4 weeks post bilateral open carpal tunnel release

chaconne68
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Before surgery on both hands simultaneously 4 weeks ago I had intermittent numbness and tingling in both hands, most often occurring when playing the violin. I am a serious amateur violinist, practicing 1-3 hours a day. I began wearing splints at night about 6 years ago and that was a satisfactory solution to the problem of being awakened by sausage fingers, numbness, and tingling. In addition to the splints, I tried chiropractic treatment and two kind of therapeutic massage. These latter treatments seemed to have no effect. On the basis of nerve conduction tests and EMG, I was told in May 2013 I had mild to moderate CTS in left hand and moderate CTS in right hand. Weakness in thenar muscles both right and left was also noted. After the surgery my thumb, index, middle finger, and half of ring finger have been numb and I feel constant pins and needles. My surgeon is dismayed and says he has never seen this result He feels the surgery went well, he completely released the ligament and he is sure the local anesthetic, administered when I was wide awake, went where it was supposed to go. He says his colleagues have seen this poor outcome very rarely.

I am doing tendon gliding, decompression, and desensitization exercises and seeing an occupational therapist twice a week. Repeat testing of sensation using monofilaments indicates some small improvement in the ability to detect light touch, consistent with my impressions of my very slightly improved ability to do tasks of daily living.

I cannot seem to get any answers here as to what likes ahead. Will I ever have the sensitivity restored so that I can play violin again? Is there some way to get my nerves, which seem all "riled up" for lack of a better term, to calm down so I can get to sleep?

jeremydpbland
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Your surgeon's comment that he has never seen this result is interesting. It reflects the fact that poor outcomes from carpal tunnel surgery are fairly infrequent so if he has not done a lot of carpal tunnel surgery (or not followed up all of his patients religiously) he may well not have come across a case like this. As you will see from other comments in this forum however there are plenty of people around who do not get the desired for result from surgery and sometimes it is possible to work out why, and even do something about it. Personally I think that simultaneous bilateral carpal tunnel surgery is unwise but I note that you describe the persisting symptoms in the singular - do you have the same problem now with both hands or only with one?

The way to start figuring this out is to get your nerve conduction studies repeated to see how they have changed. There is no adequate evidence base to say exactly when this should be done but when I have the option I would get another set done at 6 weeks post-operatively in cases where the symptoms are the same as or worse than before surgery. Ultrasound imaging can also be useful if you happen to be near someone who has the requisite experience in assessing CTS (I am afraid there are very few in the UK). JB

chaconne68
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Thanks for your response. The surgeon, per my online research, had a lot of experience. Yes I do see from this forum that poor outcomes are not as rare as I was led to believe. My sense is that my surgeon sees his patients back at 9 days to remove sutures and after that only if there is a problem.

I have identical patterns of numbness and tingling in both hands. The only good thing about having both hands operated on at once is that it seems, as my surgeon and I agree, highly unlikely that if it was a surgical error of some kind that he would have made the same error on both hands. I made this decision because I had symptoms in both hands and I need both hands to be well min order to play violin. If I recover, this will turn out to be an OK decision, but if this is permanent of course I would prefer to have one hand that works as well as it did before surgery!

I will follow up with repeat EMG testing--there should be no problem getting insurance to pay for this. I'll also research whether anyone around here has the skills to do ultrasound assessment of CTS.

Do you have any experience or opinion on using the drug Neurontin or Gabbapentin for numbness and tingling? I have several friends who have used this for various neurological issues such as Guillain-Barre syndrome. I am thinking about getting a consultation with a neurologist and asking about this option. I think this is a pretty heavy-duty drug with potential side effects. It is used here for seizure disorders among other things.

jeremydpbland
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That type of surgical follow up - just as far as taking the stitches out - is quite common. I have a suspicion that patients who are unhappy with the result of their surgery tend to be a bit reluctant to go back to the original surgeon and a sort of self censorship may conceal some bad results from the surgeons, but I could be completely wrong as there is no real way to test whether this is happening - it's just not that uncommon to hear people say 'I'm not going back to Dr X again!'.

