5th steroid injection query

I didn't specify both hands so I guess that is just the office staff reading the fact that you have NCS abnormalities in both sides. There is no need to inject the right side and in fact as both the NCS and the symptoms are generally milder on the right and just a left side injection has sufficed previously I would actually prefer it if only the left was injected.

As regards the decision as to which way to treat, it is genuinely a difficult one, as we discussed on Tuesday, but if symptoms are that bad then I would have been inclined to arrange injection as a holding measure even if we had also been planning surgery - so we might as well find out how it responds I think. JB

Dear Dr Bland,

Many thanks for your response - as previously I have only asked for left hand to be injected - that's the coward in me - but wanted to check I was right with this decision. I will let you know how the injection works and hope that it works as previously -instant cure, only lasting longer!

Thanks also for your telephone message today - I will leave a contact email for you to forward the relevant info. Do you ever stop thinking CTS??!!

Kind regards

Dear Dr Bland,

I am due to have my 5th steroid injection next Friday - but the symptoms have got so much worse in the last 4 days that I am not sleeping much at all. The symptoms have also changed slightly from the severs pins and needles in my hand to being excruiating pain (almost like my hand is in a vice with the feeling cut off) and a sever pain radiating up my lower arm. Nothing seems to help - have tried cold compress, warm compress, pain killers, splint, but nothing works at all. Symptoms are also much more common during the day and much more severe. It is now rather debilitating.

Do these new symptoms still sound like cts or do you think it may be developing into something else? My concern is that if I have the injection on Friday and it does nothing to help these new symptoms (although it has worked every time previously) that I will then not be able to have it operated on until the steroid has 'worn off'. If I had realised the symptoms were going to get so much worse in such a short space of time I would have opted for surgery. Would I be able to cancel the steroid and get an appt for surgery quickly - or is there now a long waiting list? Having decided to opt for the steroid, with the symptoms as they are I almost wished last night to perform surgery myself and cut the blessed hand off as I'm sure it would have been less painfull!!

Also - do you have any results to show whether blood sugar levels have any impact on severity of symptoms? The only reason for asking is that for the last 3 days I have woken with higfher than normal blood sugars (10-13mmol) and wondered whether this may have been effecting my symptoms?? Strange question I know _ but I am rather clutching at straws at the moment.

Kind regards

Rachel

I don't know of any link between blood sugars and CTS symptoms. That doesn't mean there isn't one but no-one has studied it. It still seems quite probable that the current symptoms are all CTS related and the best way to check that is to inject it - we can't operate before next Friday so I would go ahead and do that. We could also arrange surgery. It is not strictly necessary to wait until there is another recurrence before operating nor is there any need for delay after injection but I think one should at least defer decision making until we know the injection response. JB

Dear Dr Bland,

I wanted to update you, having had my left wrist injected last Friday.

The injection was fine and I was hopinf gor an instant cure, as in the previous four steroids. This has not been a complete success and was swondering if I am being impatient!?

I now have almost continuous tingling in the ends of my fingers on the left hand during the day. Nights are somewhat better. I no longer have the excrutiating pain - rather tingling and the odd numbness which keeps me awake.

Might it take longer for the steorid to work this time, considering the symptoms were so much worse than the previous times? I am hoping this is the case and not that this is all the relief I will get.

Rachel

Well it was one grade worse this time so the response could be different, and in any case there seems to be lots of random variability in response to steroid injection. Unless it gets markedly better over the next few days I think we should probably schedule you for surgery  - what do you think? JB

Thanks for getting back so soon Dr Bland - amazing service!

I will wait to see if it improves this week - if not then I think I may well opt for surgery. It's interesting as the Dr who did it asked where I had been injected previously and suggested as the last one had only worked for a short space of time he would aim for the centre of the wrist - higher up (nearer where the previous three had been) - it was certainly less uncomfortable afterwards - but am a tad dissapointed with the results :( no rhyme or reason to this CTS is there??!

