Any experience of CTS surgery after breast cancer surgery?

That is a somewhat tricky situation. I know of one paper addressing the issue

Assmus, H. and F. Staub (2004). "[Postmastectomy lymphedema and carpal tunnel syndrome. Surgical considerations and advice for patients]." Handchir Mikrochir Plast Chir 36(4): 237-240

The abstract is as follows and seems to suggest that surgery can generally be undertaken safely

PURPOSE
Following surgery for breast cancer, an increased risk is assumed for development or worsening of lymphedema following hand surgery procedures. The aim of this study was to find out whether surgery performed with exsanguination using a pneumatic tourniquet has any disadvantages under these circumstances. There might result consequences for patients' information of possible risks as well as for performance of hand surgical procedures.

METHOD:
52 patients who had undergone mastectomy were included in the study. In 47 of these, axillar lymph node biopsy or dissection had been performed. 41 patients had been advised not to allow measurement of blood pressure, drawing of blood or surgery to that arm. Surgical release of the retinaculum flexorum by using local anesthesia and exsanguination for a maximum of ten minutes was performed at an average of 7.5 (range from 1 - 26) years after the breast operation.

RESULTS:
Following release of the carpal ligament a temporary swelling of the arm or hand was found in four patients, which persisted for 2 - 3 months in one patient and disappeared within one week in the others. Three patients suffered from moderate lymphedema before surgery. It was unaffected by hand surgery in two patients and only temporarily worsened for several days in another patient. In all patients, neurological symptoms (paresthesia, numbness and pain) improved completely. Other complications, particularly infections, were not observed.

CONCLUSIONS:
1. Exaggerated information of patients with breast surgery in their history does not seem to be indicated in minor hand surgical procedures. 2. The hand surgeon should inform the patients preoperatively that there may occur a transient swelling which can be avoided by loose dressings and early functional training. Using a pneumatic tourniquet has no adverse effect on existing lymphedema in short lasting procedures. 3. Since patients after mastectomy and/or axillary dissection often complain about arm pain and paraesthesia, not only brachial plexus pathology but also a carpal tunnel syndrome must be considered.

Unfortunately the paper itself is in German and my German is more or less non-existent. If anyone would like to volunteer to translate it I have a copy in pdf form.

The other thing that occurs to me is - are you taking any kind of continuing hormonal therapy for the breast cancer? (Tamoxifen, Exemestane, etc). Some of these drugs are known to cause CTS and I rather suspect that most of them carry some degree of predisposition. JB

Thank you very much for your response to my query. I found the summary you gave of the research paper very useful, informative and quite reassuring to the point where I will confidently go ahead with the carpal tunnel release surgery on both hands. I would like to read the whole paper, but like you, my German is very limited and certainly does not include any medical terminology. I may, however, be able to get it translated by a friend who is a retired languages teacher and I could then let you have the English version. Would you be able to put the pdf on this site please, or would you have to email it separately?

In answer to your question about any continuing hormonal therapy for my breast cancer, I have not taken any drugs since my mastectomy 7 years ago and I did not have any chemotherapy or radiotherapy after the surgery. I have, however, been going through the menopause for the past two years so I'm aware that my hormones are in a state of flux at the present time. Could this have affected the onset of the CTS?

Thank you again for your advice and please let me know if you would like me to attempt to get the German paper translated.

The .pdf is copyright so I cannot post it on a public website but giving a copy to an individual for research/tanslation/personal study purposes would generally be considered legitimate so I will email you a copy. The menopause does seem to have something to do with CTS as there is a marked peak in the incidence rate in women in the few years after the menopause - in my data it reaches its maximum at age 58 - so that could well be a factor in your case. JB

Hi Penny13, If you have trouble with getting the article translated, please let me know. I am German, but I have lived for 4.5 years in New Zealand. I have studied biology/ecology/zoology in Germany and New Zealand. I may be able to help, but I cannot promise it. Let me know if you need help. Cheers, Moni

Hi Penny13,

Just wondering if you have had the surgery yet and how it all went. I am in a similar situation, I had a lumpectomy in my left breast in 2002 with 10 lymph nodes removed from under my left armpit. I was also told to avoid injections, cuts, surgery to my arm. I have arthritis and have now been diagnosed with carpel tunnel in my left hand. I have spoken with Macmillan Support, Breast Cancer Care and Lymphadema Support and they have all told me there is a risk involved with steroid injections and/or surgery to relieve the Carpel Tunnel symptoms. If you read this and don't mind responding, I would appreciate your comments and also if Dr Bland is available to respond that would be great.
p.s. The German research looks interesting how did the translation go?
Thank you.