The 'same error on two sides' argument is interesting and seems valid but I saw a patient today who made me wonder a little about this. This patient had one hand operated on some years ago, did not benefit, and had to have the surgery repeated/extended, after which symptoms improved. He then presented with the other hand and has had that one operated by a different surgeon... with the same unsatisfactory result. I wonder if there is not something different about the anatomy of this patient which makes the 'ordinary' operation fail. If for example the site of maximum pressure on the nerve is actually a couple of centimetres further up the arm in some patients, the usual incision would not expose this and one could easily imagine that an anatomical variation present on one side could also be present in the other hand of the same patient. This is pure speculation but note that there are a couple of patients in the forum with similar bilateral bad results.

Bilateral operations - sometimes when you do the first one the second hand improves anyway... and there is nothing like having one hand done to give you the perfect background for deciding whether you really want to go ahead with the other hand - so my preference remains very much for one hand at a time.

The best way to look for people who are good at ultrasound for CTS is probably to check for those who are publishing papers on CTS ultrasound. The International Society for Peripheral Neuromuscular Imaging currently attracts about 150-200 people to meetings so this is a fairly esoteric interest.

Gabapentin is widely used for neuropathic pain, as are antidepressants, other anti-epileptics and topical local anaesthetics. It seems to me to have a fairly acceptable side effect profile but it doesn't work for everyone and there are a couple of trials for pain in CTS (before surgery) which suggest that it is no more effective than placebo. I don't think anyone has looked at its effect on tingling (paraesthesiae) and one would not expect it to improve numbness.

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

I am now almost 8 weeks post bilateral CTR. Friday 8-16 I had repeat ncs and EMG by a neurologist who is also a friend of mine. His findings were so alarming that I was convinced my hands were not going to get better just with the passage of time. I got his report faxed to the surgeon and the upshot was I had an ultrasound today which clearly showed nerve compression upstream of the incision, just as you were speculating in your previous post. So much for my surgeon being "100%" certain he attained a complete release. And the anatomy was the same in both wrists. The surgeon joined me and the ultrasound physician in looking at the images. I am sure it was hard for him to have to admit his error. So now I am scheduled for repeat bilateral surgery on 8-21. What a waste of 2 months of my life! If only the surgeon had not been so confident of the full release, he might have requested the ultrasound 6 weeks ago and if he had I would likely be well on my way to recovery by now.

I do not know quite what to expect going forward. The neurologist says the nerve is damaged and won't recover--it will have to regrow from the point of entrapment. I have been told nerves regrow at a rate of 1/2 to 1 inch per month, so it may be 6-10 months before the tips of my fingers have normal sensation again, if they ever do. If you are aware of any data that would help predict the course of my recovery, I would appreciate it. I do have some sensation in the carpal tunnel fingers--I can feel hot/cold, pain, and pressure, just not light touch. So maybe I won't have to wait for the nerve to regrow???

I am grateful to you for this forum. Without your input I would not have insisted upon repeat EMG after 6 weeks (instead of the 3 months the surgeon was suggesting), and would not have known about ultrasound as a diagnostic tool.

You perform a wonderful service. I''ll post when I have some new information.

jeremydpbland
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Thankyou for the update. It's very satisfying for me when my speculations here on the web are followed up and reported on but I wonder how many times I am completely wrong and people never come back to say so. To make any comment about the prospects for recovery I would have to see the pre and post surgery nerve conduction results. I do have some figures for the success rate of revision surgery - about 20% of people report themselves completely cured and about 50% overall are satisfied with the results such that they are not significantly impaired in daily life. 12% report being worse still after the second operation. Those results should be better however for a case in which there is definitely a bit of missed transverse carpal ligament to divide and where re-operation is performed promptly. I've just added some data about the value of steroid injection as a predictor of response to re-operation to the failed surgery page here which is interesting (though not statistically significant in a small study). In your case the second operation is going to be so soon there would be no time to play about with steroids anyway. You seem to have a pretty good service overall from your doctors. JB

chaconne68
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I have pre and post surgery ncs and EMG results. 5-16-13 findings: Left Median Motor Nerve showed prolonged distal onset latency. R Median Motor Nerve showed same and decreased conduction velocity (Elbow-Wrist) Left Median/Radial Dig 1 Comparison and the Right Median/Radial Dig 1 Comparison nerves showed no response (Median).The Left Median/Ulnar Dig IV Comparison and the Right Median/Ulnar Dig IV Comparison nerves showed no response (Median Wr) and prolonged distal peak latency (Ulnar Wr). The Left Median/Ulnar Palm comparison and the Right Median/Ulnar Palm Comparison nerves showed prolonged distal peak latency (Median Palm) and abnormal peak latency difference (Median Palm-Ulnar Palm). All remaining nerves and all left vs. right differences WNL. Impression Mild to moderate bilat CTS affecting sensory and motor components. This is primarily a demyelinating process for the motor component. Median sensory nerves are absent bilaterally. Mild slowing of bilat ulnar sensory nerves conduction latencies but only when testing the 4th digit. This isolated finding is of unclear significance given the normal palmar studies. Would recommend continued observation for any appropriate clinical symptoms. No evidence of any other focal nerve entrapment, cervical radiculopathy or generalized peripheral neuropathy in either upper limb.