I will contact you via the forum at the end of the week to let you know how it's progressing - fingers crossed it will be fine :)

Many thanks

Funnily enough there are no really good studies testing out whether it makes any real difference exactly where you inject so no-one knows. All we do know is that it works better injected into the wrist than into the shoulder muscle so it is presumably mostly a local effect rather than a systemic one. JB

One more thing...

If (and I hope I am wrong with this) there is no more progress in relief of symptoms by the end of this week, will I have to wait for a specified time before surgery can be performed, having just had a steroid injection? I am wondering whether I will have to wait for, say, 3 months before any surgery can be requested?

Interestingly, my blood sugars have been efected much worse since the steroid this time. Not sure if this is normal after 5 injections - but the effects on the CTS are less effective but the effects on my blood sugars are much worse! Hey-ho!

Many thanks

There's no reason to delay surgery. Interestingly there are two small experimental studies which found better outcomes from surgery if steroids were instilled into the carpal tunnel at the time of the operation. Not sure what to make of the blood glucose control - it should have been the same dose of steroid each time. Perhaps the exact placement of the injection does make a difference to how much of it is absorbed systemically and how much stays local to the injection site - some tissues might be more vascular than others for example which might lead to quicker uptake and distribution of the steroid to other areas - more idle speculation! JB

Dear Dr Bland,

Just to update you on progress. It's almost a week since my 5th steroid and it is clearly starting to work its magic as I had a reasonable nights sleep last night! The pins and needles during the day are now only spasmodic and the constant dull pain up my lower arm following the steroid has also gone.

One little interesting point is that my blood sugars have been awful since the steroid. I have never had to increae all my doses like I have had to this time. Quite incredible. Not sure what they injected - but it sure has resulted in very different reactions this time.

Clearly there is no need to worry about surgery now (yippee!!). Perhaps I can contact you via the forum if I need help in the future? Hopefully this 5th steroid will work for longer than the last one, and who know, maybe it will cure it for good??

Thanks for all your help

Rachel

Anything is possible with these injections. It looks as though every time you do another one you are effectively starting again with the outcome being just as unpredictable regardless of how it has responded previously - so this one could be better, worse, or just the same as the previous ones. You are of course welcome to stay in touch through here whenever you need assistance. JB 

Thanks Dr Bland,

Can I just congratulate you and all your team on a fabulous service. Not only are the appointments given without having to wait weeks, your staff in clinic all very pleasant - but also down to booking up follow on treatments - very easy and quick. Why can't all health services be run as professionally? Well done - fabulous job.

Kind regards

Rachel

There are waits of weeks to get to see me at times I'm afraid - the clinic is very popular and today I was booking appointments, for new referrals coming in, for 24th June - which is about a 7 week wait, much longer than I would like. It's a bit easier to deal with follow-up cases where I already know the patient, especially if we can use this medium for communication, but I am a little concerned that patients without internet access do not get the same level of service. JB

Dear Dr Bland,

I thought that this might be the best way to let you know my 8 week steroid update as I was unable to answer the telephone follow up at work last Friday due to a fire-drill at school! Couldn't believe it!

Anyhow - 8 weeks on and the steroid is working very well. It took about 3 weeks for the injection to work properly but now it's perfect! I guess we can only hope (fingers crossed!) that this 5th injection cures the cts permanently.

Many thanks again for the wonderful service

Kind regards

Rachel

Thanks for the information - if you can complete a follow up severity score on here too that would be really helpful (from the My CTS pages). Somehow I suspect that it will be back again at some point but hopefully not for some time. JB

Dear Dr Bland,

Here we go again! Have had numbness in both hands during the last couple of nights and wondered if it was worth getting in contact yet? it is nowhere near as bad as it has been on the previous occasions but am aware that once it has started it seems to progress quite quickly! Typical having just had the summer holiday from school......what's your advice...just keep with it until it gets severe or get it seen straight away? RG

As usual I'm afraid we come back to my usual refrain when patients ask me sensible questions - we don't really know! It may be better to try and treat it aggressively as soon as symptoms recur or it may not. No-one has done a suitable randomised trial to try and find out the answer and to be honest no-one is likely to, a combination of the fact that there is no money in treating CTS to attract drug company funding, it not being a 'sexy' subject for the charitable and government grant-giving bodies which fund research, and the fact that there are huge bureaucratic obstacles to getting any kind of randomised trial going.

