What is normal post carpal tunnel surgery?

Daz
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What is normal post carpal tunnel surgery?

I am seeking some guidance as to what is normal post carpal tunnel surgery. Sixteen days ago I had 'open release carpal tunnel surgery' on my right hand. The decision was made to do my right hand first as there was evidence of muscle wasting at the base of the palm. The left hand is due to be done mid February 2019. Nerve conduction tests were undertaken on both hands with NCT results indications in the 'moderate range.'

In the first evening (post morning surgery) I had burning pain radiating to my fingers. The day after surgery all fingers accept my ring and middle finger were fine and normal sensation returned. However, the median nerve side of the ring and middle finger continue to remain numb. Likewise the nail beds and tips of both these fingers lack feeling. Both fingers remain swollen and somewhat stiff. That area at the base of my palm just above the wrist (to the side of the incision) remains swollen.

Prior to surgery I did not really have too much discomfort during the day, only at night with early morning waking with numbness

Stitches were removed at 14 days and the hand appears to be healing well.

At night time the symptoms of carpal tunnel syndrome pre-surgery that would wake me early morning are still apparent but slightly modified to include warmth and burning pain with tingling rather than pins and needles. My right hand feels heavy.

Prior to surgery I did not really have too much discomfort during the day, only at night with early morning waking with numbness.

I would be appreciative of feedback so that I can better understand where I might be at and how to approach this going forward.

Daz
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My apologies to you as I should have clarified in the above 'posting' that where I indicated ''However, the median nerve side of the ring and middle finger continue to remain numb,'' I should have also mentioned that it is the inside edge only of each of the adjacent ring and middle fingers that are numb. Also that edge of the ring finger tends to go between a stage of slight numbness to being okay. Also the degree of stiffness of these fingers seems to change during the day....sometimes slightly stiffer, at other times not so much.

Thanks so much for your time.

Daz

jeremydpbland
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At this stage I would not be too concerned about that pattern of symptoms but if you happen to have your pre-operative NCS results so that we can see just what 'moderate' means that would help considerably. In my experience a report saying 'moderate' might actually be anything from normal results to grade 5 CTS. JB

Daz
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Thank you very much Dr Bland for your feedback. I visited the surgeon on 21 December and his advice was similar. I had NCS tests undertaken prior to surgery and will request that information from the Surgeon when I am re assessed in early February 2019.and report back.

On another matter I would like to commend you on your web site and the support that you provide. I have undertaken some reading around the topic since surgery to better inform myself. However, finding a website that has focus and is comprehensive is difficult.

Carpal-Tunnel.net offers that resource. So, a 'big thank you' to you for that support. Excellent.!

Regards

Daz

jeremydpbland
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Thankyou. I like to think that this is the most comprehensive publicly available resource but it can be a bit overwhelming and I suspect that some surgeons feel that I promulgate an approach to CTS which they think is wrong. However they are always welcome to come on here and argue their case and so far there have only been a very few direct contributions from surgeons. JB

Daz
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Hi Dr Bland,

I have emailed to you (as per your request) my pre-operative NCS results undertaken on 7 November 2018. Carpal tunnel surgery on the right hand followed on Thursday 29 November. The right hand was selected to be done first due to some evidence of muscle wasting below the thumb. I will be interested in your analysis of the NCS test results.

I have noted in the last several days that the numbness / stiffness (median nerve side and inside edge of both the ring and adjacent middle finger as well as the tips) has been alternating in the degree of stiffness & numbness (numbness to a lesser extent).

Interestingly on further checking with minor 'pin pricks' in the areas outlined, I can feel the 'prick' sensation and I have been wondering as to whether part of the problem for me has been that both the ring and middle fingers have been (and still are) swollen thereby impeding surface nerve sensation and also that the finger swelling may possibly account for some of what I perceive as numbness?

Hopefully this maybe a positive sign?

Also, I have had minimal issues with my left hand as I have ensured that it has been well 'splinted' on going to bed.

I am reluctant to proceed with any surgery on the left hand at the moment until we see how things proceed with the right hand. My Surgeon agrees with this approach. The left hand seems to behaving itself at the moment!

