CTS surgery 8 weeks ago and I wasn't informed until 7 weeks post-op. Looking for some information regarding healing of the TCL.

The implication of that first paragraph is that this was not a standard carpal tunnel release so you will have to fill me in with the details when you can manage.

For the specific queries in the second paragraph:

If the operation is done correctly nothing much restrains the tendons after surgery - hence the bowstringing effect, but the proximal and distal 'edges' of the ligament are not really distinct - rather the TCL 'fades out' rather gradually into the forearm and hand fascia so exactly how unrestrained the tendons become varies a bit depending on how far the surgeon extends the incision.

Bowstringing is well recognised but is less common as a clinical problem than you might expect from the mechanics of the operation. It has not been studied as a marker of success/failure but from first principles it is likely that visible bowstringing does indicate that the tunnel has been adequately released to take pressure off the nerve.

Occasionally the TCL does seem to 're-form' - but it does seem to be very rare and usually it seems to take a very long time - most convincing recurrences that I see seem to be 10-20 years after the original surgery.

I suspect that the 'expansion/contraction' of the wrist you are seeing is just another slightly different manifestation of bowstringing - the contents of your wrist are now less restrained than they used to be - perhaps an interesting analogy might be the effect on the abdomen of a corset - when you take it off you can see more going on! JB

Hi Jeremy,

Thank you so very much for your reply. The hand therapist I've been seeing since surgery told me that the TCL immediately reconnects with scar tissue after being cut and that there are typically no permanent effects to the mechanics of the hand once it has reconnected. I'm glad to learn that the therapist is wrong, as I've been growing very concerned with the ability to expand my wrist by flexing my fingers. I thought I had perhaps somehow re-broken the ligament that was supposed to be connected by now.

I'm in the US. Getting good healthcare can be difficult, to say the least. I was also injured on the job, which makes things exponentially worse. A red hot piece of wire pierced my palm at the crease of my thumb just above the TCL. It proceeded through my palm towards the 1st knuckle, severing my superficial palmar arch and damaging the median nerve in two locations. The hospital pulled the wire out and sent me on my way. Two weeks later I had exploratory surgery performed, at which time the artery was reconnected and the nerve was repaired. Before surgery I had what I can only describe as mild sensory loss (a feeling of having tape over the skin) to half of the 1st and 2nd fingers. After surgery I was told the worst I could expect would be very mild sensory loss at the tips of those two fingers.

I recovered very well for the first few weeks, and by week 4 I felt well enough to play guitar again. The word 'carpal' still hadn't been mentioned to me at this point. I noticed that the pinch strength of my 4th finger was extremely weak even though I didn't believe it was affected by my injury. Much weaker than the fingers that were directly affected actually. I also began to experience significant pain at the heel of my palm at both sides of my scar. When I asked my doctor about both of these things he told me that the weakness was due to just not using my hand much for the last few weeks, and that the painful lumps at the base of my hand were just due to having a scar in a sensitive spot.

From there I declined quickly and am trying to figure out why. By week 5 my hand had grown too painful and weak to even attempt guitar anymore. At week 6 I lost more sensation in the 1st and 2nd fingers and I began experiencing loss of sensation in my 3rd finger (which seemed to begin by tingling at night). The entire length of my scar began growing more sensitive and painful, and the TCL area began to burn relentlessly. I also started experiencing swelling and discoloration. At this point I grew desperate, and started trying to self-diagnose and came across this site, which has been extremely valuable. I began to lose my mind as I wondered if I was suffering from carpal tunnel syndrome, or from the effects of carpal tunnel surgery.

At week 7 the pain was unbearable in my palm and the sensation in my fingers at an all time low. My doctor told me that I was healing as expected, and also casually mentioned that he released my carpal ligament when he had my hand open.

I'm at week 8 now and I didn't know pain could be this bad. I've been living on oxycontin for the last two weeks and at this point it's more of just a mild sedative than it is a pain reliever. The pain is so widespread and of varying types (burning, stabbing, aching) that I am unable to really figure out what the source of it is anymore.

