please help

Another difficult case. I'm not surprised they had a hard time ariving at a diagnosis because those are certainly rather atypical symptoms for CTS and I note that your questionnaire score here, assuming it was answered for the symptoms as they were before surgery, is very low. Those NCS results are a little hard to figure out, especially without knowing the normal ranges for that lab, but probably only indicate grade 1 or maybe grade 2 CTS on the right and perhaps grade 1 on the left. The MRI seems to show a significant difference between the sides but again is hard to interpret for certain without knowing where those measurements were taken and the normal range for that unit.

The things I find a little difficult to get a handle on from the description so far are firstly the quality of response to injection - does 'a little bit' - mean significant relief of symptoms or is it really a matter of a questionable response to steroids (I don't suppose we know the dose and steroid used do we?). Secondly it's not altogether clear to me whether the original symptoms have changed at all in response to surgery. It sounds as though the allodynia has perhaps improved somewhat but are the pains now worse/better, different in character/location compared to pre-operatively?

Overall I think one would wonder if the mild imaging and neurophysiological evidence of CTS might have been a red-herring and the median nerve not the main culprit for these symptoms but you were obviously in a very difficult position before surgery having been quite comprehensively investigated without anything other than the median neuropathy coming to light. The response to injection is a moderately reliable indicator of what you can expect from surgery so a poor short term benefit from injection, especially in the presence of mild to moderate NCS changes, always makes me more cautious about predicting successful operation, though I can't put precise figures to this yet (we are working on it). It would certainly be a good idea to get the NCS and imaging repeated now to see if the surgery has made a difference to the physiology and anatomy - if the measurable median nerve changes have improved with surgery then I think one can be confident that the operation has been a technical success and you can start searching again for other explanations for the symptoms. JB

Thank you for your reply. My NCS was read as mild CTS. I had 2 CS injections done- in May and August, both triamcinolone 20 mg per wrist. First dose caused more pain for a week followed by only marginal relief; increased wrist flexibility. Second dose caused more pain for a week then provided more relief for maybe a month. Hands hurt less temporarily. NSAIDs didn't help. I didn't tolerate gabapentin very well. Tried lidocaine cream, camphor/menthol cream, etc. Nothing really helped the pain. I sought chiropractic and acupuncture help as well. I was told I most likely have CTS with atypical presentation and very sensitive nerves. My hands were totally normal before. The pain was severely affecting my QOL and eventually did the sg..

Post sg, i am using my hands less than before sg so that may affect comparison between pre and post sg. I dont have shooting or burning pain. My R hand feels different after the sg; all fingers but pinky tingle when coming from cold temp outside to warm inside, whereas they wouldn't before sg ( L hand doesn't get this way). That has become less so farther out from sg. Just prior to sg i could use mouse longer than 3 min before pain and didnt have the shocklike sensation at R index fingertip when pushing a button (although in May when pain was worst it was that way too but with burning and shooting, tingling when gripping pen). Textures do feel more normal post sg and notice a diff between L and R fingers with R feeling more normal than L when touching diff textures. My arms and wrists are small.. Maybe it is the swelling or scar tissue at the palm/wrist that could be causing my current Sx? Or maybe nerve reinnervation or peripheral sprouting?

Which imaging test would be better - ultrasound or MRI?

Thank you so much

It is altogether a rather odd story. My best guess would be that both median nerve compression at the wrist and something else were both contributing to the overall clinical presentation and that alleviating the pressure on the nerve at the wrist is responsible for what sounds to me like some improvement in sensory symptoms in the median nerve territory. I think it is therefore likely that repeat investigation will show an improvement in median conduction but it would be nice to confirm it. My preference for imaging would be for ultrasound but it depends on the availability of local expertise and in your case we have pre-operative MRI for comparison so I think one would want to stick with the same modality. I am afraid I have no very intelligent suggestions as to what other problem may also be present or whether scarring around the operation site is excessive and potentially a problem - I think these are things which really require that you can see and examine the patient with access to all the current investigations - not something that can be done on the web. Your neurologist is probably the person in the best position to pursue it further. I would be fascinated to hear the outcome if a solution is found. JB

The surgeon thinks the imaging won't show the cause of my Sx (of shocklike sensation of index fingertip sometimes when pushing a button) nor change post op course so the surgeon did not order it. Is it too soon to expect complete normal sensation at ~6 weeks post op? Is it normal to have these sensations at this point? If my Sx continue or worsen in the following weeks/months, I'll probably seek someone who would be willing to order it. At the very least i could get some peace of mind if the inside of my wrist showed technical sg success/normalcy as you had written and can then look for a diff cause.

