Return of symptoms

If you can drop in to the clinic this Thursday morning we could consider re-injecting it. I'm not sure whether we will have time to re-test or not - depends how many patients turn up. JB

Thanks so much for getting back to me, Thursday is great: I can be flexible, what time suits you?

Thankyou again, Alison

Between 8:45 and 12:00 noon. JB

I'll be there at 9am -but understand I may have to wait until you can fit me in between booked patients.
Many Thanks
Alison

No problem - it's usually quieter right at the start of the clinic. JB

Hi Dr. Bland
Just wanted to thank you for seeing me yesterday and many thanks to Michael for doing my injection- (now my 4th)
My wrist was uncomfortable for the rest of the day-but really not too bad at all. Last night there was slight discomfort only.
I'll let you know in a few days how things are.
Alison

Thanks for the follow-up. I hope it works again. JB

Hi Dr. Bland,
It's now just over a week since my steroid injection and i'm pleased to report my night time symptoms have now thankfully gone. I'm getting an occasional mild discomfort during the day only-which is no problem at all.
Fingers crossed it keeps working for the next few months and hopefully longer. It's great to get a good nights sleep again.
Many Thanks
Alison

Thankyou - if we could have a new severity questionnaire added to your record on the website 6 weeks after injection that would be really helpful. JB

Hi Dr. Bland
I have just completed the severity questionnaire again. It's now 9 weeks after the injection--sorry i forgot at 6 weeks!
I'm pleased to report in the last few weeks i have had no symptoms at all. It has been wonderful. Also,the milder symptoms i was starting to get in my left wrist have also disappeared.
Thanks again
Alison

That sounds like a very satisfactory result at present. Now we just see how long it lasts. There is some new study data on longer term results with steroid injection for CTS which I've summarised in the steroids page. JB

Hi Dr. Bland,

Just wanted to let you know I'm still 'symptom free'.

My 4th injection has been the most effective.

Many Thanks for your help this year. Wising you a Very Merry Christmas.

Alison

Thanks very much for the update - always encouraging to hear from patients who are remaining well. Don't strain the wrists too much lifting turkey! JB

Will try not to!

Happy Christmas to you and your team.

Alison

Hi Dr. Bland

Unfortunately my symptoms have now returned over the last couple of weeks. I think I must have jinxed things emailing you before Christmas!
I have had the worst ever night time numbness and pain in my right hand. Also,to a much lesser extent in my left hand aswell. I have had virtually no sleep during the last 2 weeks.

I fell over before Christmas and unfortunately landed on both wrists. I had pain in my right wrist following the fall-but not carpal tunnel pain -- no night time symptoms initially. Things didn't settle so I saw the gp and he said I had ? tendonitis in that wrist and to take regular analgesia and physio may help. The pain continued and has now developed into awful carpal tunnel symptoms. I'm not sure if having the fall has made them now return or they may have returned anyway.

As things are so bad at the moment I wonder if there is any chance you could fit me in soon for another injection. ( I've had 4 )

Many Thanks

Alison

It's quite possible that falling onto the outstretched hands might have triggered it again I think. We can probably fit you in quite quickly so that we can see what we are dealing with. There's a space on Monday morning and one on Tuesday morning this week but as you live in Ashford more or less have you read the notes for Ashford patients? Who is your GP? JB

Hi Dr. Bland,

Thanks for your speedy reply.

My GP surgery is Charing surgery. It looks as though I do come Ashford patients.

As you know I work part time at Kent and Canterbury Hospital.-would I still be able to see you or would this cause problems.

Tuesday morning sounds great this week if I am able to stay under your care.

Many Thanks

Alison

From my point of view I am happy to see you at 10:00am on Tuesday but I am still waiting for clarification from Ashford CCG on how they expect patients in your situation to be managed. Bill Warrilow is one of the GPs at Charing and I know he is supportive of our current arrangements for CTS. I think we should probably just carry on as normal for now so I'll book you in. JB

That's great-Thank you.

See you tomorrow.