So far as I know Penny13 went ahead with surgery but I have not heard any more since early December and if it went well I guess she might not have any reason to log back in here. I haven't come across any more useful evidence either so that german paper is still about it so far as published evidence goes. I would like to know on what basis Macmillan/BCC/Lymphoedema support have made their comments - are they saying that there is a problem based on published evidence which I do not know about?.... or their own unpublished experience?.... or are they just being cautious and saying there is a 'risk' on purely theoretical grounds. There undoubtedly is a risk of course - there is risk of some kind in almost everything we do - the question is how much risk and risk of what? If they do have some actual evidence of risk they should come out with it because the current state of the scientific literature is pretty poor. JB

When I asked Macmillan etc if there was any evidence e.g. papers, stats etc. they said that as far as they were aware there wasn't, and they were basing their comments on their experience. They all said that it was entirely possible that everything would be OK and that the decision was mine. What are your views, do you feel that there is a risk that I could develop Lymphoedema? At the moment I am putting up with the pain and I haven't used a splint on my left arm, would you recommend trying that first? Really appreciate your taking time out to answer these questions.

Well in that case the german study is really the only thing we have to go on and that seems to suggest that the risk is low. Given that carpal tunnel surgery has a small but significant disaster rate anyway I would probably be more worried about the outcome of the surgery for CTS than about aggravating lymphoedema. Unfortunately I can find no data at all relating to steroid injection in the context of lymphoedema so that remains a complete unknown. Whatever you decide to do I would appreciate an update on here in due course saying whether it caused a problem or not - at this rate it will be a while before we have enough people to rival the germans but we will get there in the end. JB

If I go ahead I will let you know, my pain threshold is fairly high, so I will hold off for a while, just in case it miraculously goes away...I have been lucky in the past. After the breast cancer, in 2003 I was diagnosed with bone mets and treated for this for about 8 years with Zometa (this was in Australia). I returned to England a few years ago and after receiving treatment for a year my case was reviewed and my oncologist told me that I had somehow or other managed to get rid of the bone cancer and was now only suffering from osteo arthritis...so you never know maybe I can do the same with the carpel tunnel!! I'll keep you informed and thanks for your help.

Some cases of CTS do improve without treatment, there are some notes on the non-surgical prognosis page here. Do you know how bad your neurophysiological results are? - the more severe cases are probably best not left untreated. JB

Don't know what my neurophysiological results are as my GP just asked me a few questions and then made his diagnosis, however my questionnaire score on your site was: ANN = 64% LRP = 36%, so I think it is moderate. I will keep you updated, so you can add my data.

That 64% score makes it very likely that the diagnosis is correct but unfortunately it is not possibly to reliably gauge how bad the nerve damage is from clinical examination alone. By the time the clinical signs are obvious it is actually too late for the most successful treatment. You really should have some nerve conduction studies performed - especially if considering surgery. In most areas of the UK GPs can now request these directly but there are a few places which do not do this so how easy it is to arrange rather depends on where you are I am afraid. JB

When you say nerve conduction studies performed, is there a specific test that I could mention to my GP? - thanks

The electrical tests for CTS are generally known as either 'EMG' or 'NCS' - standing respectively for ElectroMyoGraphy and Nerve Conduction Studies - whether your GP can request them directly will depend on which bit of the country you live in. I have had a message from Penny13 to the effect that she has had her surgery and is now recovering but is unable to use the keyboard much as yet so does not want to try and write long replies on here until more recovered. She has suggested that you might like to contact her directly and if you would like to do that she has given me permission to send you her email address. JB

Thank you for the information on the tests and yes it would be great if I could make direct contact with Penny13 (very kind of her) - I appreciate your prompt response.