My interest in the bowstring effect is based on the only theory I currently have; that the tendon of my 2nd finger is somehow inflaming the nerve. My scar goes from the base of my palm to nearly the bottom of my 2nd knuckle, and when I flex that finger the tendon seems to align with the incision in my TCL perfectly, which I believe allows for it to protrude more than it should and perhaps put extra pressure on the nerve. In the previous weeks when I flexed that finger it would often result in a significant tingling sensation throughout my first 2 fingers. Now the same action seems to be resulting in pain.

I apologize if this is incoherent, I haven't been able to concentrate in quite some time. Thank you again for your assistance, I do most sincerely appreciate it.

Brian

The therapist is partly right. It's true that mechanical problems after surgery are relatively rare - but I think that is partly because few patients nowadays actually use their hands for activities that involve strenuous wrist flexion. He/She is also right that scar tissue forms in the gap created by the surgeon but I am not sure how mechanically effective this is in most people in recreating the function of the transverse carpal ligament. Occasionally you get late recurrence of CTS - 10-20 years after a wholly successful operation the same CTS symptoms recur and median nerve function deteriorates again - and I suspect that these are cases in which the repair process really has been good enough to recreate an anatomical space with boundaries strong enough to allow for pressure in the space to compromise the nerve. Curiously I have just seen a bilateral case like that this morning. On the ultrasound  imaging you can see the scar tissue as being distinct from the natural ligament many years after surgery. I think the word 'immediate' is probably a bit misplaced too - it takes several weeks at least for the scar to form and organise.

I sometimes wonder whether we should have a forum devoted to differences between US and UK healthcare but on balance I think it's probably better to keep the site concentrated on CTS not politics. That's a very unusual injury. I wonder if the vascular damage was mitigated by the fact that it was a hot wire - though hitting the arterial arch it may have immediately cauterized the hole and reduced the bleeding perhaps? It will also presumably have produced what is in effect an internal burn - I gather it was not removed until you made it to  the emergency department? We seem to have clear documentation of injury to the median nerve branches in the palm and even though they have been repaired (that must have been quite a piece of microsurgery) you are clearly going to have neurological symptoms related to those injuries regardless of what is going on in the carpal tunnel. Did they tell you much about surgical nerve repair and explain what you can and cannot expect? The distribution of the pre-surgical sensory loss to the adjacent sides of two fingers makes anatomical sense for an injury to one of the palmar branches of the median nerve (incidentally by 1st and 2nd fingers do you mean thumb and index, or index and middle? - some people count the thumb as digit 1). You might have to explain 4th finger pinch strength to me a bit more - I'm not getting a clear picture of exactly what you are describing.

It is a bit odd that the surgeon did not mention dividing the tranverse carpal ligament until week 7. Between weeks 4 and 7 you certainly seem to have had increasing median nerve symptoms. Sometimes you can get severe neurogenic pain which develops after a relatively minor nerve injury but I would view this as a complication, not 'normal healing' and it sounds as though it has spread to involve most of the median nerve territory, not just the originally affected digits? One therefore has to wonder if there is something untoward happening and whether it might be treatable.

The most useful investigations are going to be nerve conduction studies and ultrasound imaging, and if any were done before surgery they would be very useful for comparison, but I guess in the circumstances of your injury they perhaps didn't think of doing these? Ultrasound in particular should allow some assessment of what is happening to the tendons and the arterial supply of the hand as well as the nerve branches. I would love to have a look at it as a learning exercise but obviously we are a bit far apart! JB 

Dr. Bland,

Thank you so much for taking time out of your day to help me with this, I know my injury goes well beyond the scope of what you have intended this forum for. Please don't feel at all obligated to reply, as I'm sure you have much more important and relevant things to tend to. However, with that being said, I can use all the help I can get. You've actually already told me more about what is going on with my hand than my own doctor, so if my situation is at all interesting to you I would love to know of any additional thoughts you have.

I probably wouldn't have even noticed the bowstringing effect if it weren't for playing guitar. My hand therapist seemed baffled as to why I'd ever need to put my hand in such a position that I would be able to notice. She was also surprised that I would even detect my lack of what I referred to as 4th finger pinch strength, which does too seem very guitar-player specific.