Numbers from nerve conduction studies are in a chart with headings Site L Lat (ms) R Lat (ms) L Amp (mV) R Amp (mV) L-R Amp (%) Site 1 Site 2 L Vel (m/s) R Vel (m/s) L-R Vel (m/s)

Median Motor (Abd Poll Brev)

Reading across
Wrist 5.1 5.8 0.7 10.2 7.6 25.5 Elbow Wrist 54 49 5
Elbow 9.2 10.3 1.1 9.6 7.0 27.1 Axilla Elbow
Axilla 13.8

Ulnar Motor (Abd Dig Minimi)
Wrist 3.3 3.4 0.1 12.8 11.9 7.0 B Elbow Wrist 55 51 4
B Elbow 7.3 7.5 0.2 12.5 10.3 17.6 A Elbow B Elbow 56 47 9
A Elbow 8.9 9.4 0.5 12.4 11.3 8.9

Second Chart Comparison Left/Right Comparison with headings Site L Lat (ms) R Lat (ms) L-R Lat (ms) L Amp (uV) R Amp (uV) L-R Amp (%)
Reading Across
Median/Radial Dig 1 Comparison (Digit 1-10 cm)
Median (no entries)
Radial 2.3 2.4 0.1 7.8 14.2 45.1
Median/Ulnar Dig IV Comparison (Digit IV 4-14 cm)
Median Wr (no entries)
Ulnar Wr 3.4 3.8 0.4 26.9 21.1 21.6
Median/Ulnar Palm Comparison (Wrist-8 cm)
Median Palm 3.3 3.8 0.5 23.6 15.4 34.7
Ulnar Palm 2.5 2.3 0.2 14.4 33.6 57.1

I had second surgery 8-21-13 and am still numb and tingling and typing with big bandages. I will take a break and come back later to type in the post (first) surgery ncs and EMG results of 8-16-13. I am missing one page of the May ncs and EMG, will look for it.

jeremydpbland
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That's bilateral grade 4/6 CTS before the first operation (I think it's much easier to grasp as a grade like that - but then I would wouldn't I!). It should have felt significantly better immediately after surgery but given the severity of sensory nerve involvement one might expect relatively slow improvement in the loss of sensation element of the symptoms. Clearly your post-surgical experience was not like that.  JB

chaconne68
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Results 8/16/13
Comments "A focused exam shows weakness of thumb abduction bilaterally. It is difficult to assess opposition because she invokes thumb flexors to do so. Other intrinsic muscles show 5/5 power.
Motor Nerve Study
Median Nerve
Rec Site: APB Lat (ms) Norm Lat Amp (mV) Norm Amp Dist (mm) C.V.(m/s)
Stim Site L R L R L R L R
Wrist 10.6 5.1 <4.5 .233 .333 >3.8
Elbow 15.2 10.5 .167 .133 234 243 51.1 44.9

Right Ulnar Nerve
Rec Site ADM
Stim Site
Wrist 4.3 <4.2 9.2 >7.9
B.Elbow 8.1 8.3 217 57.9
A.Elbow 9.8 8.0 94 53.7

Sensory Nerve Study
Med/Uln 8-cm Nerve
Stim Site: Palm
Rec Site
Med'n Wrist NR NR
Uln Wrist 2.2 2.5

Med IV (14) NR NR
Uln IV (14) 3.7 3.9 20.0 17.0

EMG Study
Name Ins Act Fibs PSW Fascics MU AmpMU Dur Config Recruit

R. Dors.Int.1 norm none none none norm norm, norm, norm
R. Abd.Pol.Br. decr 4+ 3+ none nil
L.Dors.Int.1 norm 3+ 2+ none norm norm norm norm
L .Abd. Pol.Br. decr 3+ 2+ none norm norm norm <1/2

Summary/Interpretation
1. Bilateral distal median neuropathy, likely CTS, is now categorized as SEVERE-TO-EXTREME, clearly much worse than when tested by Dr.K in mid-May when there were no signs of MOTOR axon loss. Currently, signs of axon loss are severe (needle EMG abnormalities in the APB muscles, and very low thenar motor evoked responses). Signs of SENSORY axon loss were present previously and persist (unrecordable antidromic median sensoryresponses). (I note that Dr. K found sensory orthodromic responses to be robust. This, in presence of absent antidromic responses would be unique to my experience, and remains a puzzle.)
2. In contrast, the ulnar motor NCV and distal sensory studies are normal,...