There is also the vexed question of whether it is safe to continue injecting into the wrist repeatedly. If you scan through the last few weeks of the forum you will see that I have discussed it with two or three other patients recently and again we do not know what the risks might be or how big they are.

We have therefore arrived at a point where your guess is as good as mine as to the best course of action. If you wish to forge into the unknown with a 6th injection I can arrange that but I think we should document the state of the nerve as fully as possible if we are going down that road, so I would want to test it first. JB

Dear Dr Bland,

Many thanks for your swift reply - probably the answer I was expecting - shame CTS isn't the 'sexy' subject for trials - but quite frankly I can see why it isn't having suffered with it for a number of years!!!!

I think to be honest I am rather resigned to having surgery at this point as this latest steroid has only worked for a matter of 4 months - and that's a record even for me! What's the next best thing to 'get the ball rolling'? Shall I make an appointment for nerve conductive tests through my GP or can this be arranged through your office?

Many thanks

RG

At the moment I can still just arrange things for you and I'll send out an appointment today. The latest changes to the organisation of the NHS are still bedding in and I'm not sure how long I will be able to carry on running my clinic like this but for the present we are carrying on as normal. JB

Thank you - really appreciate your help. Why oh why all NHS departments can't run as smoothly as your clinic I have no idea - why change things that work?? Let me guess - 'cost cutting'.........(or not).........

Thanks again. RG

Often not simple cost-cutting. In fact more resources are being put into my clinic at present, but we are embroiled in a much larger, politically driven, revolution in the way the NHS is run. I'm trying to keep politics off this site as much as possible so I won't go on but I do feel I have to warn people that this system may well not be permitted to continue indefinitely. I don't want to make promises I may not be able to keep. JB

Dear Dr Bland,

Had my 7th steroid injection on Monday performed by Dr Miles at Wye surgery. Has worked a treat thankfully! Dr Miles did suggest I got in contact with you about finding out how we go about surgery. If you remember I was going to opt for the surgery route but it interfered with a Christmas holiday. If (and this is the big unknown) this steroid lasts for 3 months like the last one would I need to have more nerve tests before being given the option of surgery? If this is the case it could take some time to organise - is there a way of getting on a waiting list for surgery in, say, February, and then if the symptoms have not come back (and I can live in hope!) then I could cancel in good time to enable someone else to have the slot?

A bit of a quirky question - and a bit cheeky - but trying to find a way of getting this sorted once and for all! Dr Miles rather put me off having an 8th steroid.....!

Kind regards

We are currently booking surgery slots in Herne Bay about 10 weeks ahead so to get a choice of date there you need to plan about that far in front. It is sometimes a bit quicker, but less predictable, on the orthopaedic list in Margate/Canterbiury. I would not need to retest if we were operating before about March next year. JB

Hi Dr Bland,

Many thanks for your quick response. I guess it's just a case of Herne Bay or Canterbury then? IN which case - which do you suggest? Does one have a higher success rate then the other??! How would I go about opting for surgery sometime in early 2014? Do I go via my GP or can your team organise this?

Changing the subject somewhat - my blood sugars are 'through the roof' since having the steroid. I know it usually increases them, but this time I am taking almost double my day-time insulin to stay within normal limits! I wonder what was in it this time??!!

Thanks again for all your help

Hello again,

I have just read a comment from another patient who had their injection on Monday and has had facial flushing since. Really bizarre as I have had severe facial burning on both cheeks since my injection on Monday too! Wonder if there is a new steroid batch as I too have had a dull ache radiating up my arm for the first time since having these injections. I guess the facial flushing will die down will it? I am rather fed up being asked if I'm having permanent hot flushes!