What I mean by 4th finger pinch strength is the ability to touch my thumb to my pinky and squeeze (I refer to the pointer finger as the 1st). My therapist evaluates me using three tests, the first is a pinch strength test between my thumb my 1st finger, the second is my thumb and my 1st + 2nd fingers, and the third is overall grip with my wrist in a neutral position. None of these tests measure the muscles that I feel have weakened the most, the ones at the base of my 4th finger/the side of my hand (hypothenar?). It's more of overall hand stability than it is finger strength. I can curl my 4th finger just fine, but the muscles directly below it basically give out if I try to push against it. I had been assuming that this was a short term consequence of carpal release, as I believed those muscles are attached to my now severed TCL. I really hope that's the case and not an indication of more nerve damage. My thumb is also weak, but seemingly only when pushing in certain directions.

Healthcare here is frightening, I may have been better off if I had just pulled the wire out myself and not had surgery. Fortunately I only had horror movie style arterial bleeding for a few seconds, the wire did indeed cauterize the artery after it severed it. I went to the emergency room and they took x-rays. I didn't get to see them, otherwise I wouldn't have let them just pull it out. The wire went straight in and as it cooled it curled up around who knows what (I'm thinking a branch of the median nerve). They only numbed what I believe was the wrong nerve (ulnar) before pulling the wire straight out.

I had my first appointment with the hand surgeon I was assigned to a few days after injury. After describing the injury and my symptoms he said he needed to perform exploratory surgery. Nothing was explained to me regarding nerve repair at all, and there was certainly no mention of TCL release. No tests were performed or even mentioned. The entire appointment probably took 3-4 minutes. I was given a packet of exercises that I was to begin performing immediately after surgery, so I was under the impression that my wrist would be mobile.

Surgery was roughly two weeks later, and by that time I only had two symptoms. The first was the mild loss of sensation I mentioned. It was in my pointer and middle fingers, just the surfaces of them that contact each other. I believe they're both fed by the same branch of the median nerve, so I'm pretty sure we're thinking of the same areas. The second symptom is very odd and I'm hoping it may be a key to figuring out what is causing my hand to decline. At the time, if I were to extend my arm straight out to my side, with my hand at shoulder height, if I then extended my wrist slightly (point fingers towards up) it would feel as if the nerves were being pulled out of the affected fingers. Extending my wrist slightly more would immediately turn all feeling off to the skin of those areas. If I were to then straighten my wrist it would result in a shocking feeling throughout those two fingers and the sensation in my skin would slowly start to return.

As for the surgery itself, my surgeon said that the median nerve was "abraided" in two areas and that he took tissue from elsewhere in my hand and wrapped it around the nerves to give them a chance to heal. The only other things he said were that he reconnected my superficial arch and expected at the very worst that I would end up with slight loss of sensation in the tips of my fingers.

I woke up from surgery in a wrist splint that I wore for two weeks, and by time the stitches were removed I was regaining feeling in my fingers and the second symptom was gone. I improved steadily until playing guitar again. It grew too painful after a few days and I've been in decline since. Both original symptoms are back along with what seems to be a greatly exaggerated amount of pain coming from almost everywhere in my hand. Nearly every movement of any finger causes a shocking feeling in the first two fingers. Tapping very lightly along any surface of my palm also does the same, as does tapping on the median nerve in my forearm.

I've continued to wear a wrist brace at night, despite now knowing that I don't have CTS. I was thinking that perhaps in my sleep, I was somehow extending my arm and wrist at the same time and causing damage, as the numbness (in 3 fingers now) is at its worst when I wake up. This morning I realized that I no longer need to extend my arm and wrist simultaneously to get that feeling of having the nerves pulled from my first two fingers. Simply straightening my arm with my wrist in a brace is enough to bring that feeling, as well as immediately cutting off sensation in the first two and a half fingers.