This Dr. goes on to suggest a return to clinic ASAP.
There is a ncs Motor Summary Table from the May testing that I can type in if it would shed any additional light on my situation.

Thanks so much--

jeremydpbland
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No need for the motor summary from May. The second set of studies show bilateral grade 5 CTS, so one grade worse than before surgery, and in fact they are very close to grade 6 with the needle EMG results suggesting that a lot of the motor nerve fibres have now broken. This pattern of change in the NCS results after surgery is very suggestive of incomplete section of the transverse carpal ligament, even without the ultrasound findings.

I note the second doctor's comment on the contrast between the antidromic and orthodromic median nerve sensory studies in the first tests. In the antidromic study the nerve is stimulated at the wrist and the recording made at the finger and this was unrecordable. In the orthodromic study the nerve is stimulated at the palm and recorded at the wrist and this was reported as showing a 24 microV signal in the left hand and 14 microV in the right hand. This is indeed odd. As these are both tests of median nerve fibres they should give similar results - indeed the orthodromic study should be more sensitive to CTS in theory. What may have been going on is that the orthodromic recording may actually have been picking up signals carried in the motor fibres and perhaps also in the palmar cutaneous branch of the median nerve which passes outside the carpal tunnel. The orthodromic test is not usually necesary in severe CTS as the problem is obvious from the initial motor study and the wrist to finger recording so most of us would not then go on to do the palm to wrist recording. I might try this out if we get a severe CTS case this week to see if we can figure out whether my theory is correct.

In terms of the outlook for recovery I am afraid I cannot be very optimistic and I think there is a relatively low (though not zero) chance that you will regain completely normal sensation in the median innervated fingers - which is probably what matters most to you for the violin. The power in flexion of the left hand fingers which you require for the fingerboard should be unaffected. I might also add that I know a seriously good traditional fiddler who continues to play with undiminished virtuosity with quite severe CTS. Recovery will certainly be slow, and rather than quote a figure of x mm per day for regrowth I would prefer to say that you are unlikely to have reached an end stage in terms of recovery for about 2 years after the second operation. In general nerve regrowth is better the younger you are and the fewer complicating factors such as diabetes you have so you can be a bit more optimistic if you are 30 and healthy than if you are 70 and diabetic. There certainly should be some recovery from the current state however - does it feel as though there has been any change in symptoms in the first few days after the second operation?

You have documented the story so well on the forum here that your case could be included in a study of the outcome of second operations for CTS so please let me know how it progresses. There are so few cases available in the literature with this quality of data (especially bilateral failures) that every new one is a valuable addition to the evidence. If the doctor who did the ultrasound is willing to share the images that would also be very useful - though it does usually mean a bit of work with photoshop to make them anonymous. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

Thank you for this response and for letting me know what the recovery timeline might be. I will see what I can do about getting the ultrasound images to you. I would like to think that some good can come of all this.

As to how I feel 4 days post second surgery: I think it is possible that there is less intense tingling, although the numbness persists. It's a bit hard to tell because I haven't been doing much with my hands, and the more I do, the more intense the tingling is.

It is interesting to me that after the first surgery I had very intense pain once the local anesthetic wore off--but it was everywhere except at the incision site, where I expected it to be. So--pain especially at the base of the thumb, the fingers, the palm out beyond the incision. I can't help thinking that this pain had to do with the second area of compression of the nerve--more severe than the area they had released. I think of it as my nerves dying. This pain abruptly subsided at the end of the second day after surgery, and I needed no more painkillers. I told the surgeon about it at the time but it didn't seem to register with him. More recently, once the upstream compression was discovered, I mentioned this pain pattern again and asked if it could be related to the new compression and he agreed it probably was. So--I would wish that surgeons and clinicians would form the habit of really listening to the patient, especially when things are not going as expected. This time the post-surgical pain is just at the incision site. It's very manageable and I have been off narcotic pain meds since the end of the second day and off acetaminophen since the end of the third day.

