Carpal Tunnel or Radial Tunnel?
Hello,
I've been suffering from what I think is Carpal Tunnel, but now I'm not so sure. I started feeling right wrist and forearm pain about two years ago. I was not feeling numbness at the early stages, just slight pain. Conservative treatment like physical therapy and acupuncture was done with minimal results. An EMG was performed in July of 2017 showing bilateral carpal tunnel and mild tendinitis in the forearms. I also have multiple ganglion cysts at the right wrist, and near the base of the thumb. I'm right handed, and work at a job that is a mousing heavy position.
My symptoms slowly progressed to numbness in my right hand. The numbness was felt at the base of the middle and ring finger, and a slight burning sensation at the base of the right palm near the thumb pad. I wear splints at night on both hands and thankfully, I am able to sleep through the night.
My doctor used ultrasound to view the carpal tunnel area and it showed some inflammation around the area and a slight compression of the median nerve. I had a cortisone injection on 5/17/18 with the doctor using ultrasound to guide the needle. As the doctor injected I felt numbness in my thumb, index and middle finger, but not pins and needles tingling. The doctor used a numbing agent in the mixture with the cortisone.
It's now been almost three weeks since the injection and my symptoms are still present with new symptoms that have arisen. I still feel the numbness at the base of my ring and middle finger, I still feel a burning sensation at the base of the palm, and it may even be a bit more prominent. And I now feel numbness in my thumb which is new, and when I rub my forearm it results in a tingling sensation in my thumb and index finger. Doctor thinks the new symptoms are from a radial nerve impingement.
Now I feel even more uncertain than before. I'm not sure what my next course of action should be. Perhaps another EMG would be in order. When the first EMG was taken I was not experiencing any numbness at all. So another EMG at this stage would be a helpful diagnostic. Since I didn't have good results with the cortisone, does that mean that Carpal Tunnel surgery would not be a solution? And what would be the best course of action for Radial Tunnel Entrapment, if that is what is going on? The gentle rubbing of the thumb side of the forearm, which causes a tingling sensation in the thumb and index finger, is the most curios, and a new symptom. Why would it occur now after the cortisone injection?
Any advice or comments would be greatly appreciated.
Thanks.
Thank you for your reply Dr. Bland, and for this very helpful forum. Yes, I do have my EMG from July, and would be happy to forward it along. Please let me know how I can get it to you.
Also, the doctor viewed the carpal tunnel via ultrasound seven days after the cortisone injection and it showed a decrease in inflammation, and the median nerve looked ok, per the doc. What is your opinion on viewing the carpal tunnel area with ultrasound, as a diagnostic tool? It seems like a good tool to me.
Oh, by the way, I haven't had any handcuffs on my hands....thankfully!
Thanks again.
Email is usually the best way to send NCS results (Jeremy [dot] Bland [at] nhs [dot] net - remembering to tell me whose results, in forum terms, I am seeing). Ultrasound imaging is a really useful tool and I do a lot of it, but it is also quite new (in this field), we are still learning, and there are relatively few people who are really expert at it so far. One wonders what they might actually have seen that they would then describe as a 'decrease in inflammation'. Usually the most striking thing one sees in CTS is swelling of the median nerve but whether that is truly due to 'inflammation' is a more complex issue. We do see the size of the nerve reduce after steroid injection, or after surgery. There is an ultrasound section on the website here but I've barely made a start on it so far - lots more material to post when I get time. JB
Thanks again Dr. Bland. I sent you an email with a copy of my EMG taken in July of 2017. Please keep in mind that at that time, the numbness was much less prominent than it is today.
As for the ultrasound, and inflammation seeming less after the cortisone injection, the doctor was showing me a patch of light color that was larger in size before the cortisone, and seemed smaller one week after. My wrist pain has diminished, but I still feel the numbness around the base of my two middle fingers, and a burning sensation around the base of the palm near the thumb.
I am very perplexed as to the new sensation I'm feeling now. I can rub the side of my forearm, thumb side near the wrist, and feel a tingling sensation in and around my thumb. I did not feel this before the injection. Doing some research I came across Cheiralgia Parasthetica, which seems similar. Although I have not had any trauma in the area unless something happened during the injection.
One thing that crossed my mind is the doctor also did an aspiration of my ganglion cyst which is located on the under side of the wrist near where I am rubbing the forearm. The doctor also injected some cortisone there. The cyst is close to arteries and nerves. Do you think something got damaged there?
Thank you.
Thankyou. Using that lab's normal values that qualifies as grade 2 CTS both sides on my severity scale (which goes from 1=very mild to 6=extremely severe) though I'm slightly puzzled by the 'latency difference' column - without seeing the recorded traces it's hard to be sure what cursor positions that value might represent.
You might well be rubbing the superficial radial nerve there at the side of the wrist, but you can elicit tingling by doing that in a fair number of normal wrists. It doesn't necessarily mean there is anything wrong with the nerve and glorifying it with the latin name of cheiralgia paraesthetica makes it sound grander than it is.
It would be unusual to cause damage during aspiration of a ganglion cyst but it's not entirely impossible.
Overall there are quite a lot of structural considerations in your case - the exact distribution of the various symptoms, the ganglion cyst etc, which make it difficult assess via the net - you need to be 'hands-on' with this one I think, preferably with the NCS machine and an ultrasound scanner to hand to help. As the previous NCS are nearly a year old and symptoms have evolved somewhat I would not take them as a set in stone verdict on what the problem is and it's probably worth repeating them. I would love to scan your wrist and see what's going on with the ganglion cysts but as you are about 8 time-zones away from me it's not going to happen! It's possible to identify the superficial radial nerve on the ultrasound so it should be possible to see if anything is impinging on it. JB
That's quite an interesting story and at first hearing perhaps sounds like another problem leading to a secondary carpal tunnel syndrome. The lack of response to steroid injection is a poor prognostic factor for surgery (provided an adequate dose was used). Your doctor seemingly added a local anaesthetic to the injection, hence the 'dental anaesthetic' effect immediately afterwards - I can see little point in doing this myself. The radial nerve territory is the back of the hand in the region of the thumb and index finger but I usually only encounter problems with this nerve when there has been obvious trauma - handcuffs are the bext known one. If you have your EMG results from July I would be happy to take a look. JB