Constant numbness after CTS
I had CTS in September on my right hand which was classed as "moderate" two years ago. My symptoms disappeared within 24 hours of surgery. I had the surgery three weeks ago on my left hand which as classed as "mild". Since surgery my left thumb, index, and middle finger are constantly moderately numb and stiff. If I use the hand very much I get tingling. Before surgery I only had numbness when grasping objects like a phone or a steering wheel. My surgeon has said each time I ask that this is normal. I do not know if he is fully listening that I'm not talking about numbness around the incision, but that my fingers are numb. I feel in my gut that something is wrong but am getting no where with my surgeon to find out how often this happens and how long it will last.
My surgeon did not do a nerve conduction study before my surgeries. He recommend surgery based on my symptoms and the nerve tests done two years ago by a different doctor. The previous doctor did not feel my symptoms were bad enough to warrant surgery even though I had constant pain in my right hand.
So I am very pleased with the outcome of my right hand which had so much pain before surgery, but the supposedly mild left hand is worse than before.
Is my surgeon correct that this is normal and that I need to wait for any internal swelling of my left hand to go away? He says swelling is probably causing the numbness and tingling. He won't give me any timeline of when this can be expected to resolve. My hand does not look swollen and the incision is healing very rapidly. There is tenderness of the incision and the palm of course but no numbness in that location that I can tell.
One other difference I noticed after surgery was that my left wrist and palm were very bruised but my right hand had no bruising after surgery. My surgeon said the bruising was probably from the release of blood after they removed the tourniquet used during surgery.
Today my left hand start aching in addition to the other symptoms with pain at times radiating to my left shoulder. I have only ever had that kind of pain in my right hand and arm since that is my dominant hand and thus was much worse off with CT symptoms.
My next follow up appointment for both hands happens to be six weeks post-op for the left hand, so that fits nicely with your suggestion. If my surgeon will not agree to NCS and ultrasound I will seek a second opinion.
I actually read several other postings and that's what led me to write my own. There have been very few places online where patients mentioned increased symptoms after surgery. Most complaints seem to be about original symptoms not resolved.
I was told it could take six months to a year for full recovery of post op tingling, but since I did not supposedly have a severe case that just doesn't ring as true. The surgeon said not only was it normal, but also very common. It makes me wonder how many people really have increased symptoms after surgery. What is the percentage? The staff made it sound like it's almost everyone. My surgeon is rated as one of the top 2% in my state by his peers so I did not expect to get the brush off regarding my concerns.
I also think it unfortunate no NCS was done before the surgery. I was actually surprised he did not order one. Sadly I did not press him on that.
One other thing I forgot to mention. My surgeon has said several times, including in our first appointment, that since I've had CT symptoms for so long, I might not get full function back. I thought that an odd thing to say since the previous doctor I consulted with said my symptoms did not warrant surgery and I was only rated as mild and moderate. I've read many places online that people with severe CT may not regain full function but I certainly did not fall into that category.
Most of the people I see who have a genuine problem with the surgery, most commonly incomplete devision of the transverse carpal ligament, report increased symptoms post-operatively rather than no change. I have a mental image of a cheeswire effect where the pre-operative situation where a fairly broad band of ligament is exerting moderate pressure on about 2cm of nerve is replaced by one in which 2mm of undivided ligament are cutting into a nerve which has already been traumatised by the additional inflammation resulting from surgery. I suspect that 'Chaconne68' had this effect. A few people have quite different symptoms after surgery and in those cases you have to try and analyse what they indicate. This can range from nerve injury by the surgeon through to simply scar tenderness and of course different problems require different management, which may in some cases be do nothing and wait for it to get better. I presume you have found the page of the website which discusses how to set about analysing post-op problems?
Duration of symptoms is not a good guide to the severity of nerve damage and is not related to outcome of surgery once you factor in the nerve conduction results. Some patients have mild CTS for years without developing progressive nerve impairment and they do as well with surgery as those who have only had symptoms for a few weeks. Conversely one sees occasional patients with really aggressive CTS who evolve to the stage of having a more or less dead median nerve in 2-3 months and these cases do poorly with surgery. NCS grade 5 and 6 cases can indeed take anything up to 2 years to settle to a final state after surgery - that's one of the reasons why knowing what the NCS look like just before surgery is helpful in figuring out what is happening afterwards.