I wish my case were more typical. It's been a painful challenge. Thank you for reading and all your input.

Your surgeon is right that MRI is unlikely to provide an explanation for the index fingertip thing but it will help to confirm that the transverse carpal ligament has been adequately sectioned. It is probably more important to get the NCS repeated as these should definitely not show deterioration at this point - if they do then that is a bit of a red flag.

Most patients with mild to moderate CTS who have surgery report complete resolution of the CTS symptoms very soon after the operation, often by the day after, so it is not by any means too soon to expect improvement, but on the other hand your symptoms were atypical to start off with.

The pressure sensitivity of the index fingertip is a really odd symptom. It is possible that it might be telling you about a genuine problem in the fingertip but you didn't have it before surgery and I think one should be trying to think of a mechanism that might be linked to the carpal tunnel or the operation. The only thing that occurs to me is that, when you apply pressure to the pulp of the fingertip, as in pressing a button, you are probably loading the flexor tendons and they will be jostling for position in what is left of your carpal tunnel. If you watch this process live on ultrasound you can see just how mobile the nerve and tendons are and how they slip round each other and re-arrange themselves during movement of the wrist and fingers. One could guess that, if you have a very mechanically sensitive median nerve, such movements might trigger signals in the nerve which would be interpreted as 'shock like' though the radiation of that directly back to the index finger is harder to explain. That's all very speculative however and I can't think of any way of proving or disproving the idea. If you were my patient I would be wanting to look at it with the ultrasound scanner out of curiosity, looking to see whether there was any sudden change in the arrangement of the nerve and tendons when you get the shock like sensation, but I guess from hints in your postings that you are probably on the other side of the Atlantic. I have the relative luxury here of being able to do things like that without worrying too much about who is going to pay for them. Good luck with finding a solution. JB

Yes, I've been told that my nerve is very sensitive by a hand doc. So far the index fingertip is the only finger that gets that electric sensation when I use it to push a button. It'll happen at first push, then stops if i push again a few more times right after. Wait several minutes later, then same sensation at first push again.

Could a follow up NCS have any adverse effects or make hand symptoms worse? Could it lead to RSD/complex regional pain syndrome? Someone warned against getting a repeat NCS stating that my body may react against it (esp since I had finger allodynia but not currently) and I'm not sure what to believe.

There is no documented evidence of nerve conduction studies causing any ill effects of any kind after the procedure. The idea of 'body reacting against it' is nonsense. JB

Ultrasound done and interpreted to me by a different hand surgeon. I was happy to find one who does ultrasounds. R wrist: median nerve down to 7mm2, surgery was technical success, transverse ligament re-growing but looser, no significant scarring. My R hand does feel much better than before. The electric shocklike sensations are less intense and less frequent than before. He said that it should improve in time and to keep my hands warm, hydroxy vit D liquid, Co-Q10 liquid, and vit C before and after surgery. Currently, L hand tingles and hurts while R hand continues to feel better. L wrist ultrasound: median nerve enlarged at 12mm2 and bifid. What has your experience been with bifid median nerves? Would endoscopic method of surgery be ok?

Hopefully you found the ultrasound interesting, they really are extraordinary images now. It sounds as though, as we thought, there are no particular problems with the original surgery and I'm glad it's starting to improve. I'm still not entirely convinced that you had only CTS and nothing else though. The left hand bifid nerve is quite a common finding (about 5-8% depending on who you talk to) usually, but not always, in both hands when you see it and quite often accompanied by an extra artery running through the carpal tunnel. The ultrasound community hasn't finally agreed on how to measure bifid nerves yet. I think most of us measure the two branches separately and add them together to get an area measurement. 12mm2 is slightly large by most people's standards but upper limits of normal do vary depending on the scanner, transducer and user. Some surgeons would be wary of endoscopic surgery in the presence of any anatomical variation from a 'standard issue normal' wrist but you would have to ask the individual surgeon what their policy was of course. Remember that much endoscopic surgery is done without any pre-operative imaging anyway. JB