?bilateral recurrence

kceb
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I had open CT releases (L 14 months ago, right 12 months ago). My symptoms were said to be classic, and had + phalens, 'mild' NCS abN on left with normal NCS on right. Also had a trigger thumb treated with steroid injections x 2 over the last year. Preop I would have described my symptoms as mild EXCEPT for at work. my job is very hand intense (repetitive small movements 8hr/day) and my pain was quite significant with hand use. Initial surgical response excellent with complete resolution of symptoms. Returned to work 2 weeks post op
Then, 4 months ago (10 months after first surgery and 8 months after last steroid injection) had thumb pain and recurrence of trigger thumb. The pain slowly spread to involve the lateral 3 fingers and wrist with use. Then the pain started in the right hand. Two months ago the tingling started in both hands, I find my hands a bit clumsy with decrease in sensation.
My hands now feel very similar to how they felt prior to my surgery other than the fact I am not waking at night with numb hands. I now have + Phalens and Tinels (which was not positive preop). I am unable to work. Even filling out paperwork is painful. There is no swelling or tenderness on palpation. I had the trigger thumb surgically released.
High res ultrasound showed mild/borderline enlargement of median nerve (11mm) but no areas of compression. NCS and EMG COMPLETELY normal. Awaiting MRI to look for disc issue -- though neck is non painful.

Surgeon has been amazing trying to get this sorted out -- but Is at a bit at a loss to explain what is going on.
Thoughts?
Could this be 'early' recurrence and NCS changes not yet measurable?
Double crush?

jeremydpbland
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That's certainly a very difficult one and it does sound likely to be in some way work related. I suppose my first guess would be that the original symptoms were not quite 'classical' CTS, in that they may have been more a manifestation of direct irritation of the median nerve by your work rather than a true entrapment in the wrist. That would fit in fairly well with the symptoms being particularly evident on use rather than at night and with the fact that NCS signs of entrapment in the carpal tunnel were mild/normal. Despite that formulation of the problem however I think one has to say that you did also have some degree of raised pressure in the carpal tunnel, perhaps secondary to the nerve irritation, and that relieving this surgically explains the improvement in symptoms and NCS with surgery. Following that line of argument further we would now be seeing the same pathological process again but in a situation where the usual entrapment site for the nerve has been surgically modified so that you no longer develop a secondary CTS. Apart from the nerve size on ultrasound now I would also be interested in whether the transverse carpal ligament has been fully divided, whether there is any thickening of the epineurium around the nerve, how mobile it is in relation to the tendons, how superficial it is at the heel of the hand, and whether there is any evidence of hypervascularity of the nerve on doppler imaging which might indicate ongoing inflammation. One could explore the option of further surgery with things like a fat pad interposed between the nerve and skin but I would be wary of predicting the outcome and it may be that, in the end, the only real solution to this is a change of work.The possibility of pathology in the neck or brachial plexus is also worth exploring and I see that that is being looked into but it may well draw a blank. There is a full section of this website devoted to my thoughts on 'double crush' syndrome.

As a final thought this is one of the unusual post-surgical cases in which it would be interesting to know whether the 'CTS' symptoms responded to local steroid injection in the region of the carpal tunnel - though doing this is a bit of an experiment. JB

kceb
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I had expected the ultrasound to show tenosynovitis irritating or compressing the nerve as there was visible tenosynovitis in my thumb a few weeks earlier when i had the trigger thumb release. However, that was normal too. Epineurium checked out, Surgical site 'beautiful', ligament fully divided. glides normally. Scanned up to my elbow and there was no evidence of compression in the forearm.
Off work x 2 months avoiding anything that works the small muscles of the hand. Avoiding use controls the pain (minimal at rest) but the tingling/numbness is increasing over time. Guessing this will either resolve or declare itself!

If nothing shows up on the further investigations will try a steroid injection.
I'll post follow up when I have it.
Thanks for running this forum!

kceb
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Update:.
I have been having physiotherapy for recurrent repetitive strain injuries. Some improvement in pain at rest but continue to have numbness and tingling. I returned to work part time though it is uncomfortable. I had a closer look at my nerve conduction studies -- compared with preop they have improved but are not normal. CT scan of the neck shows bulging discs at c5/6 and C6/7 with mild central narrowing but no nerve compression.
However my vit B12 has come back at 142 (normal range at this lab 150) and 2 yrs ago it was low normal at 164. Normal HgB 135 but high normal MCV 100. Have some other symptoms of B12 deficiency (mild glossitis, brittle nails,....). will be worked up for pernicious anemia.

Looks like vitB12 deficiency. The pattern of my nerve symptoms really does follow the median nerves, though i now get numbness in ulnar distribution with bent elbows. Could vitB deficiency preferentially effect the median nerve due to remyelination problems in repair of nerve damage caused by my previous carpal tunnel? Though would have thought that would have shown up on the NCS.....

jeremydpbland
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There are certainly some people whose nerves are unusually susceptible to pressure/stretch. The best known example is the inherited condition hereditary liability to pressure palsy (HLPP), another may be Wartenburg's sensory neuritis in which small cutaneous nerves appear to be mechanically sensitive.There are almost certainly others. B12 deficiency is not known to be especially linked to nerve problems at entrapment sites but as one factor of many affecting the state of your nerves it may be a contributor even when, as in your case, apparently fairly mild. It will be interesting to see if correcting it makes any difference. Thanks for the update. JB

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