Failed carpal tunnel/cubital tunnel surgeries?

KBeach87
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I'm a 30 year old female, and in August 2016, I had simple cubital tunnel release and carpal tunnel surgery on my right arm/hand. Several months after, my pain/tingling/numbness came back and I then had ulnar nerve transposition surgery in May of 2017. The past few months, my symptoms have worsened again (even worse than pre-surgery). I'm experiencing soreness/pain in my elbow, hand and fingers, and tingling in my palm, thumb, fingers and down my arm (even from my armpit to my elbow sometimes). I also sometimes get a kind of warm feeling in my hand. I'm extremely frustrated and not sure what I should do. Is this because the original surgery wasn't done correctly or are these symptoms just going to keep coming back no matter what? I'm also not sure whether to go back to the same surgeon, since he his familiar with my case, or go to someone else. Has anyone else had this type of situation with several surgeries that failed? Any help would be greatly appreciated!

jeremydpbland
Online

Cubital tunnel surgery is not overall as successful as carpal tunnel surgery. What do you have by way of nerve conduction studies to tell us how much of a nerve problem there is at wrist and elbow? JB

KBeach87
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I have had 2 nerve conduction studies. The first one was before both surgeries and there was no nerve damage shown. The second one I had (about 8 months after my first carpal tunnel and cubital tunnel surgery) showed signs of mild carpal tunnel. My doctor thought I should get the surgeries anyway since exercises and cortisone shots didn't help and my symptoms were very bothersome. I'm just worried that my symptoms are getting worse pretty quickly (and it's my dominant arm and I'm an accountant and a musician so I really need that arm!). I'm just wondering if I'm out of options at this point since I've already had two surgeries and tried cortisone, exercises and also been on Gabapentin.
My doctor said that when he did the ulnar nerve transposition surgery (last May), the nerve was up against the bone which was why my symptoms were so bad. He said he did a fascial sling to prevent the nerve from slipping back, so I'm at a loss as to why my symptoms are so bad again.

jeremydpbland
Online

I think one has to suspect, with that story taken 'as is' that it perhaps never was either CTS or ulnar neuropathy at the elbow - hence the lack of response to treatment overall. If you have the NCS results I can take a look and see if there are any clues. JB

KBeach87
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Thank you! I would really appreciate that. I just requested that copies of both studies be emailed to me, so hopefully I will have them today or Monday.

KBeach87
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Actually they have just sent me the results from my most recent one. What is the best way for me to send to you? Thank you!!

KBeach87
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I was able to copy and paste the report. I can't get the formatting to be correct, so please let me know if there's a better way.
This was the most recent test done in March 2017. Any input or comments are greatly appreciated!

Part 1:
Right Median. N. Nerve
Rec Site: APB Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)
STIM SITE
Wrist 3.5 10.2 65
Elbow 7.5 9.4 250 62.5

Right Ulnar. N. Nerve
Rec Site: ADM Lat (ms) Amp (mV) Dist (mm) C.V. (m/s)
STIM SITE
Wrist 2.8 12.2 65
B.Elbow 6.6 12.4 200 53.3
A.Elbow 8.1 10.2 100 66.7
Wrist 2.8 12.2 0
Elbow 8.1 10.2 300 57.1

Right Median. N. Nerve
Rec Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
STIM SITE
Index 3.2 21.7 130 40.6

Right Ulnar. N. Nerve
Rec Site: Wrist Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
STIM SITE
5th digit 2.7 10.7 110 40.2

Right Ulnar Nerve
Stim Site: 5th digit Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
REC SITE
Wrist 2.9 13.6 140 47.7
Elbow 7.2 9.2 270 63.3

Right Bactrian Nerve
Rec Site: Thumb Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
STIM SITE
Median 2.9 56.2 100 34.1
Radial 2.5 8.6 100 40.0
Wrist 2.5 10.6 100 40.5

F-Wave Study
Right Median. N. Nerve
Rec Site: APB Latency
Stim Site: Wrist ms
M wave 3.50
F wave 26.17
F-M 22.67