Hi Penny13,
I had Grade 3 invasive breast cancer, unaffected lymph nodes in 2006.(left)
I have suffered with CTS ever since the chemotherapy finished and I started Arimidex.
I have had the op on my right hand and the trigger finger done on the left(breast cancer side) I am in a couple of days going to have the carpal tunnel op on my left hand as I can't stand the pain anymore and the sleep depravation!
When I had the trigger finger done on the breast cancer side the surgeon didn't use a tourniquet?
Will let you know

Hi Dr Bland,

I contacted you earlier this year about my possible carpal tunnel diagnosis and the fact that I had lymph glands removed from the affected arm. I just want to give you some feedback about how I'm going:

I searched the net and read up about low level (or cold) laser therapy and found a Chiropractic Clinic offering the service and went there for treatment. I paid privately for this (cost of treatment approx £200), and the treatment involved about two applications of laser surgery, accompanied by accupuncture over about a six week period. Since finishing the treatment, my symptoms have almost disappeared. Every now and then I feel a slight tingling in my hand, this is a good sign for me to stop typing or whatever it is I am doing that involves using my left hand.

I also made contact with another person using this forum with similar issues to mine and unfortunately she is suffering now from drainage issues in her arm since having surgery. I cannot say for sure whether or not I did actually have Carpal Tunnel as my local GP refused to do the tests on me as you recommended, however I can say that the laser therapy and accupuncture has been extremely helpful and beneficial. I feel as though I have 'got my life back' and I am very glad I opted not to have injections/operation. OK, it cost me my holiday money, but I wouldn't have enjoyed going away if I was still suffering from that awful tingling. I would like to thank you for your insight and help with my problem, after my GP's strange attitude, I feel as though you have restored my faith in the medical profession.

Isabella

Well at least we have three of you now on the forum with some shared experience of the situation, which is useful. It's a pity we never did get any nerve conduction study results for you of course but as long as you no longer have significant symptoms that is not a big issue. It is impossible to say for certain whether the treatments actually made a difference or whether it would have got better anyway - always the problem with single patients and a condition which undergoes natural remissions in a significant number of cases. If it was CTS one would guess that there might be a significant chance of it recurring at some point, though I don't want to be too pessimistic. I would therefore be curious to know if you are still OK in 6-12 months. JB

I have been reading through this conversation and while I don't actually suffer from CTS I currently have been diagnosed with de quervain's tenosynovitis. In 2008 I had a left breast mastectomy with Lymph Node removal. now 5 years on I have been advised by my doctor I need to have surgery on my effected arm, I do have slight lymphedema in my upper arm mainly and am petrified about the results surgery could do to my arm. I have already had an injection in the left wrist with no real issue was surfing the net to try and find similar experiences of peoples out there but am afraid am not finding much. I almost feel I have to have the surgery as the pain is so severe it effects all aspects of my daily life now. any feed back on other peoples experiences would be greatly appreciated.

In terms of effects on lymphoedema I would expect surgery for de Quervain's to be very similar to carpal-tunnel surgery. What little evidence is available seems to suggest that the chance of encountering serious problems is fairly small. JB

Hi,
I just came across this forum because I am trying to research something for my mom who is in Europe and doesn't speak English. She is terrified because she had her breast cancer few years ago with 16 of her lymph nodes removed. Unfortunately, she was diagnosed not only with CTS, but also de Quervain in that "unlucky" arm/wrist/hand. Where we are from, the doctors have never performed a surgery such as this before- CTS and de Quervain on a wrist that is already very weakened. She can barely do anything with this arm/hand as it is, and now she has to go through those procedures. She is in a great amount of pain, and I don't know what's the possible outcome. She has had those two deseases for over a year. She never had any injections done because she was not offered one. What do you think about her situation? This is a timely manner because she is supposed to schedule her surgery soon, and she is scared and has no idea what to do. But seeing her in this amount of pain, I would go ahead and do it. What do you think? Thank you.

Lilka

Provided the diagnoses are secure then I would probaby go ahead. As you will see from the discussion above there is very little documented evidence/experience but what there is suggests that surgery is actually fairy safe in these circumstances. We have done a few injections for CTS in arms with lymphoedema without problems but again, there is no large published series. JB

Thank you. I told her she should do it. I just hope the nerve isn't destroyed much because she does not listen to people telling her not to work or do anything with that hand for that matter. This actually goes for both, CTS and de quarvain. Keep your fingers crossed for my mom please. I think she will have the surgery next week! Thank you again.

Lilka

I presume that she has had some nerve conduction studies done and that these do definitely show evidence of CTS? Although I think surgery can be safely performed in the presence of lymphoedema it would be stupid to do it if the diagnosis is wrong. JB