Steroid injection problems help
Four years ago I had surgery for CTS on my right wrist. This worked brilliantly, symptoms relieved immediately, recovery was quick and scarring minimal. The symptoms on my left hand were not severe and I was advised to see how things went and if they got worse to go back to the Dr. About 2/3 months ago the symptoms in my left hand have been getting progressively worse, tingling, pain at night and numbness in middle and ring finger. I went to the GP and asked if I could be referred again for the surgery on the left wrist to be told their policy had change and they needed to pursue alternative treatments first before recommending surgery. Their recommended course of treatment was a steroid injection which I was not particularly happy about as I felt that this would not be a long term solution. However, I knew I would have to wait for surgery so thought this would be solution to relieve the symptoms. My GP injected a 40mg/ml solution of methylprednisolone acetate into my wrist on Friday and said I might have slight discomfort before I get full relief. As he did the injection I had sharp needle like shooting pains into my left thumb. Now I have severe numbness in my thumb, index finger and area between my thumb and index finger - there had been no problem there before. I can't grip / hold anything without experiencing excruciating shooting pains into that area. I am very active, go to the gym, cycle, have five horses which I am now struggling to manage and am about to go skiing on Wednesday. Is this pain temporary, will it go and when OR has the injection been misaligned and is this going to be a permanent issue. Would surgery rectify it?? Am currently taking paracetamol / ibuprofen but this is not really touching the pain. HELP advice urgently needed.
HI JB - I did tell the GP at the time that I felt a severe shooting pain into my thumb but he did not reposition the needle at all. Am afraid I live in Leicestershire which is quite a way from East Kent. I did have my original surgery with Blue Sky Orthopaedics http://www.blueskyortho.co.uk - Malcolm Clarke, if you are aware of them. I was considering ringing him tomorrow and seeking his advice. Would this be a good idea? You are not sounding v hopeful that this problem will be rectified. :-( M
I'm sure Blue Sky orthopaedics are very competent surgeons but they do their NCS with the mediracer and recordings made with a mediracer 4 years ago will be completely useless as a baseline for evaluating what has happened to your left hand now unfortunately. I take it my guess that there are no recent proper nerve conduction studies is correct. Malcolm Clarke may be able to get this assessed by someone with an interest as he will know your area much better than I do but he may also be limited by referral guidelines. All decisions on how to proceed with your case are supposed to lie, in the first instance, with your GP and unless your GP is prepared to refer you on for a specialist opinion you may be a bit stuck. Still if you can contact him it would not hurt to enquire.
I have one ultrasound image of a probable intraneural steroid injection, captured a a few days after the event. I would love to see another one to see if it looks the same but you are too far away in Leicestershire I'm afraid - my nearest clinic would be London on Wednesday!
And finally, I'm sorry if I don't sound too hopeful. The truth of it is that I really don't know how it will turn out. The patient whose nerve I was able to ultrasound shortly after injection actually recovered quite well but these events are so rare that no-one has much personal experience of them and in your case we are still only guessing that that is what went wrong anyway - I could be barking up the wrong tree entirely trying to guess diagnoses on the net. Please let me know how you get on - the more of these we collect reports of the better, even in if only on the web. JB
Will see GP first thing this morning and call Blue Sky - and will advise on outcome. No proper NCS were done this time. I would prepared to travel today, tomorrow but am booked to fly to Geneva on Wed if you could see me. MLH
Unfortunately I can't see any way to do it - we're just too far apart with too many other commitments but there may be someone around Leicester who knows what to look for on ultrasound of peripheral nerve. A neurologist up there called Yusuf Rajabally has published a little on perpheral nerve ultrasoud, Good luck. JB
It is possible that the injection has been given into the nerve itself rather than into the area surrounding it. The aim is to infiltrate the carpal tunnel area with steroid not to inject into a nerve, tendon or blood vessel. Direct injection into the nerve can cause considerable nerve damage and the usual way of avoiding it is to ask the patient to report any shooting pains radiating into the thumb and fingers when the needle is inserted and to reposition the needle until the injection can be given without these signs of direct irritation of the nerve. If this is an intraneural injection there is no simple solution as you cannot reverse it and you will just have to wait and see how it turns out - some do badly and some do well and it is a sufficiently rare complication of injection that there are no good statistics to give you ( I have only seen a handful of possible intraneural injections in 20 years).
There is some evidence to suggest that some steroid preparations are more toxic to nerves than others but irritatingly I have lost my paper copy of the research paper describing an animal study on this and the version which is currently accessible in the online archive of the Journal of Plastic and Reconstructive Surgery is missing 6 pages! Susan Mackinnon and colleagues found that hydrocortisone and triamcinolone hexacetonide were more toxic than dexamaethasone and that the degree of injury also varied depending on exactly where within the nerve the steroid was injected.
If you are within reach of somewhere that has an interest in carpal tunnel syndrome, high resolution ultrasound imaging and neurophysiology then it would be worth trying to document things with nerve conduction studies and imaging as these are very rare events but I guess if you are in a PCT area where they have adopted a policy of injection first in all cases then they have also not checked your NCS before injection either? If you were in East Kent I would see you tomorrow morning before the usual clinic but there are few areas of the country with my sort of facilities for CTS I am afraid. JB