The facial flush thing is an odd one. The first patient who noticed it got it with two different steroids. The ache in the arm is commoner. I will be able to arrange surgery for you given sufficient warning of when you want it done - no need to bother your GP. I know what the results are like in Herne Bay in a great deal of detail but the same kind of statistics are not kept for the hospital service. JB

Dear Dr Bland,

Thanks for your response. I think given the fact that the last steroid lasted for 3/4 months we can reasonably assume for the same this time? Could we look at surgery for late January in Herne Bay, please? Thanks

We haven't quite scheduled the end of January lists yet but if you remind me in a week I should be able to reserve you a space then. JB

Thanks a lot - maybe it can be sorted for a week earlier than that - it's going to unfortunately entail me having to take some time off work so it doesn't really matter when.

As John RIne was away this week I do not want to create much in the way of far in advance booking until he is back - just in case he decides to go ski-ing then or some such. Give me a poke in a week please. :-)

Dear Dr Bland,

You asked me to give you a 'poke' to remind you about my request for surgery - so I'm giving you a gentle nudge now!!

Just a quick query about what the timescale is for usual recovery as am wondering about how best to cope with work. Not only am I a Nursery teacher but I am also a Forest School Leader running twice weekly afternoon sessions at school in our woodland. These are quite physical sessions - pulling a cart load of kit down to site and then helping children with tools etc - is 2 weeks likely to be sufficient before I resume these duties? If not then maybe I should try to schedule the surgery for 2 weeks before our half term break - that would then give me 3 weeks recovery before resuming these full duties (which I love and don't want to miss). Sorry - not only a bit of a work-a-holic but also a work lover too who doesn't want to miss much...

Thanks a bundle

I now have lists just about up to the end of January so I'll book you a slot in one of those when I get in to the office tomorrow morning. 2 weeks is about the usual recovery time for ordinary activities but I would plan on 4-6 before taking up heavyweight forestry I'm afraid.

Appointment letter for surgery going out in the post today. JB

Dear Dr Bland,

Many thanks - dates arrived this morning for being seen at Herne Bay - many thanks for your help with organising it all - wish all NHS appointments were so easy to make - think they need to take a leaf out of your book personally!

Thanks again

Dear Dr Bland,

Had surgery performed @ Beltinge yesterday morning and just wanted o touch base about swollen fingers. I realise I am most probably being impatient but should my fingers still be very swollen after 36 hours? When I woke this morning the swelling was gone but gradually through the day it has got worse to the point they are hard to move now - have had the arm raised as much as possible during day and have been doing as much as possible to make sure I am using fingers. Pain is fine thankfully.

They aren't usually hugely swollen at this point. If that persists I would either let your GP look at it or try to contact Dr Rine. I'll ask him to read your comment too. JB

Thanks - phoned by Dr who said to keep it elevated - since then swelling better but comes and goes quite a bit. Have tingling sensations in index and middle fingers most of the time now and am finding it a little difficult to successfully do exercises - not sure if it's because they are not working properly yet? Thought it would have been easier to move them by now? Am I just being a very impatient patient??!! It's now 4 days post op....

The only CTS symptoms that would worry me 4 days post-op are a marked increase in pain or numbness, or obvious loss of power in the thumb muscles. Obviously indicators of other things such as infection or wound breakdown are different. Other than this I would be inclined to wait for review at 2 weeks when the stitches come out - most are clearly on the mend by then. JB

Thanks for your response - good to know I'm just being an impatient patient!! Certainly can't wait until stitches are removed as it's hard to do all the exercises with them in - particularly the extending hand and pulling thumb outwards - yuk!

It's probably time I had a talk with John RIne about post-operative care regimes. The current state of the scientific evidence is not great in terms of recommending any particular post-operative management and surgeons do vary quite a bit. There may be scope for us to take a look at the issue ourselves. JB

I think this is a valid point - I think the pre-op visit was almost unnecessary as the paperwork could have been signed on the day of surgery - this may well prove a money saver for the NHS (or whatever the local health financial body is now called!), however the photocopied sheet of exercises provides a list of somewhat similar exercises which (for me) have been quite difficult and painful to do. Maybe a better sheet of post op questions/answers page may be more useful - you must get asked so many questions post-op and some additional paperwork simply to put your mind at rest post -op would be a real benefit as patients probably all have concerns about pain/swelling/sensitivity etc. Having said that, I do think the surgery team at Beltinge were superb - very patient (excuse the pun), caring and professional - so big thanks to them.