Reading the report of what the staff at your clinic have been saying, or at least implying, about post-operative symptoms is interesting. I do not have accurate percentage figures for patient experience at 2 weeks after surgery but it would not be difficult to collect some and we might do that. My guess is that the great majority of patients will report improvement at that point. I do have good figures for 3 months and 2 years because that is when we routinely collect outcome data - we chose 3 months because almost all patients have got over the immediate surgical trauma by then - even the ones whose wounds open up or who get an infection will generally have had that dealt with by that stage.
The last thing to bear in mind is that, in CTS surgery in general, definitions of 'success' and clinical outcomes are not black and white issues. I think the popular lay interpretation of the word success is probably what I would call complete cure (no symptoms at all, hand as good as new), but in my outcome series only about half the patients achieve that. At the other extreme some publshed surgical reports consider the operation a success if the patient does not get any worse after surgery - arguing that they have prevented further deterioration. Given such a wide range of meanings in language it is easy for doctors and patients to misunderstand each other. JB
As of today I am 4 weeks post-op. I have been analyzing my symptoms and realize I have not been as accurate as I could be. They are actually different than what I had before surgery. My left hand CTS symptoms before surgery were the hand falling asleep and waking me up multiple times at night (as well as the right hand doing this). Also gripping anything with my left hand made it go to sleep within about 30 seconds. I didn’t have much pain in my left hand. My right hand is the one that ached and shot pain up my whole arm all the time. Since surgery I no longer have trouble with it at night and gripping things is mostly okay. Instead I have a constant lack of sensation (not total) that is most apparent in the middle finger and the hand aches. This becomes very apparent when I try to type (which I do for a living) and it increases symptoms. Typing did not bother me before surgery. Also the wrist feels faintly “sprained” as if the bones are ever so slightly out of alignment. The wrist aches as well as the hand. I consider this “worse” than before because the symptoms are there all the time whereas before I could stop a certain activity and my hand would return to normal. It is "cured" in the aspect that it no longer wakes me up at night with tingling. Both hands are great at night.
I spoke with my surgeon this week and he assures me he visualized the entire ligament and was certain that no part of it was left undivided. He said the nerve looked to be in very good shape after observation with great magnification. Anatomical structure of nerve branches was typical without any aberrations. He had obviously given it a good deal of thought to discern what may have gone wrong. At this point he thinks my increase in symptoms since surgery is truly from post-operative swelling. I hope he's correct. This week I did make note that the incision seems to be healing slower than the one on my right hand did. There is a slight "squishy" feeling to palm end of the incision, almost as if there is fluid under the skin. Also the pain has been more intense in the left hand around the incision as compared to the right. My hand continues to ache fairly constantly and the reduced finger sensation has remained constant. My surgeon said he thinks I had a remarkably quick recovery for my right hand surgery and that my expectation that the left hand recover as quickly may not be reasonable.
My doctor agrees that the expectation was not to have my symptoms get worse. I understood from my doctor before surgery that he felt my symptoms might not go away entirely. Although that was the expectation for the right hand. He did not feel the left hand was very impaired. My expectation was for it to be "cured" based on the outcome of the right hand and the relative mildness of impairment for the left hand.
My surgeon's suggestion is to wait until my follow up appointment in three more weeks and see if my symptoms improve by then. He feels that doing anything else at this point would be premature. He is not a fan of ultrasound because he says all that will be seen is the post operative swelling and trauma to the tissues. He suggests I resume splinting to rest the hand and allow it further time to heal. I am also dialing back my physical activities. I had been told I could use the hand without restrictions but I don't think he understood that my household demands quite a bit of strenuous activity.
So I am on hold until the second week of December, waiting for it to heal further. I do not know what my doctor will suggest if I've had no improvement by then.
Below are my NCS results from two years ago. My symptoms were progressing more rapidly at this time which happened to coincide with an the impending onset of official menopause.
Nerve Conduction Study - October 28, 2011
Right median motor nerve conduction study was abnormal with amplitude of 12.1 microvolts, (normal 4-18 mcv) distal latency 5.6 milliseconds (normal < 4.4 ms), conduction velocity 54 meters per second (normal > 49 m/s), and F response latency 28.7 m/w.