I am 68 and non-diabetic. I'm glad to hear about that fiddler. That style of play looks like a lot of fun and maybe less demanding of the very subtle control you need for bowing in the classical style.

I will certainly keep you posted as to how my recovery goes.

You've been a real lifeline. Again, thank you.

jeremydpbland
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I think severe pain in the immediate aftermath of surgery should always be of concern. Most patients having carpal tunnel surgery require no more than paracetamol/ibuprofen for pain relief.

One other thing you reported very elegantly in an earlier message was the different types of sensation which were affected/unaffected. You may already know this but the types of sensation which were preserved were mostly those served by small unmyelinated and thinly myelinated fibres. Such thin nerve fibres are not affected in the same way by pressure as the thick myelinated fibres which carry light touch and which we tend to measure the function of with NCS.

Good luck with recovery. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

Thanks for the explanation of the function of various types of fibers. I did not know that. Makes sense.

Chaconne68

chaconne68
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Saw surgeon today. He reported my responses to monofilament testing: consistent response to 300 and inconsistent but definitely improved responses to 4. He did not expect improvement so soon after surgery.

jeremydpbland
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You can get quick responses to decompression when part of the sensory loss is caused by conduction block in structurally intact nerve fibres rather than actual interruption of the axons themselves. Any progress is encouraging I think but I tend to place most faith in what the patient thinks about the symptoms rather than formal sensory testing. JB 

chaconne68
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I am now about 6 weeks post second surgery. This week my OT repeated monofilament testing and found what he believes is reliable improvement in sensitivity of the thumbs and the area at the base of the fingers, extending up to about the first knuckle. Coupled with this I think I have less tingling in the thumbs and improved sensitivity based on an object ID task I've been doing. Just seems like my thumbs are delivering more light touch info than they have since the time after the first surgery. I'm somewhat encouraged but this is tempered by the realization that my OT telling me the test results show improvement might lead me to think there is improvement in symptoms when maybe there really isn't. It's always hard for me to separate improvement due to getting more skilled at compensating for my impairments vs. actual improvement in sensation vs. the power of suggestion.

I would love to think that the nerve fibers are structurally intact!

The thenar muscles are still really weak. I would like to give a sustained effort toward strengthening them before I concede that this weakness is permanent, but it seems hard for the OT to find an exercise that isolates these muscles.

I return to see the surgeon in 2 weeks and it will be very interesting to see what his monofilament testing shows. I have had no success in getting the clinic to make copies of the ultrasound tests but will continue to pursue this.

jeremydpbland
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Thanks for the update. It's perhaps worth remembering that it doesn't really matter whether an improvement is due to a change in nerve function or to a change in your ability to compensate for the problem - an improvement is an improvement, and quite a lot of neurological recovery in other circumstances (after stroke for example) is due to the nervous system adapting to do things differently. One of my CTS contacts is interested in a programme of what she terms 'sensory relearning' after surgery - a set of manual tasks identifying small objects and textures - and has published a pilot study suggesting that this may be an avenue worth exploring. Weakness of the thenar muscles, once established with wasting usually does take a long time recover, if it does so at all. The ultrasound images would be nice but don't worry about it too much. It can be hard to capture ultrasound findings in still images as it is a very dynamic investigation. One other thought occurs to me. Is your surgeon aware of this website/forum/discussion - and if so what does he think? Am I interfering in his management of a case or am I just providing a different perspective? Many of the things I do on this site are a little experimental and I am still exploring all the possible ramifications, which include the relationships between all the people involved - myself, my own patients, other people's patients and their doctors. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

The reason I thought the source of improvement mattered is that I was thinking maybe the nerves are recovering rather than having to do all that slow regeneration. And that I might then experience more rapid recovery of sensation in general than would be predicted based on what is known about how fast nerves grow.

The 'sensory relearning' program you mentioned is part of my program as well. I put small objects in a tray and after taking a good look at them, I try to identify each one with eyes shut, using first right then left hand. Also 5 minutes of texture work a day--satin, terry cloth towels, dried beans, fur, velvet, etc. And using a pencil eraser to trace around the outline of normal sensation vs. numb, emphasizing "normal." The texture work is used here primarily for people whose scars are overly sensitive. It was recommended to me as part of a way to re-program the brain.