One last question - when I have had each of the 7 steroid injections in the past it seems to have cured the CTS symptoms in my right hand and was hoping that surgery would do the same. However the symptoms have become worse at night time in my right hand. Is this normal? I was hoping it was not going to need any injection, but the numbness is much worse than it has ever been. Is this likely to be because it is having to work much harder as my left hand is not operating at full functionality yet? I do not want to have to take any more time off work so if there is a chance of getting it 'looked at' over the next week I'd be really grateful. What do you think?

I think that is sufficiently complicated that I might have to see you and I can't look into that until Monday so I'll get back to you then. If I don't come back to this thread on Monday please post me a reminder to jog my memory. JB

Dear Dr Bland,

Sorry to pester you......any news on whether or not you will be able to squeeze me in this week to have a look at/steroid treat my right hand whilst I'm off having had surgery on my left hand? Thanks muchly

I can do tomorrow (Tuesday) at about 1:00pm if you can make it? JB

Dear Dr Bland,

Thank you so very much - I will attempt to get a bus from here and be at clinic by 1pm

Thanks again - see you tomorrow

Sorry that was a bit rushed - I ended up with another somewhat difficult patient to deal with at the same time. The right hand clearly is a little worse at present but I would not rule out the possibility of both sides improving over the next few weeks so lets see what they feel like at our usual routine review point, thre months after surgery, unless there is a marked change in symptoms in the meantime. Stay in touch on the forum here and we will play it by ear. JB

Thanks for seeing me at short notice - as I knew - right hand is getting worse - rather fed up that having had left hand operated on and those symptoms gone that the right hand is now keeping me awake at night - seems a tad unfair! Every time in the past when I have had a steroid injection on the left the right hand symptoms have immediately gone - quite miraculous! Now, having had surgery on the left hand the symptoms on right have got markedly worse. Is there any chance of symptoms on right hand easing having had surgery on left hand or is it just steroids that have this somewhat miraculous effect on the opposite hand?
Will I really have to wait 3 months before steroid can be considered for left hand?? Really do not want symptoms to get much worse over the review period.
Finally (I promise!) - left hand is now painful around base of thumb and around base of little finger on palm side of hand with certain movements - presuming this is all normal and things just settling down following surgery?
Take care and many thanks again

We can inject the right wrist anytime that symptoms are bad enough to justify it. There are people who would not inject in the immediate postoperative period because of fear of steroids affecting wound healing or increasing infection rates but I am not one of them. You know exactly what is involved in injection from previous experience so you can decide for yourself if and when you want it done and we will arrange it.

The curious effect of treating one side and getting improvement in the other is seen with both injection and surgery but is decidedly erratic.

The pain at the thumb base and at the opposite side of the scar is not uncommon after surgery but usually settles given time. Think about the normal anatomy of the wrist and how it is altered by cutting the transverse carpal ligament - this operation is quite a significant assault on the structure overall and if you did this accidentally, falling onto glass or whatever, you would expect some significant symptoms. In some ways it surprises me that we generally get away with it without causing more long-term disability than we do. JB

Thanks - as always this forum is fab for putting m9ind at rest and answering simple queries from impatient patients!!

Is there any chance of getting the steroid booked in for right hand? I know this usually takes a while to get an appointment which avoids me having to take time off work (!!) - can I please 'leave the ball in your court' so to speak? I know it is only a level 2 at the moment but am certain this is simply going to keep getting worse and don't want to wait until it's stopping me getting any sleep!

As always - thanks a million.

We can now do them almost on demand in Canterbury as well as in the GP surgeries that help us out with injection, where it takes a bit more forward planning. You can either call the SIPC office and book a GP injection (I will amend your records as necessary tomorrow), or just come and see us any weekday - just let us know on here a day or so before in case we are away at a meeting or some such. JB