pain after CTR

There is a whole page of this site devoted to the problem of analysing what has gone wrong after unsuccessful surgery and you should read that through The first thing to try to get clear is whether the current symptoms are the same ones as before surgery (irrespective of whether they are more or less severe) if they have changed in type, distribution or timing that can help in working out what has happened. The second thing we need to know is how your nerve conduction studies have changed. If they have not been done again since surgery then they need doing, preferably by the same lab that did them before jsurgery so that they can make a direct comparison with the earlier tests. The third thing which can sometimes help is ultrasound imaging of the wrist but that is not widely available - you did not say where you were. JB

Dear JB, thanks for the fast response. I appreciate it. I am sorry that I did not give more details. I am terribly frustrated about my situation and, honestly, I did not expected to get an answer at all.
Before the carpal tunnel release surgery I had increasing trouble with pain, tingling and numbness. I never had problems with weakness of the thumb muscle. Every doctor I saw for the symptoms tested the strength of my thumb muscles and were impressed how strong they were. After CRT the pain increased exponentially. The first four to six weeks after surgery I had terrible pain with which I had trouble to cope. I had to take Tramadol to cope with the pain. In the same time I had the impression that I can feel more than before the release, but the numbness and tingling never resolved. Then the excruciating pain decreased, and I tried to decrease the amount of amitriptylin (75mg per night), but I failed. Every time I attempted to decrease the amount, I was not able to sleep any more. My GP advised me to stay at the dosage and to try it again later. In November 2010, three months after surgery, I noticed that the sensation in the median nerve influenced part of my hands have decreased again. On the left ring finger at the median side I have a completely numb spot from the day of surgery, which started to extend down the finger at this time. I told that my orthopaedic surgeon at the follow-up appointment in December 2010. He said that I should not expect that my hands will get back to normal because of the severe compression. My carpal tunnels were tightest tunnels he has ever seen. Because the hands did not improve he ordered another conduction study in March 2011. The nerve conduction study showed improvement after the surgery, the motory part of the nerve improved to mild delay, the sensory part from absent to marked/moderate delay. From May 2011 the pain got worse, I was not able to sleep without night splints anymore. Not only the thumb and the wrist hurt, but also index and middle finger. I needed additional pain killers to cope with the pain. The palm got hot and hotter, what is painful for me. But when I wash my hands with cold water, I can't feel a thing in these fingers, not the towel when drying my hands. The sensation in thumb, index and middle finger have decreased further, My sister nocticed that I use ring finger and thumb to grab something or press the ring finger against my palm. And my hands got clumsier meanwhile. It is a strange feeling to grab a cup of milk to drink the milk, but drop it half way. It slipped out of my fingers. I had been clumsy before the surgery, but not to this extend. The numb area at the left ring finger has extended from the most upper part of the ring finger to it's base. The sensation has continued to decrease. I can't feel the fur of my cat anymore (I can't remember how it was prior to surgery.) When I pet my cat, I do not know how powerful I touch her. Because everything worsened I contacted my orthopaedic surgeon in July 2011. 6 weeks later I got a letter from him, saying that he does not know why I still have pain, I should continue to take the pain medication and that he wishes me good luck. The problems with my hands already have an adverse impact an my work. Last month I got steroid injection in both wrists to be able to do my work. I wanted to know how my hands are doing so I organised myself another nerve conduction study this month. The nerve conduction studies show still marked to moderate delay/slowing in both hands. Some of the values have improved slightly, but this improvement is still whitin the error tolerance of the measuring instrument, so I am not sure if there is really an improvement or not.
Regarding the ultrasound imaging I need the referral of my orthopaedic surgeon to get that done, but he is not willing to do anything for me. So I do not think that I get that organised.
I am not sure if it is of interest or not, but I have a delayed onset of local anaesthetics and a fast drug metabolism. I learnt that during the carpal tunnel surgery under local anaesthetic. My orthopaedic surgeon tried to numb the area of the carpal tunnel, but he was not very successful. I felt when he cut the skin, then the ligament and cleared the area and sewed the skin together. He injected more local anaesthetic three times, but it did not help. It was the same on both hands. Unfortunately the release surgery itself became a nightmare for me.
I have not mentioned where I am because I thought it is not necessary. I am a German studying and living in New Zealand. I found your very informative homepage while browsing through the internet. I have also read your page about when surgery fails, but I have trouble to transfer it to my situation. I try to find out what is wrong with my hands and why do I have still pain in my hands, respectively. I gave up the hope that the sensation will return to normal, I only want to get rid of the pain. Your forum is the first I found which is not updated 10 years ago. It is the first time that I posted something in a forum, but I do not know what to do any more. Thank you very much again for your answer.
All the best, AB

