Intraneural injection

Worried Dentist
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Hello Dr Bland,

I discovered carpal-tunnel.net when im looking for answers
Im asking for your help doctor, for medical opinion.

I am a male, 38yr old dentist. Left handed.

My left hand started to have aching pain on the palm area that persisted days after painting the room in my house for several hours. After one week. I decided to visit the gen ortho surgeon for check up.

My chief complaint is "pain in my palm below the fingers". During the physical examination of my hand, because im a very detailed person, I also told the doctor that sometimes when im doing a very long dental procedure (30mins to an hour) and my hands are fixed in a extension position, I experience mild numbness that will go away instantly after i place my hands in neutral position. I didn't clarify to him that the numbness is not related to the recent pain in my palm. I totaly regret telling the doctor about the mild numbness.

He then focused on the numbness during his physical examination.

He instructed me to do a reverse phalen's test for 1 minute. And by using his pen. He randomly slide the pen on certain parts of my forearm palm and fingers on my left hand. i told him i dont feel anything different he then slide his pen again on my fingers and I told him i think there is a very minor difference on the sensation on my ring finger, which im not that sure. After i made that comment he concluded that i have early signs of CTS.

The doctor told me that the early signs of carpal tunnel syndrome is due to the several hours of painting I've done a week ago.

He instructed me to wear splint and anti inflammatory meds.

I ask him "can i remove the splint if im doing dental work?" He told me that i need to rest my left hand for two weeks and i dont have the option to work. I said to him that i have a very busy clinic week coming.

He then told me that "we can do steroids"
Im with my wife during the check up. My wife is also a physician (obgyn) she ask the doctor on what to expect after injecting me with steroids. The doctor told us there will be "instant relief". I decided to go with the procedure not knowing the risk and because we knew the doctor, i gave him my full trust.

He instructed me to rest my elbow on the table, raise my hand and do a 90 degree hand extension. our position is we are in front of each other between the office table. He's specific instruction is "you should feel something during the injection, to know we are on the right area". The doctor injected me at my wrist area.

He used a cocktail of triamcinolone and local anesthresia.

During the injection. I started to feel electric shooting sensation from the injection site (wrist) to the fingers then middle of the procedure i started to feel a very painful shooting pain that radiates from my wrist to the thumb.

After injection. My hand is numb.

Several hrs after the injection my hand begins to experience severe pain and numbness. I cant hold anything because it hurts.

I managed to taked to the doctor few days after the injection and told him of the new symptoms im experiencing. Unfortunately he just told me that i just need to wait for a few days for the steroids to kick in. And he also told me the reason of the new symptoms is that maybe my cts begins to get worst. My comment is, "can cts develop that fast?" I also ask him for the possibility of nerve injury because of the injection? He's answer is "i did not hit your nerve" "i dont feel any resistance on the syringe during administration of the drug" he then instructed me to do nerve conduction studies. I asked him can the nerve conduction study show if i had nerve injury due to the steroid injection. His answer is "no".

I decided to have my hand checked by another doctor. 3 of them (1 gen ortho surgeon and 2 ortho hand specialist) all of them diagnosed my chief complaint, Tenosynovitis. My current hand ortho doctor is the one who told me that my problem is because the steroid is injected intraneural.

I had emg ncv and mri done 1 month after injection as requested by my current doctor. 3 months after injury another emg ncv is done by the request of my neurologist.

My current hand doctor told me that carpal tunnel release will not be beneficial to my nerve injury because i don't have any compression problem on my wrist. The problem is the nerve itself because of the intraneural injection of the steroids. I should just have to wait for the nerve to heal itself.

Symptoms of my left hand after injection:
Started with numbness and pain on areas innervated by the median nerve and it progress to loss of touch perception. There is also an episode of swelling on my palm and fingers 2 weeks after. After almost 1 month i begin to feel weakness on pinching and grip. And also constant pins and needles on finger tips. 2 months after touch perception improves slowly. 3 months after, intermittent episodes of pain started to radiate to my forearm. My condition now 7 months after, episodal pins and needles on my finger tips. My middle finger tip is sensitive when giving pressure. numbness improves, only half side of my index finger and half side of my thumb and small half portion of my middle finger is numb, Episode of burning pain on my hand and fingers and episode of sensitivity to touch on my wrist area and forearm. And no more pain because of the tenosynovitis.

