Persistent / Worsening Symptoms after Carpal and Cubital Tunnel Surgery
Hi all, I'm just under 30 and had surgery a little over four weeks ago for carpal and cubital tunnel in my non-dominant hand, and am having persistent symptoms. I'm not sure what to think. Some background. I had off-and-on hand problems for years, but starting about 5 months ago I began to get persistent tingling in my finger tips in the median nerve area (thumb, first two, middle of third) and very rare tingling in the pinky. I only once woke up at night from the problem. Splinting the wrist didn't seem to help much anymore, though in the years past it seemed to make a big difference. I would frequently drop things in my hand and began to suffer weakness when lifting weights: my arm "gave out" on me when doing shoulder presses. Typing on non-ergonomic keyboards, especially laptops, always aggravated symptoms. Finally, one time I caught a slow elevator door that was closing and had numbness down that arm for days. I was referred to a hand / elbow / forearm surgeon specialist and an EMG was performed. The EMG showed severe cubital tunnel: everywhere else my numbers were about 6.5-6.7, but at the ulnar region of the elbow it was something like 5.8 down and dropped down to 4.3 or 4.5 on the return. The surgeon said these numbers were really bad for someone my age and suggested that I get surgery. In addition, since I had a positive Tinel's sign over the wrist and symptoms with the Phalen's test, he recommended I get a carpal tunnel surgery as well despite having a normal EMG score in that region. Cut to recovery. At first I felt much worse: the pain would make it hard to sleep, and I would sometimes feel like my fingers were touching each other when they weren't (all except the thumb). Right now I'm at the point where the symptoms are pretty similar to pre-surgery, except that now I have some elbow pain. I have frequent tingling in all fingers (including thumb, though not as common here), sometimes an aching pain throughout the fingers, and pain in the palm. Also I sometimes have pain in the meaty part of the thumb area of the palm, particularly where the ball joint connects to the wrist. Tinel's sign over the wrist and elbow are both still positive, maybe even more pronounced than before. Physical therapy exercises, particularly bending the elbow up and down with palms up and turning the wrist over from palms-up to palms-down reproduce tingling pretty significantly. Lastly, when I touch my thumb to my pinky in a certain position, a bone or tendon in on the ulnar side of the elbow seems to be grabbing or clenching; I can feeI it moving and snagging on something. I just don't know what to think. I have a history of boxing and was a "power puncher", which involves rotating your hands a lot with a lot of force, and I type a lot; that's the only relevant history I can think of to the hand. The surgical report says moderate-to-severe compression was present in both areas, but no transposition of the nerve was necessary for the cubital tunnel. I don't think it said anything about removal of the medial epicondyle either. Another thing that may be relevant is that they took an MRI of my neck and both the spine specialist and primary physician don't think the neck is a problem, but the therapists seem to think so. I have a follow-up with the surgeon in about a week. Any advice is greatly appreciated. If nothing else, I need some guidance on what to say: I don't think he'll sit there for me to say all of this. Best, Frustrated Youth
The most important measurements in NCS results for both CTS and ulnar neuropathy at the elbow (UNE) are conduction velocities which usually fall in the range 20-60 m/sec so numbers of 4 and 6 don't really make much sense as velocities. They might be amplitudes of surface motor or sensory potentials but the sensory ones are usually 10-50 microV depending on method used to record them and rapidly become absent in severe disease, and motor amplitudes are generally in the range of about 5-15mV which again would make a difference of 4 vs 6 not much to write home about really. Unless we can get hold of the actual results it's going to be hard to get to the bottom of that.
The percentage of patients with CTS but normal NCS is debatable - opinions vary from 0% to about 30% - personally I think it's about 5% but depends a lot on technique and usually if you want to get the false negative rate down it comes at the expense of having more false positives ('abnormal' results in patients who do NOT have CTS)
Tinel's sign is deeply unreliable for both CTS and UNE - you can give anyone that shock-like sensation into the little finger if you hit the nerve hard enough at the elbow. For CTS you might just as well toss a coin and it sounds as though your Tinel at the wrist was actually negative - if it doesn't immediately reproduce the shock like tingling in the relevant fingers then that is a negative test.