My surgeon is aware of this site. I told him you weren't persuaded by the argument that it was unlikely to have been a surgical slip (since he would have had to make the same mistake on both hands), because both hands might have the same anatomical anomaly. I also told him you were speculating about an incomplete release well before the second NCS and ultrasound results were in. He made no comment either way but I didn't get the feeling that he felt the site interfered. My sense was he just registered the fact that his confidence in how the first surgery went-- based on clearly seeing the whole band of tissue and being sure he released it all-- kept him from entertaining the possibility of a second area of nerve entrapment. And that this physician thousands of miles away, who only read about my symptoms, figured the thing out.

My surgeon consulted with the other surgeons on the staff,, but none of them had any explanation for my failed surgery--for two months. If there were a way to broaden the consulting opportunities, so that surgeons could network with others and maybe find someone who had seen the problem before and knew what the remedy was, I think that would be very helpful.

jeremydpbland
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Thankyou for that. I've never found estimates of nerve regrowth in 'x' mm per day or whatever very useful. There is so much person to person and injury to injury variation that, although you can quote an average, it doesn't really mean a lot in the individual case.

Hand surgeons do talk to each other - as do all medical specialities - and we have regional, national and international meetings as well as our specialist journals in which to share experiences. Bilateral failed carpal tunnel decompression is something of a rarity however (notwithstanding the presence of at least three more reported on this site and another two seen in my own practice!) so it's perhaps not surprising there was no readily available local experience. I hope that this site will prove useful to physicians as well as patients but I'm still feeling my way, as you can see. Good luck with recovery. JB

chaconne68
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I returned to surgical clinic yesterday and monofilament testing showed marked improvement. I responded to 4 mm and also to 2. My surgeon was elated. I still have the subjective sense that my index and middle fingers are numb, thumbs much less. Tingling has decreased overall, especially in thumbs. I am noticing marked improvement in finger dexterity in daily activities. I am able to play violin now, although it increases the tingling and is a bit unpleasant for that reason. I haven't played for almost 3 months, and it will take some time to get back my facility, as it would after a layoff for any reason. But it is good to play and try to ignore the numbness and tingling as best I can, just so my "violin-playing neurons" keep firing while I await the hoped-for end of numbness. My surgeon discussed my case at the mortality and morbidity conference with colleagues this past week. I had hoped most would decide to discontinue doing bilateral procedures, but those who do them said they would continue. Several docs said they would have delayed doing the repeat ncs until the 3 month mark, and didn't seem to agree with my doctor's suggestion that more use be made of ultrasound diagnostics. At least one surgeon said he passes the scissors upstream of the main incision to release any additional area of compression. My surgeon commented that he knows of cases where this tactic led to other complications, such as transecting the nerve, since it's basically a blind cut. I think that despite my poor outcome, given my anatomy I'm lucky I had my particular surgeon. He has decided he won't do bilateral operations any more. I also talked with a surgical fellow who was in on the exam yesterday, told her a bit of my story, and she too said she won't be doing bilateral procedures.

This surgical fellow found your patient forum while we were talking, and in fact because I was not logged out she was able to read my posts once I told her my screen name. I asked her your question about whether your forum might be seen as interfering with case management by the patient's own doctor. She said patients frequently come in with questionable information they have gotten from the internet, and it can take a lot of time to persuade them that not everything found on line is accurate. That is the kind of problem doctors here are having to address. She seemed to feel that as long as you were not making medical/surgical recommendations there would not be a problem and the forum could be useful. I think it's likely that she and my surgeon will discuss this further and probably check out the site.

jeremydpbland
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Thankyou for a really helpful posting. I'm glad you are improving for a start. That's probably the most important thing but the report of the M&M meeting is fascinating. I would very much like to see some other doctors who are involved in treating CTS come on here and join the discussion, especially when they have patients who have interacted with me in the forum without being my own patients in Canterbury, but I can see why many might be reticent. We have considered setting up a private forum (ie one that would be visible only to a subset of authorised users) which could be used by doctors with an interest in CTS to hold discussions which would not be public. So far the main input from someone other than me with a genuine interest in CTS has come from the manufacturer of a device for treating CTS.

