Complications following endoscopic release surgery.
I am almost 9 weeks post endoscopic release surgery on my right hand. From the very first few days following surgery I knew something wasnt right. I had my left hand done 4 weeks prior to my right hand and everything went well with that recovery. My right hand is a completely different story. The nerve block wore off after 2 or 3 days but left me with constant numbness on half of my middle finger and half of my ring finger. This has not passed and remains numb. My hand remains quite swollen and has a very red blotchy look to it. I have constant throbbing pain in the tips of both the numb fingers. I cannot make a fist as I have limited movement and my wrist feels tight. I'm not able to lift anything either. I saw the surgeon last Friday and he doesnt know whats happening with it, so is sending me for a nerve conduction study. I fear that a nerve may have been damaged during surgery and that he may need to go back in to repair. I am trying to steer my mind away from possible CRPS as that would be a bad place to be. Anyway, fingers crossed that this can be fixed.
The only NCS on file for me was carried out in 2003. No new NCS was ordered prior to the surgery so I'm not sure if these would be worth looking at.
Back in 2003 I was advised to get the surgery done but with work commitments and endoscopic surgery not being an option at the time, I put the surgery off. I was a bit surprised that the surgeon did not order a new NCS this time.
One other symptom I forgot to mention was that the palm and inside of my hand get more sensitive as the day goes on.
If one of the palmar branches has been injured, can it be corrected without surgery? or does it depend on the nature of the injury?
Thanks for taking the time to give your opinion on this.
It does depend to some extent on the nature of the injury but relatively few of these will be surgically repairable. You are right that 2003 NCS are severely out of date but still a little better than nothing. Not sure what to make of the palm symptoms - there is a separate nerve branch supplying the palm which passes outside the carpal tunnel. This is sometimes injured during surgery but not usually with the endoscopic version. JB
Just an update on my own situation here Dr. Bland. I was referred to another surgeon by my doctor in March this year, who ordered further nerve studies and an MRI of the hand and wrist. The nerve studies were showing the same results as previous tests. The MRI showed no obvious breaks in the median nerve, with no signs of neuroma present. The surgeon recommended further surgical exploration and also suggested a median nerve collagen wrap may improve things. The surgery was performed in April 2022, so I am now 12 weeks post op. The surgeon followed the median nerve down from the upper palm to about 2 inches below my wrist, so Im left with a significant scar. She said there was continuity in the nerve, but that a section of the nerve was showing signs of being "unhappy". She showed me pictures of my hand from during the operation and the "unhappy" area was red and sore looking. She doesn't know if the nerve wrap will be of any help having seen inside the hand. I go back end of August to report on how it has been. There has been no improvement in symptoms during the last 12 weeks so I don't hold out much hope of it improving.
I'm wondering though if this type of injury would be considered a neurotmesis? Could the nerve have been transected within the nerve sheath without breaking the sheath open? Possibly during the positioning of the endoscopic tool? I'm just trying to understand what might have happened if the nerve is intact.
Thanks for your time Dr. Bland.
If you have a copy of the post-operative NCS I can take a look to see if they did the necessary supplementary testing. The risks with endoscopic deompression are mainly from blunt trauma - you are trying to insert tools into a very confined space so even when there is an injury you are not likely to see two cut nerve ends (neurotmesis). The surgical exploration may or may not have gone far enough into the palm to see the palmar branch to the affected fingers and the superficial palmar cutaneous branch branch which might be responsible for the sensory symptoms in the palm leaves the median nerve 2-3 cm above the wrist crease and travels very superficially, pretty much in the subcutaneous fat so you have to deliberately identify it at source and follow it distally to see what state it is in - quite a tricky proposition in a live patient rather than a cadaver. JB
I have emailed pictures from 29.04.22 surgery. No post operative NCS has been done or requested.
Regards,
John
Those photographs show quite a wide exploration but I can't see enough detail in the pictures to be sure whether either the palmar cutaneous branch of the median nerve or the palmar branches were fully examined. I don't think I've seen the most recent nerve conduction studies have I? (the ones from before this surgery) I forgot to say earlier that there is a technical term for damaging the nerve cells without disrupting the nerve sheath - axonotmesis, or sometimes the even milder neuropraxia, where the nerve cells are physically intact but have just stopped working for a while.How do the symptoms now compare with just before the April operation - no change? JB
The symptoms now are exactly the same as before the April operation, so no change at all. I have never had access to results of any of my nerve conduction studies so I can't send them on unfortunately.
I guess for the moment we seem to be stuck then. Sensory disturbances can sometimes take a long time to settle so I wouldn't give up on it until about 2-4 years after the most recent surgery. JB
Sounds like a problem with one of the palmar branches of the median nerve. If you have pre-operative NCS to compare with then repeating them carefully may yield some information but the new studies will need to be adapted in view of the new symptoms in the ring and middle fingers so you don't need just a 'standard' CTS test done by a technologist. High resolution ultrasound imaging by someone who knows about nerve imaging might also be useful but these are very smalll nerve branches we are talking about. JB