surgery or watchful waiting?

pharminpain
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Any help here will be greatly appreciated!!!

A surgeon diagnosed me with bilateral CTS and R cubital tunnel syndrome. I've had mild CTS symptoms >4 years, however, my symptoms worsened several months ago for unknown reasons. A recent EMG from Jan. concludes that the right is now stage 3, while the left is not positive for CTS on the EMG; Though I do have atrophy bilaterally to the APB. I feel that the symptoms are worse during the day with work, and are minimal at night. The cramping feeling in the forearms and wrists are the most bothersome, besides the weakness in the hand. I'm currently wearing wrist splints at night, and these seem to help relieve symptoms, but when I take them off my symptoms worsen again. I would not be able to wear the splints at work and perform my job duties. I'm contemplating open carpal tunnel release surgery to the right, but am anxious about having the surgery. The questions that I have are: Will my condition progress- since it has been progressing- or could I be one of the lucky patients that my CTS symptoms spontaneously resolve? If my CTS were to spontaneously resolve, how long does it take for such a process to occur? Should I be considering open carpal tunnel release surgery to the left due to the APB atrophy and symptoms, even though the EMG is not positive for CTS on the left?

pharminpain
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1 more question: Is it common to have APB atrophy in grade 3 CTS or even when signs of CTS do not show up on the EMG (as in the case of my left side)?

jeremydpbland
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It is very rare to have genuine atrophy of APB with anything less than grade 4 CTS. The thenar eminence can sometimes appear wasted due to underlying osteoarthritic change and there are cervical root, brachial plexus and degenerative explanations for small hand muscle wasting - not just CTS. If you have the EMG results I can take a look. The thing that seems to be useful in helping to predict spontaneous resolution is the duration of symptoms - the longer you have had it the less likely it is to go away. JB

pharminpain
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Thank you for your quick reply! I emailed you my EMG results from Jan 2017. I understand that open carpal tunnel surgery will stop the progression of CTS, including the muscle wasting, is that correct? My symptoms interfere with my ability to work, but my main concern and what leads me to consider surgery is to stop the muscle wasting. If the muscle wasting is due to another condition, should I still be considering open carpal tunnel surgery at this stage? In 2003, I was diagnosed with TOS; I had and still have bilateral ulnar nerve pain. My latest MRI from Feb 2017 is negative. The other question that I have is do I have irreversible nerve damage at this stage, and if I do would carpal tunnel surgery even help?

jeremydpbland
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Your NCS results seem to show at most very mild CTS. On the sensory studies they are reporting a transcarpal median sensory conduction velocity of 48 m/sec as abnormal while the same measurement on the left hand at 53 m/sec is said to be normal. I don't know that lab's normal values but for a 5 m/sec difference in conduction velocity across a short segment to make a test result abnormal strikes me as being a fairly marginal abnormality. The median distal motor latency is a bit longer on the right side but the most striking thing is the loss of amplitude of the right median motor potential which is 3.2 mV compared to 8.5 mV on the normal side (assuming this is correctly recorded - the traces look reasonable but of course I cannot check the electrode positioning etc). This corresponds to your thenar wasting and is out of proportion to the sensory conduction abnormality which should ring alarm bells for a diagnosis of CTS.

Surgery for CTS certainly should stop any further progression, but if done incorrectly it can aggravate the situation and even when done correctly it can have undesired consequences for the wrist joint. Nevertheless it is usually a pretty successful operation. Neurogenic thoracic outlet syndrome (TOS) can also produce marked thenar wasting so if that diagnosis has also been suggested it makes yours a rather difficult case I think. You don't say what the Feb MRI was negative for, but if they were looking for TOS then it can easily be missed on MRI. The most useful nerve conduction measurement for suspected TOS is the sensory potential from the medial cutaneous nerve of the forearm - about the only thing they did not test. An impressive amount of needle EMG was done, all of which was said to be normal - including the apparently wasted R.APB - which seems a little odd.