Right Ulnar. N. Nerve
Rec Site: ADM Latency
Stim Site: Wrist ms
M wave 3.08
F wave 27.92
F-M 24.83

jeremydpbland
Online

I think I can make sense of those though the 'Bactrian' nerve is a new one on me - that's a camel - from the stimulus and recording sites it looks as though they are referring to a form of median/radial nerve comparison. There are also apparently two versions of the ulnar sensory study stimulating at the little finger with somewhat different values. These are the results after surgery and in those circumstances I think I would view these as pretty much normal. Median sensory conduction is slightly slow but so is ulnar nerve conduction at the wrist. If you can get hold of the pre-operative set you can email me the lot and I'll see what I can make of them. It looks as though the left side has not been tested at all. JB

KBeach87
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Thank you! I will email both when I get the original test (which I think included the left and right side). I'm starting to worry that the problem is coming from farther up my arm or my shoulder, since I've started having some shoulder soreness and soreness/tingling from my shoulder down to my hand...although that would be very frustrating if I had 3 procedures done for no reason. I will email you early next week, hopefully, with the test results. Thank you very much for your time and your input!

jeremydpbland
Online

Thanks for sending those. As pointed out by the reporting doctor the original set of studies from July 2016 are normal, showing no evidence of either carpal tunnel syndorme or ulnar neuropathy at the elbow (UNE). Now all tests of this type have false negative results - cases in which the patient does have the problem you are looking for but the test fails to detect it - so the normal test results do not 'exclude' CTS or UNE, but they do tell you that if that is the right diagnosis then there is not much in the way of measurable nerve damage so you do not have to rush into surgery to prevent a catastrophe. For that reason my preference in such cases is always to treat conservatively and repeat studies with more information available. It sounds as though that is more or less what was done to start off with as you had 'exercises and cortisone shots'. The results of those attempts at non-surgical treatment, at least for CTS injection with an adequate dose of steroids, are a further piece of information to help with diagnosis.

This works best for CTS - provided you inject 40mg of methylprednisolone or equivalent it is rare for any genuine CTS case other than the extremely severe ones to show no response at all. This has been followed up as a prognostic factor for surgery and patients who get a good response to steroids tend to do well with surgery... and vice versa, those who do not respond to steroids do less well with surgery. By the time you reached the first operation therefore all the information available at that stage was warning of a possible poor outcome from carpal tunnel surgery at least. (If you know the dose and type of steroid used and the site of injection that would be useful extra information too)

The ulnar nerve is more of a problem as that does not respond to local steroid injection anyway and the results of surgery, in some studies at least, are very similar to the results of doing nothing. Overall I think simultaneous surgery to both the wrist and the elbow was a brave gamble - and sure enough it hasn't really paid off.

The second set of tests show very little change but sensory conduction in both the right median nerve and the right ulnar nerve at the wrist are a little slower (ie worse) than they were before surgery. Looking at the dates these seem to be after the first surgery but before the second attempt at the elbow. This was interpreted as possibly very slight right CTS but I would have to disagree I think. Firstly the slight change in median conduction might just as well have been the result of trauma sustained during surgery, but more importantly the change in the ulnar nerve (51.2 down to 40.2) is just as great or even greater than the change in the median (44.3 down to 40.6) suggesting that this might be a more widespread process. Of course it's worth bearing in mind that one explanation for this change could simply be that your hands were 5 degrees C cooler at the second test - no skin temperature is recorded in the reports.

On both occasions it seems only the right hand was tested and it is a pity the left hand results are not available for comparison - that's a typical American thing I'm afraid - here we would always test both sides.

The second set of studies still showed absolutely no evidence of UNE so doubling down and going for more surgery on the elbow was also something of a gamble.

With the advantage of hindsight I think the most likely explanation for the overall sequence of events here is that the original clinical diagnosis was wrong and the nerve conduction results right - ie you probably did not have either CTS or UNE to start off with - the lack of benefit from surgical treatment is pretty strong evidence against CTS. This leaves the question of what the problem really is, and it's not possible to tackle that adequately in a web forum. The differential diagnosis is quite wide and you can get some idea of the sort of things that have been found on this page. Someone with good neurological skills needs to sit down with you, take the history of the original symptoms from scratch, examine you, and possibly arrange some further investigations. I would therefore suggest looking for a reputable neurologist as the flavour of the symptoms is a bit more neurological than musculoskeletal. There are no immediate clues to alternative diagnoses in the currently available NCS results I am afraid.

Sorry I can't suggest any definitive answer but I would love to hear what the eventual outcome is if you don't mind coming back with an update in due course. JB

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