surgery for older patients

As you have registered on the website yourself I have no way of identifying for sure which patient we are talking about. You will have to give me a clue - you should find our identification number on the appointment letter if you still have that. JB

I'm afraid I haven't got the letter with me. I asked my father and the number he found is (edited out by JB). I hope this makes sense. I live near Brighton, and you told us that your daughter is at Uni in Brighton.

That's the right number. I know who we are talking about now. To try and answer the original questions more or less in order.

Success rates of surgeons are difficult. In the case of carpal tunnel syndrome it depends on what one counts as success - some surgeons would count stopping it getting any worse as a 'success'. When I am looking at outcomes of surgery I tend to to take the top two categories of my simple outcome scale as 'success' ie complete cure or marked improvement such that any residual symptoms are not a nuisance do not require treatment. Using that criterion the average success rate of surgery in East Kent is about 76%. We do not have accurate figures for most of the individual surgeons. It is surprisingly hard to track down who actually did a minor procedure like CTS - it is often not the consultant who is nominally responsible for the patient and very few patients seem to take note of who the surgeon was curiously. I do not have absolute control over who will do your father's operation as we are somewhat at the mercy of the hospital waiting list managers who sometimes re-allocate patients but it is most likely to be a man called Michael Nicholas - that is certainly who we are trying for at any rate. We think his success rate is probably better than the average but it hasn't been measured at 2 year follow up using my outcome scales yet in a significant number of patients for me to be able to quote a precise figure. There is at present only one surgeon for whom I can quote a precise figure and he is booked up until the end of January.

Outcomes of carpal tunnel surgery do get slightly worse with age (as for most things) but the severity of the CTS is a much more important factor in the prognosis. At present he has a grade 5 CTS and about a 70% chance of good result (without taking surgeon into account). If it advances to grade 6 then the chance of a good result falls to less than 50%. Recovery time from surgery is not likely to be greatly different, but improvement in the CTS symptoms after surgery is often slower for grade 5 than for lower grades.

Finally, it is very hard to put myself exactly in the patient's shoes, if I had CTS myself then I would be in the unusual position of being able to test it daily if I wanted to and I would be unable to resist the temptation to use myself as an experimental subject and see what happened to the nerve conduction studies and ultrasound imaging as we tried out various interventions. All I can really say here is that surgery looks to me like the best bet for a medically fairly fit 92 year old with a grade 5 CTS. Ultimately however it is his hand, not mine, and he has to decide what he thinks of the various possible outcomes and their relative likelihoods. I am hoping that eventually we can provide a personalised prognostic calcluator here on the website which will give individualised risks of good and bad results for each treatment taking into account age and other factors but I'm afraid we are still working on that so the figures I have given above, and the slightly extended version of them which you will find in the section of the site on surgical prognosis, are what we have to go on.

I'll remove the reference number from your last message now so that it is not public. JB

Thank you very much for that. It will be very helpful.

Hello Dr Bland
My father has definitely decided to go ahead with the surgery on his right hand, and we were wondering if he should have it done privately. Are you able to refer him to someone for the procedure, or do we have to go back to the GP? At the age of 92, he would like it to be done as soon as possible! Thank you.

Whether I can make a referral depends on administrative and financial issues. If you are contemplating an insurance funded private operation then the terms of some health insurance policies demand that the primary referral comes from the GP. If you are involved in an insurance scheme like that then it requires further assistance from the GP. With other insurance schemes or if self-funding I can just make a referral. It may or may not be quicker privately. Have the waiting list office in Margate come up with a date yet? There is also a possibility that I might have a space in Herne Bay on 7th December as one patient did not turn up for pre-op assessment this Saturday just gone and may therefore have decided not to pursue surgery - I stil lhave to try and contact them to see what happened. JB

Thank you for your reply. My father does not have medical insurance so he would be self funding. He has not had any communication with Margate as of today, (26th). The 7th December would be a possibility if that appointment remains available, but otherwise do you think you could arrange for the operation to be done privately by whoever you think is the best surgeon. Is it possible to find out if it would be quicker than waiting for the NHS? Thank you again.

I'll make some enquiries and let you know. JB

That would be great, thank you.

My father has today been offered, and accepted, an appointment at Margate on 13th December at 12.30, so thank you for all your trouble; he is now sorted! There is only one other thing - do you know who it is who will do the procedure at Margate on that day?

I don't know for sure but short notice carpal tunnel slots are often with Michael Nicholas/Andrew Smith. We can find out for sure on Monday. JB

Hello Dr Bland
My father had his surgery on 13th December at Canterbury. At first, there was little pain or discomfort, but now his thumb is quite painful. It is badly bruised and looks black and it is also swollen at the base. He can't touch all the tips of his fingers with the thumb any more. Yesterday he went to his GP who removed the bandage and looked at it, and said there is no evidence of infection. Is this reaction normal?

Sounds like there might have been a bit of post-operative bleeding which would account for both bruising and swelling. If that is the explanation then it should slowly settle over a week or two. If his GP is happy that it doesn't look infected (ie not hot at the site and he's not running a temperature or getting cellulitis spreading up the arm) then I would carry on with just simple analgesia until next week. If it seems to be getting worse rather than better over the next few days I can squeeze him in on Monday or Tuesday to take a look at it. JB

That is good to know. I asked him today what it is like, and he thinks it is no worse. He can touch 3 finger tips with his thumb, whereas yesterday he could touch 2, so I am hopeful that there is some improvement. The practice nurse at his GP surgery is going to check him out tomorrow. If necessary, can I contact you on Sunday or is that too late? I hope by then it will be clear if it is getting better or not. BT

You can contact me through the website here as much as you like and whenver you like. Sunday is fine. JB

It is 6 weeks since the surgery, and my father went to Margate to see Michael Nicholas (who operated) for the follow up appointment. Just a sort of evaluation of the procedure - the feeling has not come back to the fingers and thumb, but the pins-and-needles effect is less bad and he is not so aware of the problem at night. i.e. pain is less. The wound has healed well. So all in all, not a massive improvement or cure, but better than it was. And maybe it will stop it getting to a Level6 degree of severity? Thank you for your care.

That's probably about par for the course at this stage and starting out from grade 5. I would expect further slow improvement over the next 1-2 years, though I would not be surprised if some impairment of sensation peristed permanently. JB