You are a little on the young side for CTS too - though that does not of course make it impossible (the youngest case of 'idiopathic' CTS I know of was diagnosed at 3 months). Your case is complex enough that I would not want to give any concrete advice without actually seeing you myself. JB

pharminpain
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My cervical MRI from Feb. was normal and was done to rule out Double Crush Syndrome. I failed to mention that my CTS started after a MVA in 2012. I have a previous EMG from 2013 that reports:

Left Median (Abd Poll Brev) Wrist 6.68 mV (compare to 8.50 mV in 2017)
Right Median (Abd Poll Brev) Wrist 7.45 mV (compare to 3.16 mV in 2017)

I’m confused by these reports, because I was diagnosed with bilateral ABP atrophy. Are these recordings from the NCS the only measurements that are used to diagnose ABP atrophy, or is visual inspection used? In your opinion and just based on these values, how severe would you rate the ABP atrophy?

jeremydpbland
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MVA? Motor vehicle accident? Atrophy is technically an examination finding rather than a diagnosis (visible loss of muscle bulk). Whether it is present or not and how severe it is is judged by eye. However it happens that the surface motor potential that we record when doing nerve conduction studies is roughly proportional to the number of muscle fibres contracting under the recording electrode so it is quite closely related to atrophy. A surface motor potential of 7 or 8 mV (the left side) is fairly normal so it is unlikely that there is severe true loss of muscle fibres in the left thumb and if it 'looks' thin then one should be wondering how it is managing to produce such a good electrical signal. The difference between 6.68 and 8.5 is probably within the normal range of test-re-test variation but the right side is different - that has halved in amplitude in 4 years (suggesting you have perhaps lost about half of the muscle, or at least that half of it is not contracting) so something is changing there. This pattern of change would be rare in carpal tunnel syndrome but could certainly happen in neurogenic thoracic outlet syndrome. Another thing one can correlate with is muscle power - a muscle that looks atrophic but still has full power is usually not actually abnormal. JB

pharminpain
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I really appreciate your time in giving such thorough responses. Thank you!

jeremydpbland
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You are welcome. You can make the exercise rewarding for me by remembering to let me know what the eventual diagnosis and treatment outcome is please. JB

pharminpain
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Will do! And yes, it was a motor vehicle accident. The following is on Wikipedia:
"As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area of the palm, branches off of the median nerve and passes over the carpal tunnel.[53] This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, or pronator teres syndrome."

Is this true and does this correspond to a particular value reported on an EMG or NCV study?

jeremydpbland
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It is true, but as with most things in medicine there are wrinkles. Severe CTS results in sensory loss, as in inability to feel a pinprick for example, in the fingers but not the palm - because of that bit of anatomy. However not everyone is necessarily 'wired up' in exactly the same way so this can be a bit variable from person to person and some of the sensory symptoms of CTS, particularly pain, do not respect anatomy textbooks and often spread outside the territory that they should theoretically occur in.

We do not usually separately measure the physiology of the palmar branch. It might be possible to do it with a near nerve needle technique but would be technically difficult, painstaking and unpleasant for the patient I think. I don't know of anyone who does it offhand. The palmar branch can usually be identified on ultrasound as it leaves the main median nerve above the wrist but in most hands I cannot follow it much beyond the distal wrist crease.. JB

Cecil
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Good day my friend, sounds like maybe you have a choice to make about your career. I was similarly graded with moderate (level 3) CTS in my main (R) hand, and mild in the (L). Sounds like the cause of CTS for you was/is the same as it was for me, a repetitive stress injury @ work (I was operating a crane, and my fingers had to constantly depress buttons, creating the issue)? In any event, whatever your doing that's causing this, you need to stop NOW, if there is any hope of recovery, and in avoiding an operation (which like me appears, again, you do not want). A couple of things that did help me as I was working were a tourmaline wrist strap (to heal and bring blood flow to the wrist: Wrist Support, and a clear capsaicin cream  for the trouble areas, my Rheumatologist prescribed me diclofenac, a very good NSAID. When using all of these together nobody noticed at my work place, and I was pain free; until night time. I then used a handheld ultrasound device to help heal my wrists, which did work somewhat ($200 CA). Consequently though, after my nerve conduction tests with the specialist I decided to quit my job, realizing this was the only way to recover, avoid surgery, and to stop permanent and irreversible damage to the median nerve (If you can get on workers compensation, unemployment insurance etc, do it, I got unemployment insurance). So it's now approx 1 month after leaving my job, my healing has been substantial, I barely have any numbness and tingling, and just a bit of pain below my thumbs; here's how I helped myself to heal. 1) two buckets 1 with ice, 1 with hot water... start with the warm and end with the cold. Go back and forth three times 1 min, 2 min, 3 min 2) ultrasound device (mentioned above) 3) splinting at night (this is very important) 4) Bioactive Curcumin, and B1, B2, B6, and B12 Tthese B vits are super important as they help with pain and also to heal the damaged median nerve. Curcumin is a very strong natural NSAID with analgesic properties. 5) Most importantly *give your wrists a break from any agitating activity* * Good like Phar, I trust you will make the right decision, 'you can and will heal, and get better in time'.

jeremydpbland
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I think we have to bring a bit of balance to that. Cecil has applied so many different interventions simultaneously that it's impossible to know for sure whether any of them have actually made any difference individually. It may well be that laying off work is what has really helped and all the rest is irrelevant. There is, I have to say, quite good evidence that B vitamins make no difference at all to CTS unless you are actually deficient in them.