Thank you for any feedback given Dr Bland.

jeremydpbland
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Thanks for the NCS results by email. The 7.11.18 set show bilateral grade 3 CTS (out of 6) which in my clinic would not generally make me rush to surgery, though if patients with grade 3 want to get the op done we arrange it for them. I would usually expect cases operated at grade 3 to make a swift and pretty complete recovery so the fact that you have some persisting symptoms a couple of months later is some cause for concern and I would be thinking about checking the NCS again to see that nerve function really is improving. As you have symptoms in a specific subdivision of the median nerve territory I might also be inclined to try and test those branches separately, though this is difficult, and I would also take a look at it with the ultrasound scanner to see if there was anything structurally unusual. I doubt if the swelling is affecting sensation only in that very specific 'half-finger' distribution.

It's not uncommon for the 'other' hand to improve when the first one is operated on so the change in NCS on the other side would also be interesting if symptoms there have improved. JB

Daz
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Thank you Dr Bland for the comprehensive feedback which is appreciated.

I will follow up with your advice and report back in due course.

Daz
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Hello Dr Bland, Further to the information as shown in the discussion thread above a note to advise, update and to accordingly seek your feedback please.

1.The persistent numbness in my fingers as outlined disappeared after 6 to 7 months and the feeling slowly returned to normal. 2. My surgeon tested for feeling in my fingers by using a paper clip to distinguish the required number of points and I responded accurately.
3. I requested repeatedly during 4 follow up visits to the surgeon for a follow up nerve conduction test to verify that I was indeed recovering. The surgeon would not refer me for these tests.
4.Throughout this time period I have had increasing tingling in my right hand which is the hand that I had CT surgery for.
5. I discussed the situation with my own GP who referred me for follow up Nerve Conduction Testing.
6. I will email the Nerve Conduction Test results to you and would appreciate your feedback.
7. Obviously I will be taking further advice from my GP which will likely involve further intervention. However, I would be most
appreciative of your advice re nerve conduction test results and your recommendation / suggestions about the process going forward.

Thanking you.

jeremydpbland
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It sounds as though whatever injury was suffered to the sensory branch to ring and middle fingers has recoverd OK but increasing tingling in the operated hand is not what is supposed to happen - in 'normal' circumstances your hand is suppose to be back to normal by 2-3 months post surgery. Is it disturbing your sleep at present? Is the tingling recognisably in the median nerve distribution or is it more widespread? JB

Daz
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Thanks for your feedback Dr Bland.

Yes, I wake with tingling which is across the classic carpel tunnel area as described in the literature. However, the tingling is in general is to a lesser extent than the original complaint but still disturbing. It appears early morning as per classic CT and is exacerbated / further aggravated if I have done any gardening, shifting firewood, long driving or anything that requires a sustained grip.

Also above my wrist to the elbow can be sore and the ability to lift things (shopping bags etc) can be a bit of a struggle as hands feel weak. I am fit and a keen runner so from my perspective it is not a fitness issue.

The main concern originally was the ongoing complete numbness around the sensory branch to ring and middle fingers. That recovery was rather slow but appears complete.However, now the classic CT symptoms are of concern. Those symptoms (tingling) may have been present during the earlier phase post surgery but masked due to the numbness which has now gone but can reappear to an extent early morning.

The neurophysiologist suggested that my reaction during surgery (open surgery) where I felt the sudden intervention may have been where the surgeon touched the nerve. I felt the intervention and responded to the surgeon accordingly to advise him of this at the time.

The reaction was that 'it was not uncommon to feel something or a sensation.'

jeremydpbland
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That rather sounds as though the median nerve is still compressed/irritated. It will be interesting to see what the repeat NCS show and I would normally examine that by ultrasound as well as that can often show whether the nerve has been successfully decompressed or not. JB

Daz
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Hi Dr Bland,

Thanks for your comments. You noted the following, '' It will be interesting to see what the repeat NCS show.'' Can I check with you please that you received a copy of my repeat nerve conduction test which I sent to you at

Jeremy [dot] Bland [at] nhs [dot] net

The clinical neurophysiologist noted the following in the test results emailed to you. '' There has been a mild deterioration in the right median nerve conduction findings since the pre-oprerative examination on 7 November 2018 suggesting inadequate decompression of the nerve.........''

I will re email you the repeat NCS which I sent several days ago just prior to my forum comments. Thanking you Dr Bland.

jeremydpbland
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I've now got them at the second attempt thanks and I've replied by email. It does look fairly probable that this was an incomplete decompression. JB

Daz
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Thank you very much Dr Bland for your comments and feedback via email which I have responded to. Your feedback has been superb and most appreciated. The information and support available on Carpal-Tunnel.net is world class, comprehensive and a great help in understanding the complexities associated with CTS.

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