Unexplained new symptoms after CTR

The idea of any surgery as a 'no risk' option is of course bonkers. However a conventional carpal tunnel incision in an anatomically normal hand is very unlikely to have damaged the nerves supplying the ulnar side of the palm and little/ring fingers. I have seen an incision so far out of place as to end up entering the canal of Guyon where the ulnar nerve lies rather than the carpal tunnel. There are also some interesting anatomical variations which may have some bearing on this though I can't think of a common one which would produce exactly these symptoms. MRI is not an ideal method for investigating post-operative nerve problems - inadequate resolution unless you have a 7T scanner and no facility to examine the structures dynamically as the hand moves - ultrasound imaging is much better if you can find someone who is good at it. If you have copies of the two sets of nerve conduction results we can take a look and see if there are any clues. Aggravation of an existing ulnar nerve lesion at the elbow is perhaps the most likely explanation - one would need to know details of the anaesthetic method used and post-operative care to explore that further I think. JB

Thanks for your reply Jeremy and apologies for tardy response. I thought I had the forum set up to notify my email but I must have not done it correctly.

I don't have copies of the 2 x Conduction tests but I can ask my GP if he can access them for me. I have had the wrist looked at with ultrasound but no dynamic inspections but it really does seem that there is no sign of damage from the surgery from all the scans - just signal of some inflammation. Perhaps you are right about the elbow issue but it just seems so specifically on the palm skin surface and so immediately after surgery that I struggle to think the symptoms are not at least partly caused by the surgery - even though I know i have other nerve impingement issues in neck and likely shoulder and elbow.

You mention odd anatomical variations - whilst the surgery and scans gave no indications of anything odd I recall when the surgeon first tried a cortisone shot into my wrist and told me to expect numbness in the Thumb to middle finger I actually got numbness in all fingers (including little finger) except the ring finger which was less affected - so that didn't make much sense.

I believe the anaesthetic was "twilight"?? which means I was meant to be awake but I have zero recollection of the surgery. I went home the same day and back at work after a couple of days doing light work only (no manual labour). the surgeon suggested there was no need for any hand therapy at all. I did look up some gliding exercises and did them a bit.

I do have a lot of tendon and arthritis issues which I suspect may have been a big part of the problem all along (hence my doubt of the wisdom of getting the CTR done) so I wonder if the settling of the wrist components after release has just created new issue from something else that is amiss?

It is all probably a bit academic now but if I can get the comparative conduction studies I will let you know. Really appreciate the comments and feedback.

Sounds as though they injected a local anaesthetic along with cortisone, something that always strikes me as pointless. What happened to the hand symptoms in the weeks immediately following injection? As you can't remember anything about tthe surgery we can only guess at what might have gone on during it I'm afraid. Happy to look at the NCS if you can get them. JB

Thanks Jeremy

I have booked to see my GP in a fortnight so will try to get those NCS then. The symptoms after the injection of cortisone was not really any different to before - seemed like it made no difference. I feel like I get symptoms now more easily under heavy use of the hand now than before surgery but less nightime issues. I still think half of the symptoms were due to issues further up the arm/neck but the neurologist said the NCS post op showed an improvement.... Just doesn't feel like that is the case from my first hand experience. Hopefully I will have those results soon. Thanks again for your thoughts.

Just to add - as an example of how it feels like it is worse now than before surgery, in the past I would have to use vibrating machine like a strimmer for while to get numbness in my fingers but it would subside after a while. I find now it takes a bit less time to do this although it varies - sometimes it is not so bad. Then today for example I was walking around with a document folder in my left hand, not heavy and my wrist is pretty straight holding it but after a while i have tingling in my thumb and first 2 fingers so i swap to my other hand and no problems. I realise there are so many things at play and but it is these kinds of things that make me think the problem has not really been sorted wherever that problem is - and the fact that I have this permanent altered sensation on my ulner side of my palm straight after surgery leaves me rather disappointed with the treatment, especially considering it has been so long since surgery that I don't think I can expect any further improvement.

Lets see if we can get the NCS results so that we at least know what sort of CTS we were talking about to begin with. JB

Hi Jeremy

apologies for the long delay - took ages for the neurologist to send the tests after several reminders. Do I email them to you or something - just not seeing an attach/upload on this.