Left median motor nerve conduction study was normal with amplitude of 11.2 millivolts, (normal 4-18mv) distal latency 4.2 milliseconds (normal < 4.4 ms), conduction velocity 54 meters per second (normal > 49 m/s), and F response latency 27.5 milliseconds.
Right median palmar mixed study was abnormal producing amplitude of 40.0 microvolts (normal > 50 mcv), distal latency of 3.2 milliseconds (normal < 2.2)
Left median palmar mixed study was abnormal producing amplitude of 85.5 microvolts (normal > 50 mcv), distal latency of 2.6 milliseconds (normal 2.2ms)
(All ulnar studies were normal. I have not included those details here.)
Summary/Impression: This is an abnormal electrodiagnostic study. There is electrodiagnostic evidence of bilateral slowing of the median nerve at the wrists. There is no evidence of denervation in median innervated muscles below the wrist with no changes above this region in the more severely affected side.
These findings are consistent with the clinical diagnosis of mild to moderate bilateral carpal tunnel syndrome. There is no evidence of an upper extremity plexopathy, myopathy, or radiculopathy.
I guess we start from those NCS, even though they were a long time before surgery. In my terms they almost certainly represent grade 3 CTS in the right hand and grade 2 in the left so yes the right hand was worse than the left. It is a pity we do not know what they were like just before surgery as they could well have changed in 2 years. It does seem to be true however that CTS does not usually change grade significantly without the patient feeling that the symptoms are significantly worse (or better) so, if you think the left hand had roughly the same symptoms this year as in 2011 then there is a fairly good chance that it was still grade 2.
The relief of night-time symptoms in the left hand is strongly suggestive of successful division of the transverse carpal ligament and release of pressure on the nerve, but it is not possible to be completely certain of this and I would still check the NCS again, even in the absence of ideal pre-operative studies for comparison.
The aching wrist and sensation that things are out of alignment is a not uncommon consequence of cutting the ligament and fortunately usually does settle in time, though not always.
I have to disagree with your surgeon about the usefulness of ultrasound imaging but in practice how much you get out of it will depend very much on what expertise is available in the local imaging community. Ultrasound imaging of peripheral nerve remains a minority interest and there may not be anyone near you who can provide a really good opinion, especially in the context of problems after carpal tunnel surgery, which is a relatively uncommon problem to encounter.
That leaves the most difficult aspect of your new symptoms til last - the increased numbness of the fingers (if I understand your description correctly). That suggests greater impairment of median nerve function than immediately before surgery. It might just be neuropraxia (temporary cessation of nerve conduction) as a result of the trauma of surgery and the consequent inflammation in the area but 4 weeks is starting to be quite a long time for there to be no evidence of this even starting to improve if that is the case. I could not evaluate this myself without new nerve conduction studies but of course if it does go away in the next 3 weeks without further intervention we will not need to worry about it.
As usual in this forum I would be delighted to hear how it turns out, especially if the outcome is that, in three weeks, it feels as good as the first one. JB
It's very difficult to describe the sensation in my fingers. I don't really notice it unless I press them against something and then I notice they lack full sensation. The very tip of the fingers are most affected. They don't have the pins and needles feeling like when the whole hand used to fall asleep, but it does start to "tingle" some when I persist at an activity like typing for several minutes. The best analogy I can think of is that it's like I've had a local anesthetic injected which has almost worn off, but not quite. The symptoms have not improved any at all.
I have actually been treated by a physical medicine doctor in the past who is a master with ultrasound imaging. I've sent a message to his office to see if peripheral nerve imaging would be within his area of expertise. I live in Austin, Texas and we have quite a few high quality medical facilities here. You can find pretty much anything you need here and if not here, there is Dallas and Houston with a tremendous amount of medical talent as well.
I will have a new NCS done in December either through my surgeon's office or a different doctor if he isn't keen on the idea. I think I will call on Monday to set up that testing prior to my follow up appointment. I prefer to do that than to wait until we're very close to the Christmas holidays.
Thank you very much for your help. As others have mentioned, this oasis on the web for CT issues is very rare and much appreciated. I will be sure to let you know how it turns out.
