to the nerve. He does expect the persistent numbness will eventually heal, but might take many months or even years to completely heal.

I decided to wait a month and if symptoms are still present then I will get an MRI done.

Will be going back to work soon, it sure sucks that this surgery did not have the same outcome as my left hand. I guess I will have to deal with this condition the rest of my life.

Sincerely, Jon

I've just had a quick look at those - will do so in more detail later. They do still show grade 3 CTS so there has been no significant improvement. The commonest explanation for that is failure to fully divide the transverse carpal ligament. It would be worth imaging this but I find that ultrasound is more useful than MRI for this purpose - you get higher resolution images, you can adjust the plane of the image in real time to optimise the view and you can watch the nerve and tendons move. The only real problem is finding an ultrasonographer with the right knowledge and skills. JB

OK I have time to look at those in detail. First of all the right median nerve studies. The new set still show grade 3/6 CTS in my terms but comparing them directly with the first set the amplitude of the median motor potential has fallen from 12mV to 4.8mV while the distal motor latency has gone up from 5.0 msec to 6.1 msec. The median sensory conduction velocity was 28.7 m/sec before surgery and is 25.4 m/sec after. The change in sensory conduction is probably not significant but I think the change in motor conduction suggests that this has in fact got worse (within grade 3) after surgery - at least if we assume that all these measurements have been made correctly. It's worth noting that the left median motor potential was measured this time and was 12.0 mV - very similar to the measurement from the right side before surgery, suggesting that this is the 'normal' size of your median motor potentials.

The ulnar nerve was abnormal before surgery by that lab's own normal values (DML = 4.5 msec, normal < 4.2 msec) and remains abnormal now (DML = 4.3 msec). I also think the ulnar motor potential was rather small compared to the median at 3.35 mV and it hasn't changed much, now 4.04 mV. They still haven't made any comparisons with the other side for the ulnar nerve nor have they made any comment on this abnormal result.

Oddly the 'Impression' in the NCS report shows no awareness that these are being done for follow-up purposes and does not actually compare the old results with these. It is just written as though this were the first presentation of CTS, though they are clearly aware of the surgery because they mention it in the description. I would ask the electromyographer why they think the median motor study has changed so markedly. If this is incomplete division of the ligament then that might explain the partial response to a short course of oral steroids that you reported - effectively the steroids would have been treating what is so far an 'untreated' CTS. JB

Thank you for your comments and analysis. At this point I am going to wait and see if the symptoms improve. If the symptoms stay the same I will get an MRI and another NCS test. I will ask the electromyographer about the median motor study and mention that I would like to see a comparison between the results. Since I don't really have a full understanding of what the NCS results mean I find it difficult to question the results and methods of the test with the electromyograher doctor. When I conversed with the electromyograher doctor I got the impression that he was sympathetic to the surgeon who performed the operation. Thus I felt that his impressions might be swayed somewhat.

Ultrasound tests are probably not going to happen, unless I find out that some place local has the expertise/experience to do these tests on nerves of the hand and wrist.

Sincerely, Jon

The NCS results are not too difficult really. The size of the recorded waves tells you about the number of conducting nerve cells while the speed of conduction tells you about the quality of the insulating layer (the myelin) on the largest nerve cells. As CTS gets worse, first the myelin layer degenerates so that conduction speed slows and later the cells start to die off so that there are fewer of them and the waves get smaller. That's pretty much the basics of it. Good luck with recovery and please let me know how you get on. JB

OK, it's been a while since I last posted here. Unfortunately my symptoms have not improved but have gotten worse. The tingeing numbness now is present most of the time and gets worse with any use of my right hand. The persistent numbness has stayed the same. I have had a MRI performed on the right wrist with the results below. My family practice doctor has told me that both the NCS test and MRI show no evidence of incomplete division of the tendon and going by the surgeon's notes he recommends against further surgery. He did say that he could refer me to specialist if I wanted. Could you look over the MRI report and advise me on what type of specialist you would reccomend? 

I've taken the images out of that message as they make a bit a mess of the page formatting like that. I don't find MRI very helpful for assessing failed surgery - you can't see enough detail of the nerve structure and most radiologists are not that familiar with post CTD appearances. Unless you are near someone who is really expert in median nerve ultrasound we are a bit stuck with imaging. A further set of NCS demonstrating progression might be useful given that symptoms are worsening. The best specialist for a second opinion is probably going to be different hand surgeon as it does still sound as though the problem is CTS rather than being an incorrect diagnosis - so far as I can tell remotely.

Edit - I've just checked the AANEM directory for members in your area and I'm afraid there is no-one nearby who I immediately recognise as being a good ultrasound opinion so repeating the NCS is probably the next most useful thing. JB