I happened to have an appointment with my doctor today. He was entirely dismissive of everything I told him. I asked him if there was any sort of testing that could be done, and he said he would consider a nerve study in the future but 9 weeks post-op is too soon to have one done. I responded drastically well to prednisone a couple of weeks ago, but it was short lived. 36 hours after beginning a 6 day dosepack the pain went back to a non-exaggerated level and my hand began to feel like it was mine again. It only lasted two days though. I don't understand how it had such an effect, nor does my doctor, so that was dismissed as well. He did end up giving me another prednisone dosepack today, but he said that it was for the flare up that I was going to have over the next few days due to the injections, and proceeded to inject me with another steroid in 5-6 places throughout my palm. He still says I'm healing well and that I just have some inflammation.

I know you can't diagnose me over the internet, but I would be very happy to hear any thoughts you have at all regarding my situation. Thanks again for your time and for this resource.

Brian

Now I've got the little finger thing. I've been practicing a piece this week that involves a lot of little finger hammer-on/pull-off ornaments so I know what you mean. Most of the power for that movement is actually provided by the long flexor muscles in the forearm, transmitted by the tendons so I wonder if the weakness is more mechanical, either adhesions of the tendon or maybe just the loss of the 'pulley' effect of the transverse carpal ligament, or a bit of both.

I would guess that a lot the symptoms precipitated by movement are perhaps manifestations of the formation of scar tissue and the development of adhesions in the palm. This was a pretty horrible injury and the timescale of several weeks after the injury and surgery sort of fits in with the period during which there will have been a lot of reactive inflammation with consequent fibrosis. The response to tapping is just telling you that the median nerve is very mechanically sensitive at the moment. Steroids are powerfully anti-inflammatory so those make a sort of sense.

I would disagree with your doctor that 9 weeks post-op is too soon for nerve conduction studies. In this situation I want to know if your median nerve is improving or deteriorating and the earlier I get a baseline set of measurements to compare with the better. After acute nerve injuries it is often better to wait 2-4 weeks to carry out a diagnostic assessment but that is not the main reason for doing them here. Of course I practice in a system where there is no immediate cost to the patient or an insurer for doing the test and the only real economic reason for not doing it is the effect on my waiting list - which stands at about 5 weeks for routine cases - so I can usually test when I feel it is clinically appropriate and repeat as necessary.

I'm afraid I can't suggest any course of action which is likely to be immediately helpful in alleviating the symptoms. Obviously I can't see or examine the hand for a start-off and your surgeon is in a far better position to know what he found at operation. Predicting what will happen after nerve injuries is notoriously difficult in the individual patient even when you are there in the flesh I'm afraid, and in addition yours is quite an unusual injury. I would like to hear how it evolves though if you don't mind staying in touch and if you do end up having nerve conduction studies or ultrasound imaging of the palm and carpal tunnel performed I would be very interested to see the results. JB

Dr. Bland,

The strength required to do little finger hammer-ons/pull-offs is exactly what I'm referring to, though what first made me realize there was something very wrong with my hand in general was trying a wide spread on the top strings down near the head. 2nd fret on the top string/4th fret on the 5th string/6th fret on the 4th string (Every breath you take? I was playing Rocksmith). That position now makes my ulna rub on a bone in my wrist rather painfully.

The Kenalog injections in my palm were very rough for a couple of days, as expected. The relief has been minor, but it's been enough to allow me to identify what exactly is irritating the nerve instead of my hand just giving up and telling me it's on fire. Unfortunately everything seems to be irritating it. I think that you are right about adhesions. Where the median nerve branches off to the adjacent sides of the 1st and 2nd fingers, it seems like it has adhered to another structure and is being injured every time I put my arm in a position where the nerve is stretched. That area is growing a lump rather quickly, and when I touch that lump my nerve tells me that I'm touching my finger instead. The site where I was punctured by the wire (much lower in my palm) now seems to be directly connected to my fingers as well. Yeah, I know I sound crazy.

Now for the relevant part. I now know for certain that the bowstring effect of carpal release is making things much worse. Simple things like scratching my other arm results in tendons popping in and out of my wrist, sometimes strongly enough for it to be audible. When they pop back in it instantly brings on parasthesias and pain. I don't understand why I seem to notice this effect so profoundly when it doesn't seem to be a big deal to anyone else. Perhaps the scar tissue delayed forming due to the other damage in my hand at the same time?