Alison

Hi Dr. Bland

Many Thanks for your time and advise this morning.

Please thank Emma again for the pain free injection

I'll keep you posted how things go.

Alison

Hi Dr. Bland.

Just a quick update;

My 5th steroid injection was 6 days ago;

I had just a couple of days of slight discomfort in my wrist following the injection but now I'm virtually symptom free which is fantastic! I'm still having slight pins and needles in my right hand during the day-which I didn't get after my previous injections so I'm thinking perhaps this one may not last as long. However ,i have had no night time waking with pain and numbness which is wonderful. I can actually get a decent nights sleep.

I've been thinking about the operation and feel I do want to have it done as i don't really want a 6th injection once my symptoms return. As we discussed I guess it's just knowing what's a good time to go ahead with having it. I'll go with what you think is best.
For the moment though it's great to be symptom free.

Many Thanks.

Alison

In the ordinary way of things I would say that we can plan surgery for you at a time when you think it is convenient subject to you being able to give me about 8 weeks notice but the changes to the management of CTS being pushed by Ashford CCG may interfere with that - a very difficult situation at present. I would suggest asking your own GP what the current situation is in Ashford area as he will be kept better informed by the CCG - they don't talk to me much except when they want something. Meanwhile you can of course talk to me as much as you like on here JB

Hi Dr. Bland

Thanks for your reply.
I know things are likely to change soon ,however i really want to stay under your care and have my surgery done by Dr. Rine in Herne bay. I assume even though i come under Ashford as a patient i do have a choice?

On average my injections tend to last a few months. Would it make sense to think about having surgery before they may return-- ? June time. I don't think i could cope with an 8 week wait-or more once my symptoms return.

Many Thanks

Alison

I'm afraid we don't quite know whether you have a choice at present because the Ashford CCG are not really discussing their intentions with us so far - there is talk of a meeting in April. All we know is that the April 2013 changes to the NHS made by this government place the primary responsibility for making arrangements for the treatment of CTS (that is in terms of agreeing some form of contract with a healthcare provider, or more than one, to provide the service, not making clinical decisions about individual patients) firmly with the CCG, and that the Health and Social Care Act places few absolute restrictions on how they do that. The act itself is massive and largely incomprehensible. The phrase 'patient choice' has been much bandied about in propaganda over the last 10 years but sometimes turns out to be illusory in practice.

Dr Rine's operations are paid for on an individual case basis - ie for each one he does he sends a bill to the relevant CCG, they pay him and he pays his ancillary staff. So far the 4 CCGs have honored this arrangement, which was put in place by the Primary Care Trust in 2004. My inclination is to book you a space with Dr Rine for a time that suits your work and holiday arrangements, and I have no problem with going ahead with surgery regardless of whether symptoms have recurred or not, but I have no idea what would happen if Ashford CCG then decided they did not want to honor that arrangement and pay the bill - either before, or even worse after, the surgery. Until they provide us with some clarification of their policy I don't really know what to do. JB

Dear Dr Bland

Thank you for your quick and informative reply. I think as things stand, and as you mention, perhaps it is best if you could go ahead and book surgery for me with Dr Rine. Hopefully the Ashford CCG will honor the arrangement, and all will be well!?
Anyway; I have a few family commitments to try and work around, but ideally if I could have surgery in the first two weeks of June that would be great.

Many Thanks

Alison

I'll see what John is planning by way of annual leave and then try to figure out what we can book. JB

That sounds great!

Many Thanks again for all your help.

Alison

Hi Dr. Bland

Just wondered if you have been able to speak to Dr. Rine yet?

Alison

He's been away. Back soon I hope. JB

Hi Dr.Bland

Sorry,it's me again!

Just wondered if you have managed to speak to Dr.Rine yet Re; surgery beginning of June ( if possible.)

I need to give work as much notice as possible.

Thank you.

