Steroid Injection

There is a very small but definite risk of injury from the needle when doing steroid injections for CTS and for that reason I prefer to have them done by a small group of general practitioners who we have trained to do them and who get lots of practice. This does not stop other GPs from doing them and some of them may be perfectly competent to inject the wrist - it is just that I do not know them. From my point of view injections carried out sporadically by 'other' GPs are a nuisance because they send no records of the steroid, dose and route to me and they do not carry out any systematic assessment of the outcome for me, so a patient who has an injection performed outside my care pathway represents a lost opportunity for me to add to my experience of CTS and its treatment.

First injections for CTS may be said to be a securely evidence based medical intervention with ample scientific studies demonstrating their efficacy and safety. There are as yet NO published systematic studies of second or subsequent injections so anyone giving you a second injection is, in effect, applying a treatment for which there is no good evidence. My approach to this is to carefully document and monitor patients who have more than one injection - something which does not happen when people other than my selected team carry them out.

Ultimately it is a decision for you and your doctor - you can consent to him or her carrying out a further injection if you are properly informed of the sort of issues discussed above - you do not have to consent to anyone carrying out an invasive procedure on you if you do not wish to. JB

Many thanks for your reply. I was very worried at the time but wasn't sure of how to tell him. Do I need to go through my Doctor if I am still having problems?

Regards

Julie Wanstall

My preferred way of running the carpal tunnel clinic is to allow patients who I have seen for CTS to contact me directly, as and when required, indefinitely, and preferably via this website. This model of care however may not be flavour of the month with the new Clinical Commissioning Groups (CCGs) who are now supposed to hold the purse-strings for much of the NHS and who will be expected to pick up the bill if I actually see patients again, test them, or arrange injection or surgery for them (contacts on this website are of course effectively free to all). We hope, over the next few months, to come to some agreement with the new CCGs, who are only just settling into their roles, over how to manage the CTS care pathway in East Kent and I hope to establish some hard and fast rules over what we can and cannot do. However, for the moment, the old informal arrangements are being continued - you can contact me through here whenever you like and I can arrange further treatment for you.

Did your GP actually inject in the end or did you put him off? If he did inject, and between you you agree that you want me to continue looking after it, then I will need to know what steroid was used, the date and the dose and then we can carry on as before. If your GP explcitly does not want me to be involved any more then we are a bit stuck - under current NHS arrangements I cannot treat you against his wishes. JB

He did inject my left wrist, I have another Doctors appointment on Thursday 9th May with my usual Doctor and I will ask her what steroid was used and the dose etc. as I assume it will be on my notes. I would much prefer to be treated by yourself regarding my CTS as I didn't feel happy with the other Doctor.

Julie

Hopefully it has been recorded in full in the notes - has it worked? JB

It does seem to have worked, feels a lot better at the moment. I will let you know on Thursday the dosage etc.

Julie

Hi Dr Bland

I have the information you require re my injection.

The date was the 2nd May 2013
Depo-Medrone 40mg/in 1ml
given with lidocaine 20mg/2ml

I informed my Doctor that I wanted to have any further treatment with yourself.

Julie

OK I've added that one to your records. It's not the steroid we would usually use but is a roughly equivalent dose. We don't add a local anaesthetic as there is no good evidence that it achieves anything but as you have had a pair of injections without local and one with I would be interested to know how you think they compare from a subjective experience point of view. The other question is - do we need to do anything about the other hand.

From a planned follow up point of view what I could do with ideally is a new severity score recorded by you on here along with a message on the forum 6 weeks post injection if you can manage that? JB

Yes I will do a new severity score and inform you 6 weeks post injection.
A lot of my pain is in my thumbs and wrists with a dull ache going up to my arms. I only get numbness now and again during the night.

Julie

OK we'll have another think about it 6 weeks post injection. JB

Hi Dr Bland

It is now 6 weeks post injection in my left hand. It does feel a lot better, no numbness or pins & needles.

I do have a bit of a problem with my right hand again. I am experiencing pain in wrist area and up my arm, I don't hve a lot of strength in hands. I have numbness during the night which wakes me up and normally first thing in morning but nothing during the day except on one occasion whilst driving.

Julie W

Is the right hand problem sufficiently severe that you want us to do anything about it? JB

I will wait another couple of months and see how it goes for now. I will update you if there are any changes.

