Post bilateral CTS release
Hello to everybody, I wanted to hear an opinion from my esteemed colleague regarding my situtation So Im on my final year of neurosurgery, and i did myself couple of dozen of carpal tunnel release surgeries. And to make story short, I became the patient 3 weeks ago when my Colleague orthopedic surgeon did carpal release on my Left hand (dominant), mini open, and I noticed that he didnt use bipolar to cauterize the edges of the ligament. From that day I had no symptoms even though i have to admit I did not keep My hand relaxed as mich as I should have. 2 days ago I did my right hand , and my Friend neurosurgeon did it and he thoroughly cauterized the ligament which was very thick and compressed the nerve. Mind you, this is something you probably mever heard about, but on that day I actually assisted him for acute subdural heamatoma because he was on call, and I used bone rongeur which caused some pillar pain but everything went well for the patient. Then two hours later he did surgery on me. I know- we doctors are sometimes irresponsible towards our health. So for two days now I have intermittent paresthesias in my index finger of my left hand which was done three weeks ago, and i wonder is jt because I was compressing the nerve with imstruments Pre op emg was normal by the way , ultrasound showed compression bilaterally, and i had comstant paresthesias in both hands, more pronounced on the left. Should I be worried that first release was incomplete or that its just My stupidity that caused it, Cheers guys P.s postop emg of left arm showed even higher amplitudes of median merve conduction speeds.
You might perhaps have traumatised the nerve slightly using instruments shortly after surgery. Remember that once the TCL is divided the nerve often ends up lying immediately subcutaneously at the heel of the hand so it doesn't take much effort to poke it. Why did you feel it necessary to undergo surgery at all with normal NCS and only ultrasound evidence? Given any choice in the matter I would generally opt to keep my TCL intact if possible. JB
Symptoms that corresponded to CTS, which went from intermittent to constant - paresthesias, and i had thenar atrophy on left hand, right hand just paresthesias, emg in 30% can be negative, especislly surface emg which i have done, but on ultrasound and intraop collesgues said the ligament was very thick and the merve was compressed. So i did jt more in order to prevent further deterioration.. however Tinel sign is still positive, Im guessing it will take time to subside , bjt when it comes to symptoms i dont have them anymore, except what i mentioned in the post above, which is noe getting bette rso i guess i overstrained it with instruments
I have never seen a patient with thenar atrophy from CTS and normal nerve conduction studies in 35 years, but I have had a surgeon show me their perfectly normal looking hand and say "look I've got thenar atrophy" :-) The amplitude of the surface motor potential from APB is directly proportional to the amount of contracting muscle under the electrode. if it is correctly placed over the motor point of APB and you have an 8-10mV surface motor potential you do not have atrophy of APB regardless of what it looks like to the eye. TCL thickness has very little do with CTS and all surgeons, in my experience, on operating on any and all cases of CTS all feel that it looks really bad in virtually every case. Surgeons have been thinking for many years that the median nerve is compressed under the TCL and thinking of this as thinning of the nerve at the carpal tunnel but in reality that is not the situation at all - the nerve is actually enlarged from just proximal to the wrist to the palm, but because the space for swelling is very tightly constricted under the TCL the swelling is greater proximal and distal to the mid point of the tunnel. When you open it up, the bit you are looking at appears thinner rellative to the porixmal and distal segments, and it is, but it is still swollen compared to a normal nerve. This was well documented in an ultrasound paper by Nakamichi and Tachibana many years ago. Your suggestion of a false negative rathe for NCS of 30% is outdated - with modern methods the false negative rate is probably more like 5-10% though it's impossible to give a precise figure in the absence of an absolutely reliable indicator of the diagnosis. JB
Thank you for your comprehensive reply, I appreciate it. However there has been a study where most of symptomatic and negative emg patients were the younger ones (30-40y old). So in my case, regardless my age (32y), when I said I had positive ultrasound it wasnt just median merve compression, but also edema around it. I tried PT, gliding exercises etc, nothing helped, and I agree with your statement sbout thenar atrophy, it probably wasnt really it. However postop I do not have symptoms anymore, well , when it comes to CTS, i have cubital sy in left arm, but grade I on EMG, teying to solve it with bracing and rest.
I agree that I had a slight hypochondriac-like approach to my problem, but the thought of further deterioration made me do what I did. Atypical symptoms, yes, both ortho eho did my left hand and colleague NSG who did my right hand said that the tcl was thick and nerve looked pale and compressed, but as you said, maybe we tend to exaggerate the finding intraop. Cheers
And forgot to mention , regarding my right hand that was done two days ago, symptoms are completely gone. Regarding my left hand, postop symptoms disappeared aswell, that is, until two days ago after manipulation with instruments