That's quite a lot to take on board but thanks for the extra information. The account of surgery is atypical for carpal tunnel release. Markedly increased pain after surgery is unusual if the procedure has been performed correctly and usually the only post-operative analgesia required is simple things like paracetamol/NSAIDs rather than tramadol. What is typical is the surgeon's comment about it looking like a severe compression at surgery - they seem to say that about most of them. In neurophysiological terms, if the motor potential from the thumb was still recordable it cannot have been worse than grade 5. One normally expects the nerve conduction studies to improve by two grades with successful decompression. It is hard to be sure about yours but they were probably grade 4 or 5 before surgery (it depends on the distal motor latency) and they are probably grade 3 now. Any improvement at all is unusual with incomplete carpal tunnel release so this reduces the likelihood that this is your problem but even so I would consider re-exploring at least one hand. It sounds as though he had trouble with the anaesthetic during surgery and this will in itself have made the procedure more difficult. Steroid injection after surgery is unusual and I have only seen one case report of this being done - did the symptoms seem to improve at all after this? If so then I think that might be further grounds for operating again. I really would like to see the ultrasound imaging in these situations but it can be hard to find an expert in peripheral nerve ultrasound, that is why I was curious about where you lived. There are good people in the USA, the Netherlands and Italy but I have no idea about NZ, or Germany for that matter. If you do decide to get one hand re-operated then I would be inclined to look for a specialist hand surgeon or a plastic surgeon who does lots of carpal tunnel surgery rather than a general orthopaedic surgeon. JB

Dear JB,
thank you very much for your advice. Yes, the steroid injections helped a lot with the pain. After the injections I was able to do my work again and to sleep more than 4 hours at night.
Thanks again, Antje

Dear Dr Bland,
we have seen EWS last Monday. After an initial examination he did ultrasound scans of our wrists. I am really impressed what one can see in an ultrasound image. Beates median nerves are pretty bad swollen and have some bruises. The nerve area was about 0.19-0.22 centimetre squared. EWS said it will take months rather than weeks for the irritated nerves to shrink. The carpal tunnel ligament is fully cut, the median nerves stick a bit to the scar tissues, but not to the tendons. It was interesting to see how the median nerve moves to the side when one moves the index and middle finger or makes a fist. My median nerves are swollen as well. The nerve area was about 0.13-0.16 centimetre squared in stead of 0.1-0.11 centimetre squared which a normal nerve has. That my median nerves are swollen is puzzling me a bit. The surgery is 1.5 years ago, and I would have expected that the nerves are back to normal size. EWS explained us that nerves swell up when they get irritated. At the ultrasound images we could see that the carpal tunnel ligaments on my wrists were fully cut as well and the nerves are not sticking to the tendons or the scar tissues. EWS wants to exclude spinal influence and will ask our GP here to get MRIs of the cervical and thoracic spine done. Up to now we had only X-rays done, but EWS explained us that an X-ray does not show the complete story. He keeps the fingers crossed that there no spinal influence, but it will take some time until we will know it. At the moment the waiting time for MRIs in the hospital is about 3 months. Our mum had to wait 3 months to get one of her knee done. After that we will see how it will go from there. We keep you in the loop.
At the moment I am terrible frustrated about my hands. They hurt more than ever before, even more than before the CTR.The fingers/area influenced by the median nerves are tingling, getting so hot that it hurts, and are sometimes numb. Sometimes it hurts so much that I need to take codeine phosphate to get relief. It still goes down hill and does not seem to stop. I really want to know what is wrong with my hands and if there is a chance that they will ever get better. At the moment the hands are so bad that I can hardly work in the job which I have learnt and I love to do. And I do not want to give up my job. Why on earth are the hands so bad when the carpal tunnel ligament is completely cut?
We wish you all the best for 2012 and hope everything is working out for you.
All the best,
Antje

Thankyou for the update and I'm glad you got to see Einar. He has more experience of ultrasound in CTS than I have but I think it is fair to say that the literature on post-operative ultrasound is still a bit sketchy. It is well established that the median nerves are enlarged in patients with CTS and I must get around to posting some images on the ultrasound pages of this site, but it is not clear whether we expect them to go back to a normal size after successful surgery. We know that some nerves do reduce in size after surgery but that does not mean that all do, so assessing the significance of a large nerve seen after operation is still difficult. The ultrasound is very useful for confirming that the transverse ligament has been sectioned though. I'm slightly surprised to hear that you have never had MRI of the neck - it's usually one of the first things people think of now when faced with arm symptoms which do not have an obvious explanation, and I'm also a little surprised at the 3 month wait - I was assured by someone I was arguing with about healthcare the other day that there are 'no queues' in Germany. Did Einar repeat your nerve conduction studies too?

The other thing that occurs to me, which does not help with your hand problem I'm afraid, but what are the medical ethics of myself and Einar discussing your cases. From a medicolegal point of view I am effectively a stranger to you - just someone writing messages on a website, while now that he has seen you as a patient Einar has ethical responsibilites to maintain your records and medical history in confidentiality. Given the globe spanning nature of this story so far I think this raises interesting questions about what safeguards should be in place for patients. I am sure that you personally fully understand the public nature of this forum and I would think that if you give Einar your permission to discuss the case with colleagues then that would not be a problem - but what about a patient with little appreciation of how far their medical history could spread on the net and a more 'sensitive' medical problem than CTS? JB

Dear Dr. Bland,
We are aware that the forum is a public one. That's why I never mentioned any names, neither the name of my osteopath nor the orthopaedic surgeon who cared a great deal about us and tried to help where they could. Feel free to talk with EWS about us. Without your help we would never have met him. Thanks a lot for that! I would like to ask you for a favour. When talking with Einar, could you please do it outside of the forum?
All the best,
Antje

Of course - I think it would be wholly inappropriate for Einar and myself to discuss it here - this is intended as a forum in which I can talk semi-anonymously to patients and where patients themselves can exchange experiences. As suggested above I think there are even some ethical constraints on whether I can discuss the case with Einar at all which deserve a little thought. JB