I'm having a real nightmare of a time getting care for my hand. If you've ever heard horror stories about worker's compensation insurance in the states, they are likely real. I complained that the doctor they were paying to fix my hand wasn't doing any testing, despite my hand being much worse than before surgery. I thought they were being extremely nice by setting me up for an MRI of my wrist and hand outside of my doctor's orders. Should have known better, as the MRI went to a radiologist paid by the insurance company. Their radiologist's report shows nothing wrong. They'll likely stop all treatment soon.

I did get the images on disc though. So, while I don't have a nerve study or ultrasound to offer you, I do have lots of cool pictures of squiggly lines and such. I've looked around the internet quite a bit for an MRI to compare mine to, particularly the gap in the TCL, but I never seemed to find any showing what it's supposed to look like post-release. I hope my poor ligament's sacrifice can be useful to someone somehow. If you're interested in the views of my carpal tunnel (or the whole MRI) just let me know how to get it to you.

Brian

This really is just a very nasty injury I think. I hope that workers comp at least eventually pays out for the disability.

The lump which gives you sensation in the numb bits of the finger suggests that there is a terminal neuroma underlying that lump somewhere. The neuroma itself will be very small so is unlikely to be visible at the surface and is probably not the lump that you can see. What you are describing there is a form of Tinel's sign and is usually indicative of nerve regrowth when you are following up the recovery of a severed nerve. In your case we are not sure quite what the nature of the nerve injury was.

I wonder if the particularly prominent bowstring effect is because you have actually had a much more extensive section of the TCL than is usual just for carpal tunnel decompression. It doesn't have entirely discrete edges but fades out into the palmar and forearm fascia so the conventional operation is in some ways more like making a slit in the middle a sheet of material. As they will have been exploring the palm because of the injury you probably have a much more extensive slit, if you see what I mean. I wouldn't expect to see anything very useful on MRI in this situation so a 'nothing wrong' MRI report is not a surprise, and I'm not very good at reading them so it's probably not worth try to get it to me. I would argue that it was just a waste of money for the insurer myself but then I'm not a radiologist. You might eventually be a candidate for some kind of rescure procedure such as the interposition of a hypothenar fat pad flap between the nerve and the surface but I think it's going to take some time for the burn and surgical scarring to consolidate and re-organise and you wouldn't want to do anything else surgical until it has had a fair chance to settle. Many people believe in massage and physiotherapy of the incision area - I keep an open mind and it almost certainly doesn't do any harm. JB

It was a pretty nasty injury, but I think that what I'm going through now is mainly a result of having a doctor that doesn't care. I had been hoping I'd never have to receive a disability check, but it seems as though it may be cheaper for the insurance company to pay me a small sum for the loss of my fingers than it would be for them to fix all of the issues I'm now having.

Thank you for throwing out the word neuroma, I've been suspicious of that for the last 7 weeks or so. I believe it's actually been growing for about 12 weeks now, since the time of injury. My scar is huge but it stops short of this mass, I don't think my doctor even looked that far. Only in the last 2 weeks has it become large enough to be somewhat palpable.

Your slit in a sheet of paper analogy is excellent, it really clarifies what is supposed to happen vs what has happened to me. My sheet of paper was basically slit in the middle and then cut all the way through the top. I do have to respectfully disagree on the MRI though. I believe the 'nothing wrong' MRI report is only due to the radiologist having the same motivation as my doctor - saving the insurance company money. I'm far from being a radiologist but I've been easily able to identify the neuroma (or other such mass) in many different views, as well as the nerve leading into it and perhaps even a branch of that nerve growing out of where it shouldn't (to the site of my injury on my palm?). The cross section of my wrist at the level of the hook of hamate is particularly interesting and disturbing. It shows the path that my tendons have been following to escape my carpal tunnel, along with the median nerve being right on the edge of escaping also. I should probably find a lawyer who can get me to a good doctor.