CTS in paraplegic

DWB
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I am a 66 year old male and a T5 paraplegic for the past 41 years. I have been diagnosed with CTS in both hands. Both Nerve Conduction test and EMG confirmed this diagnosis - moderate in my left hand (which bothers me the most) and severe in the right/dominant hand (which bothers me very seldom). After researching the data, it is not surprising as I use a manual wheelchair for all of my mobility on a daily basis. I am single and live independently.

My question is in regards to CT surgery and post surgical issues. I would have one hand done at a time. I have looked at information regarding open as well as endoscopic release and it appears endoscopic would be the least traumatic to my hand as the incision is more at the wrist as opposed to on the palm which is used to propel the chair (your thoughts are appreciated).

However, my concerns are in regards to
1.Transfers (wheelchair to bed and back to wc). Can this be done without adversly affecting the healing, resulting in problems in the future? Would a temporary splint to stabilize the wrist be helpful? If transfers are not possible, how long after surgery before it would be allowed?
2.Continuing to use a manual wheelchair during during the post surgical healing. Since the primary pushing on the rims is a pinching with the thumb and other fingers will this be possible?
3. I would assume post surgical PT would be advised?

Obviously this is a somewhat unique situation, but I am sure, not unheard of. There is very little information on the web regarding CT release and paraplegia. I have an appointment with an orthopedic hand specialist next week to discuss my options. I am open to any ideas or input you might have.

Thanks in advance

jeremydpbland
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There is actually some scientific literature specifically on CTS in wheelchair users (some 10 papers in my reference database) but it is mainly concerned with whether wheelchair use causes CTS, not with how to treat it. There clearly are some practical issues with surgery and you will find it difficult to manage for a few days afterwards. Endoscopic surgery may help to alleviate this problem a little but it is important to remember that, however the operation is done, the whole object of the procedure is to cut the transverse carpal ligament and whether or not an incision is made through the overlying skin is probably of lesser importance for wrist function overall.

I would probably be trying to avoid using the operated hand for chair/bed transfers for at least 3-4 days, even after endoscopic surgery. How much the procedure affects your ability to use a manual chair and whether physio would help is going to be highly variable from one patient to the next and I would not make any hard and fast predictions. Your surgeon will have definite ideas on post-operative care I am sure and you should follow that.

Personally my starting point here would be to try and avoid surgery if at all possible but I would want to know the actual NCS measurements before making any recommendations - unfortunately 'moderate' and 'severe' have no widely accepted definitions and can mean anything. JB

DWB
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Dr Bland:

Here are the results of my NCS and EMG that you mentioned in your post. Any additional input you might have is appreciated. This is a great site for CT patients!!!!!

Nerve Conduction Studies: Nerve conduction studies were explained to the patient, including risks and benefits. Patient understood and agreed to the testing. Extremities were appropriately warmed. All amplitudes given are baseline to peak amplitudes. All sensory latencies are peak latencies and all motor latencies are onset latencies. Results are as follows: .
Right Upper Extremity:
1.Right median nerve sensory distal latency at 14 cm is unobtainable.
2.Right ulnar nerve sensory distal latency at 14 cm is 3.7 msec and amplitude 9.0 V,
3.Right radial nerve sensory distal latency at 10 cm is 2.6 msec and amplitude 16.7V.
4.Right median nerve motor-distal latency at 8 cm is 5.1 msec and amplitude 2.3 mV and conduction velocity is 48.8 m/sec.
5.Right ulnar nerve motor distal latency at 8 cm is 3.3 msec and amplitude 8.7 mV and conduction velocity is 54.5 m/sec.
6.Right ulnar nerve motor study across the elbow reveals below elbow latency of 7.0 msec with amplitude of 8.9 mV and the above elbow latency is 11.3 msec with amplitude of 7.5 mV, and over a distance of 25.5 cm conduction velocity is 60.0 m/sec.

Left Upper Extremity:
1.Left median nerve sensory distal latency at 14 cm is unobtainable.
2.Left ulnar nerve sensory distal latency at 14 cm is 3.6 msec and amplitude 12.7V. b 3.Left radial nerve sensory distal latency at 10 cm is 2.4 msec and amplitude 18.0 V.
4.Left median nerve motor distal latency at 8 cm is 5.2 msec and amplitude 4.8mV and conduction velocity is 52.3 m/sec
5. Left ulnar nerve motor distal latency at 8 cm is 3.3 msec and amplitude 8.6 mV and conduction velocity is 53.6 m/sec.
6.Left ulnar nerve motor study across the elbow reveals below elbow latency of 7.3 msec with amplitude of 8.3 mV and the above elbow latency is 11.9 msec with amplitude of 8.3 mV, and over a distance of 27.0 cm conduction velocity is 57.8 m/sec.
Electromyography: Needle electromyography was explained to the patient, including risks and benefits. The patient understood and agreed to the testing. A sterile disposable monopolar needle Was used. Results are as follows:

Right Upper Extremity:
The right abductor pollicis brevis reveals occasional positive sharp waves, occasional fibrillation potentials, also occasional polyphasic motor unit potentials, with normal appearing motor units, normal recruitment, with slight decreased interference pattern.
The right first dorsal interosseous, flexor carpi ulnaris, pronator teres, brachioradialis, triceps, biceps and deltoid were all silent at rest, with normal appearing motor units, normal recruitment and full interference pattern. . .
Left Upper Extremity.
The left first dorsal interosseous, abductor pollicis brevis, flexor carpi ulnaris, pronator teres, brachioradialis, triceps, biceps and deltoid were all silent at rest, with normal appearing motor units, normal recruitment and full interference pattern.

Cervical Paraspinal Musculature:
The right and left cervical paraspinal musculature from C4 through T1 were examined; all were silent at rest,
Electrodiagnostic impression: .
1. Abnormal nerve conduction studies of the right upper extremity.
2, Abnormal nerve conduction studies of the left upper extremity,
3. Abnormal electromyography of the right upper extremity, with normal electromyography of the right cervical para spinal musculature.
4. Normal electromyography of the left upper extremity and left cervical paraspinal musculature.

Discussion; Nerve conduction studies and electromyography were performed today to both upper extremities of Dr. Baesel, and overall results revealed abnormalities. In particular, on nerve conduction studies, the right median nerve sensory SNAP distal latency is unobtainable, and the right median nerve motor CMAP distal latency is prolonged with diminished amplitude and diminished conduction velocity. In the left upper extremity, the left median nerve sensory SNAP distal latency is unobtainable, and the left median nerve motor CMAP distal latency is prolonged with normal amplitude but low limits of normal amplitude and normal conduction velocity but low limits of normal conduction velocity, The right ulnar nerve sensory SNAP distal latency is mildly prolonged with normal amplitude, and the right ulnar nerve motor CMAP distal latency is within normal limits with normal amplitude and normal distal conduction velocity as well as normal conduction velocity across the elbow. The left ulnar nerve sensory SNAP distal latency is within normal limits but upper limits of nomal with normal amplitude, and the left ulnar nerve motor CMAP distal latency is within normal limits with normal amplitude and normal distal conduction velocity as well as normal conduction velocity across the elbow. Radial nerve sensory study was also performed today to help rule out peripheral neuropathy and it is within normal limits in both upper extremities including distal latencies and amplitudes. With regards to electromyography, there were signs of acute and chronic axonal denervation in the right abductor policis brevis with acute findings of occasional positive sharp waves and occasional fibrillation potentials and chronic findings of occasional polyphasic motor unit potentials though amplitudes were normal and recruitment was normal, there is also slight decreased interference pattern. All other muscles. tested in the right upper extremity were within normal limits, and all muscles tested in the left upper extremity were within normal limits and the right and left cervical musculature were all within normal limits as well. No other abnormalities were noted today,

The above-mentioned abnormalities are most consistent with: 1) A severe right median nerve focal compressive neuropathy at the wrist with acute and chronic axonal denervation findings consistent with a severe right carpal tunnel syndrome including signs of acute and chronic axonal denervation findings. 2) A moderate to high moderate left median nerve focal compressive neuropathy at the wrist consistent with a moderate to high moderate left carpal tunnel syndrome. 3) A mild right ulnar nerve focal compressive neuropathy at the wrist. No other abnormalities were noted today including no signs of radiculopathy, plexopathy, peripheral neuropathy, other areas of focal compressive neuropathy (though the left ulnar nerve sensory SNAP distal latency is upper limits of normal), and no signs of myopathy,

jeremydpbland
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OK in my terms that is grade 4/6 bilateral CTS, slightly worse on the right but not enough to take it into grade 5. All other factors being neutral I would generally slightly favour surgery for grade 4 but a fair number of my patients decide otherwise and try injection with a few of them getting surprisingly good results. I think a lot of people reason that it does very little harm to give injection a try and one can always operate shortly afterwards if there is not a dramatic benefit. Here the wheelchair issue might encourage one further along that line - has anyone considered the possibility of treating it with steroids? JB

DWB
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I really appreciate your time and input.

I have an appointment this coming Monday with an orthopedic hand specialist, who trained at Mayo in Rochester, to discuss my situation. I really like your conservative approach of doing a "trial" with steroid injection to see how it responds. The worst that can happen is no improvement, or maybe I get lucky.

I will respond after my appointment and fill you in on the discussion with my Doctor. Thanks again.

jeremydpbland
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To be wholly accurate - the worst that can happen is that you can lose a fingertip I think - but I am aware of only 4 cases of that worldwide after injection for CTS. I'm working on a study of the risks associated with injection at present and the risk of serious problems, if it is done by someone competent, appears to be <1/1000. Much safer than surgery basically. JB

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