I'm afraid I really don't believe much of what surgeons say about the state of the nerve at surgery. None of these observations have ever been tested against any other measurement and for 50 years surgeons have been telling us that median nerves in CTS are 'thin', 'flattened', 'wasted' when in fact imaging shows that they are swollen. The really interesting surgical observations are when they find something anatomically odd about the tunnel. JB
Best thing to do is email them to me - they stay private that way. Jeremy [dot] Bland [at] nhs [dot] net is best for such material. JB
Thanks for the NCS report. I've now had a chance to look at that in detail. The first observation concerns the way they are measuring sensory conduction velocities. The recorded waveform for these consists of a peak rising from a flat baseline and one can measure the timing of this either to the point at which it leaves the baseline or to the top of the peak. They do not say which measure they use but looking at their quoted normal values I think these must have been measured to the top of the peak. Assuming that guess is correct then your sensory conduction velocities would probably come out at about 50 m/sec if measured my way, except for the left ulnar nerve which would be about 42 m/sec. Your left ulnar nerve thus carries sensory signals betwen the little finger and the wrist a little more slowly than it should. The right ulnar nerve and both median nerves are normal on this measurement. Motor nerve conduction in the wrist segment is just about normal by that lab's quoted normal value.
Ulnar motor conduction around the elbow is just a little slow. Most American labs feel that a velocity less than 50 m/sec around the elbow is significantly slow (your lab do not exactly specify a normal range for this themselves) and yours is 43 m/sec. There is thus evidence of mild left ulnar nerve dysfunction but the evidence locating the problem at wrist or elbow is a bit mixed. My guess would be that the problem lies at the elbow and that the sensory slowing seen at the wrist is just a downstream effect of that. There is no evidence of any median nerve problem (CTS)
That was seemingly interpreted by your surgeon as 'severe' or 'really bad' cubital tunnel syndrome, at least for someone your age. There is no widely agreed definition of what constittues 'severe' cubital tunnel syndrome but I would suggest that someone who has no loss of amplitude of either the sensory or motor potentials does not have 'severe' cubital tunnel syndrome. Like your neurophysiologist I would say this was mild, or maybe moderate if we believe that the sensory abnormality at the wrist is secondary to a problem at the elbow. Your symptoms to start off with were not obviously suggestive of an ulnar nerve problem so the significance of these nerve conduction results has to be taken with a pinch of salt.
It's hard to make anything definitive of the other symptoms and history that you provide above and in email. All I can say is that none of the observations immediately ring bells as indicating a particular alternative diagnosis. As you still have significant symptoms after the surgery that was supposed to fix them the next thing you need is probably repeat NCS to see how these results have changed - mostly to check that the surgeon has not actually made any of these things worse. JB
So the NCS results have improved but the symptoms haven't. Perhaps the NCS abnormality was not really the problem. Do you have the new NCS results for detailed comparison? JB
You are most likely to be feeling the ulnar nerve itself. This movement is known as 'subluxation' of the nerve and there is some doubt as to whether it is a 'bad thing' or not. JB
I think I agree with him about the subluxation issue. I read another article this week suggesting that if anything subluxation of the ulnar nerve might actually be protective against damage. I'll continue looking out for the NCS. JB
OK so the repeat NCS (thanks for the email) are now entirely normal by that lab's critteria so the good news is that the surgery has not made anything worse so far as the median and ulnar nerves are concerned. The only real change is an improvement in your ulnar nerve conduction velocity around the elbow. We can attribute that to surgery but it makes it even more likely that the ulnar nerve abnormality was not the cause of the symptoms in the first place. There has never been any good evidence of carpal tunnel syndrome and median nerve function has been unaffected by the surgery. My inclination would be to turn to a neurologist in looking for an explanation for these symptoms. There is a small group of patients with upper limb symptoms like this which are very resistant to diagnosis I'm afraid but there is little evidence that repeated surgery is the answer for such cases. Some of them resolve spontaneously fortunately. JB
That just sounds as though your ulnar nerve is now even more vulnerable to being stressed by sleeping position than it was before surgery. JB
Even something as simple as a towel wrapped around the arm at night to give you gentle reminder not to flex the elbow sometimes helps. There are custom designed elbow devices intended for this but you have to be careful to find one that does not compress the nerve itself. JB
I would make two quick observations - firstly that CTS is quite unusual in your demographic (29 and I'm guessing male) and therefore the diagnosis should be really secure before embarking on surgery. Secondly those nerve conduction numbers do not make sense - do you have the original report by any chance? Surgeons always say that the nerve 'looked compressed' at operation - I have never heard a surgeon admit to operating on a nerve that looked normal. JB