Cecil - I try very hard to keep this site evidence based and non-commercial. Some of that posting is getting very close to what I would consider advertising for a variety of unproven remedies. I appreciate that you are trying to share experience of what seemed to work for you but this is quite a difficult area. Could I ask that you remove the specific commercial references. For example - I don't mind people posting on here 'Capsaicin cream seemed to help my CTS' - and indeed there is a section on capsaicin in the 'Alternatives' page - but I think mentioning specific preparations is going a bit far. Likewise with commercially sold devices. - Sorry!

Cecil
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Sorry Jeremy, the same could be said about surgery, so many people have had post op or recurring problems it's very hard to say if this has helped. On the contrary, where maybe CTS could have healed over time, with rest and other methods, now you you have permanent damage (IE Injury to the median nerve or nerves that branch out from it, injuries to nearby blood vessels,
a sensitive scar to name a few).

In any event I have removed the commercial links, trust me I'm not trying to sell anything; only to help a fellow comrad in pain (he seems to be also not too receptive to new ideas; having a closed mind) .The methods I have mentioned fall under alternative medicine(s) I'm sure, most clinicians are not educated, trained or versed very well in these, and seem to posses a bias. I have seen a number of controlled clinical trials that have showed B1, and B2 effective for CTS, don't wanna post links at this point, as I may be breaking rules. Adequate intake of vitamin B1 ensures the development of myelin sheaths and aids nerve functioning. It is also required for regulating the transmission of particular types of nerve signals along the brain and the spinal cord. B2 keeps tissue healthy and to help accelerate healing of injuries & protects the nervous system. B6 acts as an analgesic by raising pain thresholds; all proven.

jeremydpbland
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Thanks - I've made a couple more minor edits too, hope that's OK. I've reviewed all the B-vitamin literature and there is also a systematic review specifically of the issue of Vit B6 which enjoyed a vogue for treatment in CTS some years ago. I'm afraid none of the 'evidence' really achieves the standards required for evidence based medicine. If you think you know of a published study which I may not have seen by all means post the reference (not a manufacturers website). I don't think the medical establishment is overtly biassed against 'alternative' medicine and you will find a comprehensive list of alternative treatments for CTS in the treatment pages (I have a few more to add at the moment but little time for editing). We do however have quite high standards for evidence. Any treatment that can clearly be shown to work we will usually be happy to adopt, regardless of where it comes from. Advocates of 'alternative' medicine usually seem to have bigger budgets for advertising than for conducting well designed studies of their treatments I'm afraid and the standards of research into alternatives are lamentably poor. JB

Cecil
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Agree with you here.. that the medical data does exist to support, but that not enough studies have been done for it to be proven or conclusive; and probably never will. I know all of my physicians would agree with you too Jeremy, save my Naturopath, that employs an array of practices branded as "natural", "non-invasive", and as promoting "self-healing, rather than evidence-based medicine, and have provided me with some of these therapies. Also, Naturopathic physicians are the only medical professionals formally educated to practice pure natural medicine independently or in conjunction with conventional medicine, so their opinions based on their exceeding knowledge in these fields, would be alot more objective than their counterparts. 'We can't help everyone, but everyone can help someone'.

pharminpain
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JB- If the APB atrophy is definitely due to CTS, would you recommend open carpal tunnel surgery, regardless of the severity of symptoms? Is this level of atrophy something that should drive the decision for surgery- if we knew that CTS was definitely the cause of the atrophy? Thanks again!

Cecil
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Oh and your welcome Phar

pharminpain
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Cecil- Thank you for your thoughts. However, I agree with JB on this topic, and I don't think it's fair to say that one is bias or not educated just because they don't support the above mentioned- there is a lack of strong evidence for the treatments that you mentioned. If there were more clinical trials on these- double-blinded, randomized with statistical power- they would make the cut and be incorporated into the practice guidelines.