There is lots of expertise available in musculoskeletal ultrasound but although the people who do that recognise nerves in their images they mostly have not taken a special interest in what happens to them in pathological states because their focus is on joint, tendon, ligament and soft tissue abnormalities. Expertise is spreading however as more gets published on the topic and most people doing ultrasound are now familiar with the idea that the median nerve swells in most cases of carpal tunnel syndrome. The hotbed of nerve ultrasound in the USA is a little north of you at Wake Forest and Duke Universities in North Carolina where there are very active research groups who do a lot to spread the word. JB
Having my left hand looked at with ultrasound on Dec. 18th. This doctor does have a special interest in imaging nerves and has recently seen another patient with symptoms similar to mine after CT surgery.
That's good to hear. If they want to share some snapshots of the imaging that would be very interesting. JB
I know it's been a long time since my last post about this, but thought I would update now that it's been several months. I still have a faint numbness in the tip of my left middle finger. The imaging I had done in December did not show any obvious issues. The nerve moved freely, etc. I had the nerve conduction tests redone in January as well. The results were actually worse than the ones I had one two years before surgery but since there were no tests done right before surgery, there's nothing to compare to. I actually have permanent nerve damage in my right hand although I don't notice except in loss of grip strength. All of the doctors feel the issue with my left hand is a by-product of the surgery. It's been eight months and so I do not expect to have any further recovery with it. Luckily it does not impair function even though it is bothersome in a sensory way during certain tasks needing fine control. So all in all I consider my surgeries successful, however I am deeply angry at the first neurologist who did the 2010 nerve conduction tests and did not feel I was "bad" enough to warrant surgery.
Thankyou very much for the update. I'm always delighted to hear how things turn out, whether the news is good or bad. I've just read through the whole story again to remind myself of the details. Overall I would say that the residual problem in the right hand, the weakness of grip, is not the result of nerve damage but more likely to be a mechanical consequence of the operation. I imagine the repeat nerve conduction studies of the right side were abnormal in January and this is being interpreted as 'permanent nerve damage' but in fact most cases of CTS continue to show residual nerve conduction abnormalities after the operation, regardless of how good the subjective outcome is, so I tend not to regard this as nerve damage - more a case that regenerated myelin leads to nerves which conduct a little slower than before.
The left side is trickier. I'm reading the overall description as being that there is now a permanent, albeit mild, sensory deficit in the fingers which was not there before surgery. That is the kind of symptom which probably is attributable to nerve damage and if it apeared at the time of operation, and was definitely not there beforehand, I think one has to assume that nerve was traumatised in some way during or about the time of surgery. In that context it is interesting that the new NCS are worse, suggesting that nerve conduction on that side really is more impaired than it used to be. I would not give up on it yet though. I have seen mild sensory impairment due to nerve trauma recover 2-4 years after the injury in one or two patients so I don't think all hope is lost for it yet, though at the same time I would not be especially optimistic either.
I would have agreed with your original neurologist that the first set of nerve conduction studies did not demand immediate surgery but I would not have left you untreated if you had significant symptoms. I just have a preference for an initial trial of non-surgical measures such as splinting and local steroid injection in milder cases. This preference is mainly because of the significant incidence of problems such as the ones you have after surgery. I have no problem with surgery if less aggressive measures fail or if patients present with severe CTS.
Thanks again, and I hope you get some further improvement still. JB
It may be worth reading a few of the other postings in this forum. You will see that surgeons claiming that increased numbness after surgery is 'normal' is quite common. Your surgeon may be right and that this is a temporary impairment of nerve function related either to rough handling of the nerve during the operation or to increased pressure on the nerve related to inflammation at the operation site but in my experience most mild cases of CTS should respond in the way your right hand did and what you are describing in the left hand is a significant cause for concern. If it is still like that at 6 weeks I would repeat the nerve conduction studies and get an ultrasound done if possible, though it is a pity there are no immediately pre-operative NCS for comparison. If there was a lot of bruising then I think that rather suggests that they did not check very carefully at the end of the operation. Usually one takes the tourniquet off or slackens it off before finally stitching up so that you can see if there is any obvious major bleeding before closing the wound. JB