Ive done physical therapy guided by my rehab doctor. TENS, therapeutic ultrasound, paraffin wax or hot bath. stress ball exercise for pinching and wrist neutral position tenson gliding exercises.

Im also taking up Pregabalin for my nerve pain 50mg in the morning and 75mg in the evening and Supplement capsule ones a day (α-lipoic acid 300 mg, borage oil (GLA, 22% in γ-linoleic acid) 300 mg, vit E 7.5 mg, vit B1 1.05 mg, vit B2 1.2 mg, vit B5 4.5 mg, vit B6 1.5 mg, selenium 25 mcg)

Dr Bland my question is,
1. Do i have cts now because of the intraneural injection of steroids?
2. Now Im only doing almost only 20% on my clinic obligations but after doing only minor dental procedures, my hand shows again symptoms of nerve injury; numbness on my fingers, pins and needles on finger tips, sensitive to touch on wrist and forearm and burning pain. Is it recommended that i stop my dental practice and give my left hand a full rest for it to recover and heal? If so, how many months?
3. Will the pain symptoms improve or go away permanently?
4. When doing physical therapy, hand exercise using stress ball, rubber hand trainer for grip and pinch strengthening. Symptoms of numbness and pins and needles increased and burning pain starts again but subsides after several hours to few days of resting my hand. Is there a possibility of nerve re injury when doing those strength exercises?
5. How long is the maximum months for me to consider if the remaining symptoms will most likely be permanent?
6. Are there any other treatments that will help on recovery for this kind of injury?
7. May I send my diagnostic records (emg ncv and mri results) to your email doctor?

Im am very worried now because of the possibility of loosing function and dexterity of my hand and loosing my dental practice if my median nerve will deteriorate and not heal and recover.

Carpal-tunnel.net is a very good website. I learned a lot reading the topics.

Thank you in advance doctor

jeremydpbland
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It does sound possible that that was an intraneural injection, and also quite likely that you did not have CTS at the time. It's hard to give evidence based answers to your questions because intraneual injection is actually a very rare complication of corticosteroid injection for CTS and there are no published series of outcomes, only a scattering of anecdotal reports. The few cases that I have seen personally have eventually recovered but one of them took 3 years and another is still ongoing after about a year. Whether you are now developing CTS as a secondary phenomenon is debatable - if you send me your nerve conduction studies (Jeremy [dot] Bland [at] nhs [dot] net) I will take a look and see if I can make anything of it. Another tactic that might be informative at this point would be ultrasound imaging of the nerve. JB

Worried Dentist
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Thank you so much for your reply Dr. Bland. I have sent the nerve conduction studies and mri result to your email.

An ultrasound was made recently by a physiatrist but unfortunately the result was not significant. Im having a hard time looking for a doctor here in my country who specialized in neural ultrasonography.

jeremydpbland
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Thankyou for those. The first set were interpreted as showing evidence of a left median mononeuropathy affecting primarily motor fibres with the lesion lying at or distal to the carpal tunnel - ie neurophysiologically a 'motor only' carpal tunnel syndrome. This entity is almost vanishingly rare (8 out of 2727 cases in one series) and I have some doubts as to whether it really exists at all. I think all of the reported cases are probably due to diagnostic or technical errors or in a few cases, anatomical variations. In your case I am fairly sure from your description of the original symptoms and these results that you did not have CTS, and as the latest set are entirely normal it seems unlikely that the current problem is CTS so surgery is not really likely to help - though nothing in life is ever entirely certain of course. That still leaves the possibility of neurogenic pain secondary to intraneural injection as this can continue in the presence of perfectly normal nerve conduction studies. By this time I think the acute nerve swelling which can be seen on ultrasound just after the event would have long since settled but if the physiatrist did not see any enlargement of the median nerve now then that is additional evidence against a diagnosis of CTS. I'm afraid there is no evidence based approach to this problem - you just have to experiment with different symptomatic treatments (Gabapentin/Pregabalin, Amitriptyline, Duloxetine, Lidocaine patches, Capsaicin etc) to try and find something that allows you to function until it eventually resolves I think. Rest may help too but is impractical and no-one knows for how long you might have to stop activities so I would be inclined simply to avoid prolonged strenuous use of the hand - including 'strength' exercises - things that keep the hand moving without increasing the carpal tunnel pressure are probably a good bet. Principally you should be advised by your current hand doctor who seems to have the right approach. JB

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