Alison

We're just about getting to the point where the surgery lists for June exist for us to book patients in. Ashford CCG are very anxious that patients are offered the choice of surgery in Ashford as well as in hospital or in Herne Bay and at present they are insisting that they do not want me to offer patients that choice but want it to be done by an adminsitrative office. We are still negotiating and I will keep the website updated with progress as it occurs. The first Saturday in June would be the 7th I think - would that be about right for surgery? JB

Thanks for the update.

The 7th June,if possible sounds perfect.

Many Thanks

Many Thanks for arranging a date for me. Really appreciate your help.

Alison

Hi Dr Bland

I am just thinking about the pros and cons of surgery/ongoing steroid therapy ,

In your experience do you know of any long term effects of continued steroid treatment with the doses that I have received?

Has there been any research done on this?

Many thanks

Alison

Good question. I am afraid there are no simple answers. There is no published research on long-term treatment of CTS with serial steroid injections. There are a couple of anecdotes from the USA but these have never made it in to print. At the moment the clinic with the best documented population of patients who have had two or more injections into the same wrist is Canterbury (unless someone pops up to correct me) so I can summarise our current experience but we have not published this either, at least not yet.

So far we have had patients persevere as far as 10 injections to one wrist but the majority of people give up after 1-3 injections and resort to surgery if it keeps coming back. We have seen very few serious side effects from injection at all but the one that is of concern with respect to having many injections is the possibility that many injections might weaken the flexor tendons leading to tendon rupture. We have definitely seen this once and there may be a second case where we are less sure of the diagnosis. At the moment it still looks as though the risk of this is smaller than the risk of a bad outcome from surgery, but unless many more patients experiment with serial injection treatment we will never really know what the size of the risk is.

Personally I think there is enough circumstantial evidence that serial injection is a viable strategy for treating CTS that it would be worth doing a randomised controlled trial comparing the two options but it would be difficult to design, hard to get through ethics and governance approval, and very expensive to follow up a cohort of patients for long enough to get the results. If you asked a surgeon of course they would probably tell you that this is nonsense and that surgery is obviously the best option. For the moment then, our anecdotal experience from the Canterbury clinic is all we have. I will try to get some figures onto the website at some point, and at some stage I will try to get some of this data published in the journals to get a debate going but there are many projects I am trying to pursue relating to CTS and I only have limited time. I am not really likely to have anything more concrete for you to work with before 7th June I'm afraid. JB

Hi Dr. Bland.

Thank you for your very informative reply.

I didn't realise the injections had the potential of weakening the tendon .

I was actually thinking of the more general effects on the body such as effecting bone density etc. I guess it's the lack of studies with this aswell?

Emma emailed me asking for an update post injection.
Would you mind informing her my wrist is totally symptom free-which is fantastic!!

Many thanks for your help again. I'm just having a few wobbles thinking about surgery-but know I really don't want any more steroids. It's a tricky one-especially as my wrist is so good at the moment!

One last question; Do you think the more injections you have can effect the outcome of surgery?

Alison

There is unlikely to be any significant risk of general steroid side effects as these are all dose related and the total dose used in injections to treat CTS, averaged over the interval between them, is negligible - so no problems with diabetes, weight gain, osteoporosis etc.

We are in the process of looking at the surgical outcomes in patients who go straight for surgery compared to those who have injection first... and they seem to be identical. JB

Many Thanks for your reassuring reply.

Alison

Hi Dr. Bland.

Just a quick update and a question!

I had my surgery just over 3 weeks ago. The op went well and my scar has healed well.
Dr. Rine suggested 3 weeks off work which I have now had.

Unfortunately last week I tripped up the stairs and fell and jarred my hand which was operated on. All rather painful as you can imagine. Things have now started to settle again but I'm still having some degree of pain when writing for example. Hopefully this will settle in time.
At work I spend most of the day on the computer or writing in patient notes. Do you think doing tasks that cause pain will delay long term recovery?

Many Thanks

Alison

Injuries during the recovery phase after carpal tunnel surgery are so rare that it's impossible to say much about what to expect. However I generally feel that keyboard work and writing are relatively 'light' activities and are thus likely to be low risk for most purposes. JB

Many Thanks for your reply.

I'll let you know how things go.

Alison