I think the weird thing about the altered sensation on the ulner side of my palm is that is pretty much permanent but varies in intensity depending on my neck. That is to say I suspect the neck is the cause of most of the issues in both hands but especially the left but even when the rest of my hand is OK there is this area on my palm to the ulner side of the incision that has sensation that is unusual or reduced and seems to be most noticeable when gently brushing it with something soft. the actual incision line has sections that are either without feeling or super senstitised so I feel like this effect somehow reaches out across that side of the hand towards the side below the little finger.

anyway - whilst I suspect the results may not be of much help let me know how I can send them.

thanks for your time

They can be emailed to me. Address in the contacts section of the website. JB

Thanks for the NCS. On the pre-operative set the left hand would have been grade 2 (out of 6) while the right hand might have been grade 1. They didn't quite do enough for me to be sure of that. Post operatively several of the sensory recordings show quite slow conduction velocities, even for studies where the peak is used for latency measurement rather than the onset so I'm not sure that they are entirely normal but at least the median results do seem to be better than the pre-operative set so the surgery probably achieved something. Unfortunately they didn't do the other hand for comparison at the second visit. There is no evidence of an ulnar lesion at the elbow but they didn't fully explore the possibility of an ulnar lesion at the wrist. I would want to look at the ultrasound imaging and compare with the other side I think. As the methods used for those studies are a bit different to mine the normal ranges for that lab would also be useful. JB

Thanks for your thoughts Jeremy. I have some ultrasound image prints that are pretty poor resolution and only of the left hand I think but I will try and scan them to you if you think that is of value. the MRI with dye post op is something I dont have a copy of and would be a big file that I doubt I could send anyway - but with both the ultrasound and MRI the second hand surgeon I got an opinion from said he did not see any problems there with the ulner nerve - hence his comment that he had no idea why I am having this sensory change ulner side of palm. I will see if I can get you images of the printed ultrasound but as stated I'm not sure how good they would be - maybe I can convince the doc to send me electronic copies of better quality but getting these seems to be difficult at times.
I doubt i am going to be able to get you any further info on the NCS lab methods as it took a lot to get the prints.

I think you really have to see ultrasound 'in the flesh', at least for subtle nerve abnormalities. Someone who is really expert in peripheral nerve ultrasound can choose single pictures or video clips to illustrate what they are seeing but I rather doubt if you saw one of the handful of people who are really good at this after surgery. MRI won't be much use - insufficient resolution. Sadly I don't think I could get any further with this without seeing you and I guess you are not local to Canterbury UK! I would love to know the explanation however, if someone does manage to work it out. I do occasionally see people with ulnar side symptoms after carpal tunnel surgery but it's usually because they have either an ulnar problem as well or else thoracic outlet syndrome. JB

Thanks Jeremy

I sent those images to you despite that probably being of no use. I will certainly let you know if I find anything out at some stage in the future.
Thanks again for taking the time to discuss and comment on my hand issues.

Hi Jeremy

just dropping back in to this rather old thread to ask a couple of questions I'm hoping you may have time for.

As per the thread above the previous issues with reduced sensation on the ulner side of the palm is the same now and i have yet to try any further consults but feel I will need to (hopefully with a different Neurologist more willing to follow up on things as my last one seemed to lose interest the moment the surgery didn't help the way it was hoped). The problem is that I have some new symptoms happening now which I suspect will be from my neck problems which do feel like they are getting worse but are I think affecting the hand.

basically now i am having intermittent buzzing sensations deep within the hand but mainly on the ulner side, more easily provoked tingling sensations in all fingers after using my hands playing guitar or using tools, and in the last couple of weeks my middle finger has started to have spasms and moves around by itself when in I am in certain positions or after using the hand. I think my posture affects this hence why i think it is mainly the neck affecting the nerves as they exit the vertebrae which are in poor shape, but I also notice i can make the finger twitching worse if i simply make a fist and release even when holding a good neutral neck posture. I'm wondering if the neck is causing the problem does it make sense that an isolated hand movement can bring on a response like this? that is to say does any movement along the nerve from wrist to elbow, up to the neck likely to provoke a respone even if the neck was the problem? I hope you understand my meaning. This finger twitching is something completely new.

i have also noticed that after making a tight fist the relaxing of my hand seems to be very slightly sluggish like the tendons don't want to relax and let the hand fall open quite as easily as my other hand. Not terrible but noticeable. like my tendons need lubricating. I first noticed this playing guitar a few weeks ago when releasing from holding chords and found my fingers just did not lift off as quick as usual.

I am still convinced that some of the longer term issues I have written about before within the hand is due to the surgery itself but these new symptoms are something else. I think its been over 5 years since my full spine MRI and much the same since surgery and the neurologist never got back to doing any further looking at other crunch points such as shoulder or neck as was planned, so I would have thought that looking at the neck again might be my next step?

Other than imaging are there any other ways they test for pinch points in the nerves between neck and shoulder? I don't recall any NCS in that area but is that because it cant' be done or is too sensitive to an area to be subjected to the shocks?

I plan to see my GP shortly about asking for another look at things but if you had any comments or suggested things to ask they would be very welcome. apologies for the lengthy post.

Overall it seems quite likely that this is a mixture of cervical root problems and peripheral nerve, possibly with some contribution from musculoskeletal disorders as well as it doesn't all have to be primarily neurological. Even a full assesssment with imaging and physiology as well as physical exam might not be able to conclusively work it all out I'm afraid. JB

Thanks Jeremy
i appreciate. your thoughts.
I guess I will see if my GP suggests anything further.