Cecil
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Fair enough, it seems you have quite different logic in the UK. I would liken it to 'tunnel vision', how has this rationale helped you so far? We need enlightenment, not just individually, but collectively. If I were a betting man I'm guessing you do what you're told, and go for the surgery.

POINT BEING (seems you've all missed it): Given, what works for one person may not work for another, and that it may be hard to discern what the most effective treatment is/was. Wouldn't you want to do all that you can to help yourself (some very backwards thinking here people)?

jeremydpbland
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I would not view atrophy as an indication for mandatory surgery in itself. Once it has developed it usually does not recover after surgery so in a sense it is too late so there is not much reward in operating to try and reverse. If weakness of the thumb is a serious problem then one might have to consider a more complex procedure known as 'opponensplasty' and if it's not a problem (as it is not for some people) then why bother treating it? JB

jeremydpbland
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Evidence based medicine is pretty much the same worldwide and is, in my view at least, one of the greatest achievements of  human rationality. It allows us to overcome our innate biasses and psychological maladaptations to arrive at courses of action which are most likely to benefit us. It provides exactly 'enlightenment' and its methods are equally applicable to 'alternative' medicine, though for some reason practitioners of many alternative disciplines are unwilling to submit their treatments to proper scrutiny. That doesn't entirely deny the value of personal experience - many effective treatments started with one person noticing an improvement in their symptoms after doing something - but before we start officially recommending anything for general use by everyone we need to know that it is cost-effective and safe, and one person's experience is not enough to do that. If you are interested in how the world of 'medical' treatment works I can recommend Ben Goldacre's books which provide a very accessible lay introduction JB 

pharminpain
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JB- I hope that these are my last questions for you :/ What keeps CTS progressing? Is it the activity that aggravates or causes it to flare up in the first place, or will CTS just continue to progress with age? I might have asked a variation of this question before- but, is it likely that more atrophy will occur, if CTS is not treated surgically?

jeremydpbland
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It's a very good question and we don't really have a definitive answer. The best guess I can come up with for the pathophysiology of the condition is set out here on the site - if you start reading at the 'About-CTS' page and just keep following the links at the bottom of each section. This theory of causation is supported by a fair amount of circumstantial evidence but is only a theory. In terms of natural progression if untreated it can do anything. It can be a monophasic illness which spontaneously remits, it can run a relapsing/remitting course, or it can get progressively worse, and after following any of these patterns for years it can then switch to one of the others. Your 'atrophy' is interesting and unusual and I wish I could see your hand and test it but you are clearly not in my catchment area! I am not altogether sure that it is necessarily due to CTS. JB

pharminpain
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Hi again,

I had open carpal tunnel surgery to the right about 1 month ago. Tingling is gone and most of the forearm pain is gone. Question is should I still be feeling wrist pain this far out? When my wrist is bent and light pressure is applied- e.g. Changing diapers- there is some pain that I'm feeling. The surgeon did not suggest that I go to physical therapy or massage the incision, but wondering if I should be doing those things now.

jeremydpbland
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It's not uncommon to have wrist pain after carpal tunnel surgery for some time, and if you are very unlucky it can be effectively permanent - a side-effect of cutting the ligament. Different surgeons have varying ideas on how to minimise the risk of this problem and how to treat it when it occurs. Various forms of massage and hand therapy are popular options but the evidence that they actually make a difference is scanty to say the least. Most such interventions though are at least harmless and there is probably some psychological benefit in feeling that you are 'doing something' about the problem so I don't object to these being tried. I just never promise dramatic cures. How's the wasted thumb doing? JB 

pharminpain
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It feels a little strained at times, but I think it's better. Im thinking about getting another NCV/EMG in six months to see if there are any changes in both right and left.

How long do you recommend or how long should one avoid heavy lifting after surgery? And what do you consider heavy lifting to mean?

jeremydpbland
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Three months post-op for follow-up NCS is long enough to see if there has been any change if one is doing it out of curiosity but waiting longer is not a problem.

Heavy lifting is interesting - quite a lot will depend on how you carry out a lift but if it was me I would avoid doing anything more strenuous than lifting the proverbial 2 lb bag of sugar for about 2 weeks post-op. In terms of the activities of daily living that I encounter in my, relatively ordinary, daily life the things that probably raise my carpal tunnel pressure the most are heaving 20 kilo suitcases around when travelling and lifting our very substantial mattress to get a fitted sheet round it (don't laugh, a US colleague of mine has a patient who gave themselves acute CTS doing this!). I would avoid activities like that for about a month and then re-introduce them cautiously, laying off if it hurt much. JB

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