Many Thanks

Julie W

OK - feel free to communicate through here as much as you like. JB

Hi Dr Bland

In the last 6 weeks my symptoms have got gradually worse, I have been experiencing pins and needles when reading and driving and wake up most days with my right hand numb. I have a lot of pain in both my thumbs going down to the wrist and my hands feel weak. I have been wearing my splints on and off but the pain doesn't go away. Can you please advise me what to do.,

Many Thanks
Julie

We should re-test them now and see what we are dealing with. If they are measurably deterorating then we may be looking at surgery. I'll send out a new appointment (appointment sent 15.8). JB

Hi Dr Bland
Just upating you since my last visit to you in September.
I have an appointment on 8th November for injections in both hands, this was the earliest appointment I could get.
Since my visit to yourself I have been in a lot of pain with both hands, hopefully the injections will work for a while but if they don't I would like to go ahead with the operation if that's ok with you.

Many thanks
Julie

We can inject on Monday in Canterbury if that helps? JB

That would be great on Monday, what time would I need to be there.

Many thanks

Julie

I would aim for about 11:00am. There are quite a few people coming for injection Monday so there may be a bit of hanging about involved. Can you let the SIPC office know so that someone else can have that GP slot please JB

Thank you very much and yes I will let the SIPC office know this afternoon.

Julie

I had injections in both my hands on Monday, coud you please tell me if you can get any side effects from these iinjections as yesterday I had a dull ache in the top of my left arm for most of the day and both my cheeks are red hot to the touch.
I applied heat to my arm and took painkillers and the arm feels a lot better but today my cheeks are still red hot to the touch.
It may just be a coincidence but not sure.
Thanks

Julie

We have had one other patient who gets transient facial flushing after steroid injection. It does not seem to be a serious or persistent problem. The ache at the top of the arm may well also be related - as long as it settles in a few days it probably does not indicate anything wrong. JB

Many thanks for getting back.

Julie

Just to keep you updated after my injections on the 14 October.
My red hot cheeks only lasted the three days as you said and I felt fine after that. I have had no problems since then so all going well at the moment.
Many Thanks
Julie

Hi Dr Bland

Just to keep you updated, I have been getting pins and needles now and again but my left thumb has been in constant pain sometimes right up to my shoulder. I had my third injection last October, please can you advise what I should do now.

Many Thanks

Julie

I think the first challenge is to figure out whether the thumb pain is part of the CTS or whether that is a different problem. Arthritis at the thumb base is quite common. Was the thumb pain element of the symptoms affected by the earlier injections? If so then it is perhaps time to be thinking about surgery on the left side as that one was worse last time we tested.  Also, have you read the notes for Ashford patients? JB

After having the last injection last October both my hands were ok up till the last few weeks. I had previously had the same symptoms in my thumbs and wrist and after each injection the pain disappeared. I feel I would like to have the operation on the left hand now instead of any more injections.
Do I need to go to my GP at Kingsnorth first for a referral to yourself, I would rather have it done in Canterbury as I have had all the previous tests there and having suffered with the injection previously carried out by the local GP at Kingsnorth.

Many Thanks

Julie

I can arrange surgery for you if the Ashford CCG will let me. We might do this either in the hospitals at Ashford or Canterbury or in primary care in Herne Bay. This is a bit of a test case for Ashford CCG's new arrangements so it would probably be wise to discuss it with your surgery and see what they have been told about who they can refer to. JB

Many Thanks I will ring the surgery tomorrow and let you know the outcome.

Julie

Have just spoken to my Doctor at local surgery, she is going to find out from the Doctor there (who deals with the CT) about the CCG and will ring me next week with the outcome.

Many Thanks

Julie

Thanks. We have been able to find out very little about the doctor who has offered to provide a CTS service for Ashford. It is said that he already runs a similar service in Maidstone but this service seems to have no public presence and all we have been able to find out about the doctor is his basic registration qualifications. JB

I have just received a call from my Surgery and have been told that a Mr. Wetherall will do the surgey on my hand and I will receive a letter within the month.

Julie

That's yet another variation. Mr Wetherall I know very well as he is the hand surgeon at the William Harvey Hospital. I could have sent you to him in any case if the CCG were going to permit that. We have still not heard anything further about the proposed 'new CTS pathway for Ashford and the GP who is apparently to provide surgery but obviously they are not sending you that way, at least at present. Have they said where you are likely to go for surgery - Mr W has operating lists in several places. JB

No I suppose I won't know anything until I receive the letter in the next 4 weeks. I will get back to you and let you know when I receive it.

