Have i done the right thing?
Too late now as had carpel tunnel release on right hand yesterday. Symptoms started a year ago, tingling, numbness and excruciating burning pain at night. NCS showed moderate CTS in both hands, but how reliable are these studies? Burning passed and other symptoms settled to mild tingling. I was called for surgery but was unsure whether to proceed. Concerned about nerve damage I consented to the procedure. I'm now worried if I was right, is it possible CTS can go away? Worried about pillar pain too. Too late for right hand, bt what about left?
Hello Post Op,
Regarding your concern about pillar pain. I had CTS release surgery on my left hand over a year ago. I too was concerned about my hand being sensitive to loading for many months after surgery. However after 12 months it is now fully recovered, with no notable difference compared to before the operation, or compared to my other hand that has not had CTS surgery.
Nerve conduction studies are pretty reliable as physiological tests go, though they do depend on the skills of the person doing and interpreting them (much more than on the machine, contrary to what some manufacturers would suggest). The main issues one has to allow for are:
False negatives - a few people with undoubted CTS have normal nerve conduction studies. There is argument over exactly how many with estimates ranging from 0.5% to 30%. It is impossible to be sure in the absence of a better test but my best guess as to the false negative rate of modern techniques is around 5% - 1 in 20 hands.
False positives - The way we work out our 'normal' range of values for the NCS measurements mean that there will be about 5% of the normal (no CTS) population who have 'abnormal' results. On top of this there will be some people who do have mild CTS but whose symptoms are mainly due to something else. Both of these situations may be considered false positives.
A better way of interpreting NCS in possible CTS cases is not as the arbiter of whether the disorder is present or not but as a measure of the severity of nerve damage. Interpreted in this way, a normal result in someone with clinical CTS is not a false negative but a very reliable indicator that there is no irreversible nerve damage and mild abnormalities in patients with symptoms which are not altogether typical can be viewed with caution as possible red herrings. Using NCS in this way requires a relatively sophisticated and reproducible way of expressing how bad the results are and how they are changing. Unfortunately far too many NCS are simply reported as 'mild/moderate/severe' with no proper indication of what these terms mean so we cannot know quite what your 'moderate' CTS actually looked like. Irreversible nerve damage begins at about grade 4 on my NCS rating scale.
CTS can resolve, or at least improve, spontaneously without treatment, possibly in about 20% of cases based on an Italian study, but there is no wholly satisfactory study of the natural history of untreated CTS to give an accurate idea.
Pillar pain that becomes a permanent disabling problem is fortunately relatively rare so I would not worry at this stage, one day post-op. However it is well worth waiting a few weeks to see what happens to the other hand after surgery on the first before deciding what to do about it and possibly repeating the NCS.
The fact that people have two hands and that CTS is mostly a bilateral disorder presents lots of statistical problems in analysing trials of treatment but in one sense it presents an opportunity for a trial which I would like to see done. Someone should take patients with CTS which is symmetrical in terms of both neurophysiological severity and the subjective severity of symptoms, of whom there are a reasonable number, and get them to have surgery on one hand and steroid injection on the other. One could randomise them regarding hand dominance so that equal numbers of dominant and non-dominant hands ended up with surgery or injection. This would require about 1-2 years follow-up and then the patients opinions on which was the better overall option for treating it would be very interesting indeed. To my knowledge such a study has not been done - perhaps because of the difficulty of finding enough patients with such symmetrical disease. JB