As always in medicine there are differences of opinion even over such an apparently simple condition as CTS and that is not surprising when it requires so much work to collect unbiassed scientific data to answer even quite simple questions. There is a patient satisfaction study comparing bilateral simultaneous carpal tunnel decompression with sequential operations and satisfaction was higher amongst the bilateral simultaneous group but that was, of necessity, unblinded and was a fairly small study which included no patients with bad surgical outcomes so it is of limited use. My own approach is simply to discourage, but not prohibit, bilateral procedures. As long as the patient is aware of the potential for results like that of your first operation and the curious fact that, when the first hand is operated, the other one sometimes improves anyway, then if they decide that the convenience aspect of bilateral surgery outweighs the small risk of a bilateral bad result then that is fine. The key thing is that the patient should be fully informed.

I have stronger feelings about the timing of re-investigation when surgery does not produce the expected swift alleviation of symptoms, though this is slightly qualified by what the pre-operative nerve conduction studies look like. In general however I subscribe to the idea that you can never have too much information and you might as well test again as soon as you suspect there might be a problem and it is reasonably practical. It is not as though nerve conduction studies and ultrasound for CTS are either risky or expensive. The ultrasound does however depend very much on the availability of local expertise in imaging peripheral nerve. You are quite lucky (speaking for the whole of the world) to have someone who was able to do that and I have seen several instances where general radiologists have completely missed significant abnormalities on MRI and ultrasound because they are not familiar with being asked questions about nerves.

I too encounter the problem of patients coming in with dodgy information from the web and that is why I have tried to make a point of ensuring that the provenance of information on this site is clear and verifiable. I also try to take as balanced, and evidence based, a view as possible of the issues but balance would be much improved by having, for example a hand surgeon from another country as co-editor - a form of cooperation which the web makes possible in a way that was unimaginable just a few years ago.

The most difficult point is that relating to individual medical recommendations. In your case of course I did exactly that - I suggested that you should get re-investigated sooner than your surgeon was originally planning. There are relatively few occasions when someone makes a posting on here and I feel that I have enough information about the case to make such a concrete recommendation... but there are a few, and I would very much like to debate that with the doctors on the 'other end' of the exchange. If the overwhelming majority of opinion were that I should not comment at all on cases where I have not met the patient, or if we came across an example where patient harm had resulted from a suggestion of mine, then I would change my approach I think.

Thankyou again for one of the most thought-provoking threads in the forum overall. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

I have thought a lot about your concern re making concrete recommendations for patients you have not met. I can only say that I am sure that in my case your recommendations led to a better outcome than would otherwise have been the case. I think it is possible, and maybe even likely, that a delay of another month would have led to more damage, a slower recovery, and possibly even a less complete recovery. So--NOT making a recommendation could result in patient harm. On the other hand I don't see how a recommendation such as you made--for getting as much information as quickly as possible--could lead to patient harm. Even if a majority of doctors were to weigh in on the side of refraining from making recommendations, I hope you will continue to be the powerful voice for the patient that you are.

jeremydpbland
User offline. Last seen 21 min 24 sec ago. Offline

Thankyou. Every opinion expressed here helps me get a feel for what the 'world out there' thinks. I hope the hands are continuing to improve. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

I am continuing to improve. Less tingling, more sensitivity to light touch. My OT tested thenar muscles last week and said there is improved strength there as well, which is really encouraging. I continue to be hypersensitive to cold. Cold water feels almost like a burn and sets off increased numbness, stiffness, and tingling. I am keeping my hands very warm as much as possible. I am able to play violin for up to an hour at a time, not with the facility I had before, but with a semi-acceptable tone. Playing does increase the sensation of numbness but I can kind of ignore it.

rrr10
User offline. Last seen 5 weeks 2 days ago. Offline

To Chaconne68, thank you for sharing your experience. You are so brave and I really admire your strength. I had my R hand done ~7 to 8 weeks ago and experienced increased sensitivity to cold in my R fingers after the sg too.

jeremydpbland
User offline. Last seen 21 min 24 sec ago. Offline

I'm glad it's getting better. It might be interesting to see how your symptom severity score on here now compares with the old one from when you first did the questionnaire - you can do a new one from the 'MyCTS' pages. JB

chaconne68
User offline. Last seen 48 weeks 4 days ago. Offline

My new questionnaire shows marked lessening of symptoms.

jeremydpbland
User offline. Last seen 21 min 24 sec ago. Offline

That's very encouraging - the change of about -1.5 in the severity scores is approaching the sort of improvement seen in primary successful carpal tunnel decompression (averages about -2.2) so it was clearly worth the second operation. It will be interesting to see what the long term result is but I would be fairly optimistic I think. JB

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