Many Thanks

Julie

I will be interested to see what surgery date you end up with. If I had arranged it, it is likely that you would have had surgery between 3 and 8 weeks from now. One of the reasons put forward for the change in care pathway in Ashford is to shorten waits. JB

Hi Dr Bland

Finally got a letter through, bit confused as I have an appointment at Hayley Smith's outpatient clinic at Canberbury Hospital on Monday 7th April. Not sure if this is for my op on my left hand and thought I was having to go to Ashford now.
Regards

Julie

That will be an out-patient appointment where they will almost certainly decide that you are suitable for surgery and then add you to the William Harvey Hospital waiting list for the operation (though they ay also offer to do it elsewhere). The hospital amdminstration, once they had a referral from your GP would then have put you in whatever clinic offered the earliest option I think. Hayley is a hand therapist who works with the orthopaedic surgeons. Keep me posted please - if I don't hear from patients then I don't get much of an idea what is going on to refer to when I'm talking to the next patient. JB

Hi Dr Bland
Had my appointment today with Hayley. She is putting me forward for surgery on my left hand, apparently there is a long waiting list with 2 surgeons but a shorter list with somebody under Dr Wetherall so I have gone with that one. I have to wait for a phone call now.
Also a lot of the pain I have been having in my thumb and arm is apparently dequervains disease for which she is sending me for hand therapy at William Harvey.
Regards
Julie

I'm sorry it has been so disorganised. My arrangements for treating CTS were very efficient until Ashford CCG decided that they could come up with a better scheme. Had I simply arranged surgery for you under the old arrangements it would have been done by now. Please let me know what date you end up with.

DeQuervain's tenosynovitis is certainly a plausible explanation for thumb pain, usually radiating up the forearm in line with the thumb. That too responds to steroid injection and surgery but it is a separate problem from CTS. I hope they are successful in treating it. JB

Thank you for your reply, I will let you know as soon as I get a date.

Many Thanks
Julie

Hi Dr Bland

Just received my letter for surgery on left hand, The constultant is Mr P Housden and will be on 12th June at Kent and & Canterbury Hospital.
Regards

Julie

Thanks for letting me know. Mr H is a pretty good surgeon and you should get a good result - though it will be interesting to see if he does it himself or not. JB

Hi Dr Bland

I had my phone call from the Hospital this morning re questions on my health etc before my surgery on 12th June. They still think it is my left hand, have you heard from Mr H yet?

Many Thanks

Julie

I haven't heard anything back from Mr H though I did copy my report of 13th May to him - on the other hand I have been away at a conference in Vienna for a week and my first day back in the office in Canterbury is tomorrow so I don't know what is waiting in the in-tray there. Hopefully you told them during the pre-op assessment that it is now the right hand which is worse? JB

Yes I did say that the right hand was worse and they told me to mention it on the day of the op to Mr H.

Many Thanks

Julie

Hi Dr Bland

Just to let you know that I had surgery on my right hand last Thursday by Dr Singh and his team, who were excellent. I'm due to have stitches out on the 26th June. Just have some swelling and pins and needles in my thumb at moment.

Regards

Julie

Very good. I'm glad we managed to get there eventually, though the administration was a little byzantine. I would appreciate being told how it is three months after surgery if you rremember. JB

Hi Dr Bland
It has been just over 3 months since my surgery on my right hand. I had my check up a few weeks ago at the Hospital, the scar is healing very well, I do have a lot of scar tissue in the form of a lump on the side of my scar which has been causing me a lot of pain but the Consultant has advised me to use E45 cream and to keep massaging it in and it would take a bit longer to heal.

I am still experiencing pain in my thumb and wrist , shooting pains, not sure if this is to do with the CTS but I do have it in my left hand as well. I do get pins and needles in the left hand still but not so bad as it was before.

Regards

Julie

That lumpy tenderness around the scar is quite common. The shooting pian in the the thumb and wrist are harder to assess but could still be connected with the CTS. Do we know which surgeon actually carried out the operation? Have they discharged you now or are they reviewing you again? If it remains a problem we can see you again but I don't want to tread on the surgeons toes. JB