Numb 9 Days Post-Op

chasanne48
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Had endoscopic CT release 9 days ago & my thumb, index, middle &, to a lesser extent, my ring fingers are numb with the tips being the numbest. The post-op swelling has greatly subsided.

I am not experiencing any pain & no longer experience the pre-op intermittent pins & needles sensation that would generally go away if I shook my hand. But, unfortunately, the numbness in the affected areas is now constant & clearly worse than pre-op.

The surgery took longer than average & the surgeon informed me that he was having difficulty getting into the tunnel because the area involved was thicker than normal. He asked if I had ever broken my wrist. I was awake during the procedure & on two occasions I experienced pain while the surgeon was operating on my wrist/hand.

Wondering if numbness is because the nerves involved were irritated during the procedure.

I am concerned because I read on this forum that relief of CT symptoms is generally immediate, which is not the case for me. Do some patients still have a successful outcome even when the affected areas are more numb a week after surgery?

Thank you.

jeremydpbland
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Loss of sensation so that you can feel less after surgery than before is worrying but it can sometimes just be a transient problem (neuropraxia) due to the stress on the nerve during surgery. If forcing the endoscope into the tunnel caused an acute and dramatic increase in the carpal tunnel pressure then it could have caused the median nerve to stop working. The hard thing is to guess whether this is reversible, or whether it indicates more serious nerve damage - can you abduct your thumb? How dense is the sensory loss - can you feel a pinprick in the end of the index finger? Do we know what your NCS results were like before surgery. If there were pre-operative studies and you have clear loss of sensation 2 weeks after surgery I personally would repeat them but many surgeons would leave it a lot longer than this. JB

chasanne48
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Thank you so very much for your informative & comprehensive response.

Yes, I can abduct the thumb & have the same full range of motion of the affected left hand thumb as the thumb on my other hand. And yes, I can feel a pinprick on all my fingers. EMG & NCS studies were done 5 years ago, showing CTS in both hands, more severe on the right than left at that time. Had CT release done on right, completely successful. An intervening medical event put the left hand CTS on the backburner. But my left hand symptoms were so mild over the past few years that I was hardly even aware of them. About 2 months ago, I started to feel the classic pins & needles & felt that I had to address it. I was relieved that the surgeon didn't want another NCS study & he opined from his own exam that he didn't think I had suffered much nerve damage over the years & that I should get a good response from a CT release.

Can a follow-up NCS differentiate between a (hopeful) neuropraxia, permanent nerve damage, or a situation in which the median nerve was not sufficiently released?

Again, thank you for the wonderful public service you provide.

jeremydpbland
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Post-operative NCS can often clarify whether re-operation is needed but ideally you need to have up-to-date pre-operative studies (which I think means within 6 months of surgery) for comparison. Judging by that extra information you can afford to wait for a while in the hope that this is just a neuropraxia. If it still feels worse subjectively 4 weeks after surgery then get some NCS done, and if possible ultrasound imaging by someone who knows about this technique in CTS - I am afraid there are not many. JB

chasanne48
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Thank you. Will keep you & my fellow CTS patients informed about my outcome.

chasanne48
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Saw the surgeon. He advised that the release was successful, as I no longer experience pins & needles at night. He is optimistic that the post-op numbness will go away over time, possibly as long as a year but probably a lot sooner. The surgeon believes the numbness is from some sort of irritation to the median nerve during surgery & that it will take time for the nerve cells to regenerate. He told me to take Vitamin B6 (the Mayo Clinic website says OK to take 200mg/day for 12 weeks). He also opined that I did not suffer a cut in the nerve because I was awake during the procedure & he would have known from my reactions if such did occur. There has been an improvement in sensation on my palm below my thumb, but is it possible that that may be from the reduction in swelling that has occurred in that area? Cannot tell yet if finger areas have improved.

jeremydpbland
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That's a slightly mixed set of comments from the surgeon. Relief of night-time paraesthesiae is a fairly good indicator of successful decompression - so long as that symptom is not replaced by loss of sensation. Patients with very advanced CTS often find that the tingling stops and is replaced by numbness, though this is not universal. In your case it sounds as though the numbness is fairly mild rather than being a dense sensory loss so my guess is that the ligament was successfully divided.

