carpal tunnel advise
Dear Doctor,
Could you please give me comments one my current state of wrist. I had burning aches and cutting pains in both wrists, fatigue and pain in fingers. No numbness though. It started when I overused my hands playing video games. Plus I work a lot with the computer, use the smart phone.
Had tried NSAID, rest (up to 2-3 weeks) and then steroids, it eased the pain but did not cleared it out. I don't have pain when I rest, but do have it when I work with the hands and fingers and use fine motor skills.
Later on I did ultrasound and EMG and was advised to make endoscopic surgery. Which I did 8 months ago on my left wrist, since it was much more painful than the right one.
After 8 months from the surgery my hand feels better, but I still have burning aches above the carpal tunnel or on its boarder when I type and use my fingers and the wrist. However the pain down the tunnel and stiffness went away.
I was advised to have second opinion and did a different ultrasound. Here it is (translation from my native language):
"Right wrist:
On the level of carpal tunnel median nerve lays «deep» between flexors of the 2nd and 3rd fingers. Median nerve is thickened on this level with the size of 0.54x0.32cm. Structure of the nerve is of reduced echoicity. Color doppler imaging does not show any blood flow. Nerve sheath is thickened and
hyperechoic. Carpal ligament is not thickened with the size of 0.05cm.
Conclusion: ultrasound evidence of “deep” location of the median nerve.
Left wrist:
Carpal ligament is cut on the proximate level of carpal tunnel. In the location of the cut adhesive process is not profound. On this level median nerve is structurally normal. On the distal level of the carpal tunnel the ligament is not completely cut in length of 0.4cm. Carpal ligament is not thickened with the size of 0.07cm. On the distal level the median nerve lays «deep» and thickened with the size of 0.59x0.31cm.
Conclusion: evidence of the endoscopic surgery of the carpal ligament. «Deep» location of the median nerve on the distal level of the carpal tunnel".
Another surgeon told me that there's no way to fix it since this is my anatomy of the nerve's deep location between the flexor tendonds. When my flexors work they strain and rub sore the nerve. When they rest they don't. So it does not give me pain. It's not a typical CTS. And thus it can't be cured / treated. The only thing I can do it to modify my work. No surgery can solve it.
Could you please advise if that is so? I work a lot and use my hands quite regularly. I'm only 32 and feel very sad about my "wrecked" hands.
Many thanks!
Hello. Thank you for getting back.
I can send you a copy, but it's in Russian language.
Here's translation of EMG conclusion:
Conducted studies of both motor and sensory fibers of the median nerve in both hands.
Conduction through motion fiber is normal.
Conduction through sensory fiber is decreased to 45 m/s in the right hand and 48 m/s in the left. Residual latency is normal.
Antidromic conduction in the right hand is 35%.
Demielinising affection of the sensory fibers of the median nerve in both hands associated with slowdown from suprasegmental structures on the level of C8-Th1.
I don't mind the conclusion in Russian. It should have tables of numbers that make sense in any language. A couple of them are mentioned in that conclusion but if they were done competently there should be quite a few more. From what is in the conclusion I'm a bit doubtful that those showed enough evidence of CTS to justify surgery but I would like to see the whole set of results. JB
Hello! Thank you, please find below:
https://drive.google.com/open?id=126vOiZzyOaz2_xLRMZd_VEXFoKOpCQ7w - EMG
https://drive.google.com/open?id=1N98va2WSKLU6k0LmIZs43xIHU2dXGLTm - Ultrasound photos
P.S. in EMG запястье means the wrist. Лев is left, пр. is right.
If you need some other translation pls let me know.
OK those NCS results make reasonable sense. You did not actually have very clear evidence of CTS, at most a very marginal abnormality of sensory conduction in the right hand, which should really have been confirmed with some detailed comparative tests. If this was CTS then it would have been grade 1 out of 6 on my scale in the right hand, with the left hand probably being normal. Combined with the rather atypical symptoms I would have interpreted the situation as it being unlikely that your problem was primarily CTS and if someone did want to pursue the idea further the best approach would have been to try a local corticosteroid injection rather than the irrevocable step of dividing the transverse carpal ligament. The main problem here then, I would guess, is that there is another diagnosis which is mainly responsible for the symptoms which has not so far been identified. You may have had very slight CTS as a secondary complication and that is why the symptoms improved slightly with surgery but the underlying problem remains undiagnosed and is still causing you grief. Unfortunately I can't offer much in the way of diagnosis for that other problem via a web forum.
One of the left median sensory potentials is oddly small compared to all the other sensory studies. It might just have been understimulated but if not then it is an odd observation which does not seem to have been picked up on.
The ultrasound images, which are post-surgical, are not very much help. The selection of still images which we keep from ultrasound are often not very representative of the overall impression gained from the examination, which is a very interactive process, but as far as they go I am not especially impressed that these sample images show anything very definitely useful. You probably need an opinion from a neurologist and/or a rheumatologist rather than a surgeon, and it might be a good idea to repeat the NCS to see if there has in fact been any change in nerve conduction.
Please let me know how you get on. JB
The original description of the symptoms does not really sound like CTS so my initial thought would be 'was the diagnosis right?' - do you happen to have a copy of the original nerve conduction results you could send to me? JB