If it was symptomatically mild to moderate CTS before surgery (ie no thenar wasting or fixed sensory deficit) then it really should improve quite quickly after surgery - numbness lasting a year is not right and if it lasts that long that is not 'irritation' of the median nerve during surgery - that is substantial damage. Hopefully it will recover more quickly than that.

You can take vitamin B6 in moderation (it is toxic to the nerves in high doses) but there are now good quality studies and meta-analyses that show it is no more effective than placebo in CTS. There is no evidence that it has any particular role in recovery after surgery but at least it is unlikely to do any harm.

As regards your reactions during surgery had he cut the nerve I think that is wishful thinking. If the site is adequately anaesthetised then you should not be 'reacting' whatever he does. However you would have a much more significant neurological deficit at this point if he had cut it, and even with endoscopic surgery lacerations of the nerve are very uncommon. This is much more likely to be a pressure/ischaemic effect.

If your current symptoms persist I personally would repeat the nerve conduction studies at 6-12 weeks post-op, though the lack of up to date pre-operative studies is a nuisance. (I would have done them earlier had your responses to my original questions been different). This is one situation where needle EMG in the thumb might be of interest as acute denervation changes at that point would suggest fairly recent injury. Many orthopaedic surgeons however would just sit tight and hope that it improves so your surgeon is in good company. As I presume you are in the USA how it is dealt with may depend as much on your insurance as on the preferences of your doctors.

Let me know how it pans out please. I would love to have reliable figures on how often this common approach of 'wait and see' employed by the surgeons results in long term good/bad results. JB

chasanne48
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Thank you for your very comprehensive comments. You have presented a lot of info that is very much worth thinking about.

On the hopefully positive side, I have a sense that I may be experiencing an improvement. As I have no way to objectively measure it, I cannot be absolutely certain at this point. Moreover, swelling has completely disappeared from my hand so it may be that development which accounts for my overall sense of improvement. I will have to give it another few weeks to see if I can definitively state that I am indeed having more sensation coming back to my fingers.

If I am absolutely certain that I am not experiencing an improvement in about a month or so, I will seek a second opinion from a surgeon recommended by my internist. I am indeed in the US of A but don’t anticipate an insurance problem.

Regarding vitamin B6, I was quite surprised to learn of studies that indicate it may not be effective for nerve regeneration in carpal tunnel syndrome. Accordingly, I will continue at the daily 200 mg rate for a few more weeks and then reduce it to 100 mg whether my hand is improved or not, eventually getting off of it altogether. Who knows? Maybe I will have one heck of a positive placebo effect???

I am putting it on my calendar to contact you in the latter part of June with an update. Again, thank you so very much for your input & perspective. I remain profoundly appreciative.

jeremydpbland
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A fairly handy way to check progress of sensory loss, although it needs an assistant and a pair of compasses/dividers, is to measure your two point discrimination - the ability to detect the difference between a single pinprick and two closely separated ones on a fingertip. JB

chasanne48
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Giving you the promised update, at three months out it is my distinct impression that the sensory loss in my left thumb has improved. As time goes on, I'll know more & will get back to you.

Thank you for your help on this matter. Chuck

jeremydpbland
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Thanks for taking the trouble to come back. Persisting numbness at 3 months suggests that this is indeed a moderately severe nerve injury, but there is still time for that to improve further. Best wishes.JB

chasanne48
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Just letting you know that I pretty much have 100% recovery.

jeremydpbland
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Thankyou very much - so that took 6-9 months altogether which is probably fair for re-growth of damaged axons from the wrist to the fingers. I think this was probably rather more severe than a neuropraxia but I'm glad to hear it has eventually recovered. JB 

Cecil
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Don't confide in what you are being told about B6 here (some people just don't believe in it, and would criticize the truth). Your operating doctor, and the faculty you've dealt with are experts in the field, and obviously know more about B6.. Here are a few controlled studies done proving the effectiveness of B6

https://www.researchgate.net/publication/242019249_Treatment_of_carpal_t...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3848223/

jeremydpbland
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Cecil - I've moved this posting to a new thread because I think it is worth discussing whether or not B6 is an effective treatment for CTS or not but it will get buried this far down another thread about a specific patient's problems. JB

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