Post- Op Complications

I have a video of the surgery at the elbow.  It depicts classical hourglass sydrome of constriction of the nerve.  It appears that the constriction was somewhat severe.  The surgery occurred after chasing chrnic arm pain and tingling in 4th 5th finger and also have chronic C-7 C-8 stenous.  However, neurosurgeon did not think neck was pinching the nerve.  This wsa somewhat proven after a root base injection at the C-8 produced no relief.  Had an EMG prior to surgery.

Being a neurophysiologist I tend to believe the NCS rather than observations at surgery which have been shown to be erroneous and unreliabe in the context of carpal tunnel syndrome (no-one has looked at this in detail for the ulnar nerve at the elbow yet but the ultrasound evidence so far seems to favour the structural change at the elbow being swellinf of the nerve in most cases rather than 'classic hourglass constriction'). The 'heroic' element of this is that they chose to carry out two other procedures at the same time. The pre-operatibe NCS will be very useful for comparison with now if symptoms are worse. JB

Thanks for your reply.  To add to the to the current situation I cannot spread my fingers on my right hand since surgery.  If I am correct this is controlled by the PIN nerve which had nothing to do with the surgeries.  I have another EMG scheduled, however, it is 60 days out.  Using same neurologist that i used before for consisitancy.  Seems like the surgery opened up a "can of works so to speak"  Could be my neck is causing problems.  Very perplexing.

Spreading the fingers is almost entirely ulnar nerve so most of the current symptoms seem to fit with ulnar nerve trouble. The PIN/Radial nerve does finger and wrist extension. JB

He is currently describing mainly ulnar nerve symptoms, not CTS, even though they have operated on both nerves. The ulnar nerve problem at the elbow is completely different to CTS. JB

I had an emg today from the same neurologist that performed the procedure pre-surgery.  The results indicate that it points to a Cervical Spine 7.  I had a nerve root epideral injecton prior to surgery that did nothing for the lower arm pain that ahd been going on for over a year.

​So I am a little confused.  The first emg was performed to see if there was a pinch at the c-7 level.  The MRI was not clear enough but the emg said ulnar.  All those studies were done with a neurosurgeon and neurolgist.

​Then an orthopedic surgeon did the aforementioned surgery.  The neurosurgeon suggested it as she wanted to be conservative with neck surgery.

​So with today's emg the neurologist says like the first time its ulnar.  Another MRI was also taken and indicates a potential pinch on the right side of c-7 near the foraminal opening.  So the palsy is slightly worst and the neuro says the nerve cant heal if is still pinched at the neck.  What are your thoughts.  FYI information all tests are conducted at a major teaching university.

 

Your first paragraph says the EMG indicates C7 root but the last one says the EMG still indicates ulnar neuropathy - which is it? My guess would be the latter because severe ulnar nerve NCS abnormalities generally do not return to normal after surgery so I would expect your results to still show ulnar nerve problems at the elbow now if they did so before the operation. In contrast C7/8 radiculopathy is hard to diagnose on EMG unless the anterior C7/8 roots are compromised. If it is the posterior (sensory) roots, causing pain and tingling, then the neurophysiology is usualy just normal.

Ulnar nerve surgery is frequently unsuccessful and many surgeons will agree that their main aim is to stop the problem getting any worse rather than to produce a 'cure'.

thanks for your reply.  Maybe I will start over to explain everything so we are both on same page.

The neurologist who did both emg sept 2015, june 2016, think my problems are in the cervical spine.

The neurosurgeon suggested that i have decompression surgery at the elbow because in Dec 2015 she thought the MRI of the cervical spine did not indicate a severe enough pinch to cause my symptoms.

Dec 2015 had the trifecta surgery descibed earlier.

June 2016 I have claw deformity 4th 5th finger.

Pain has subsided greatly although it lingers from time to time but a less level.

Atrophy and claw occurred after surgery not before.

Also index finger which is median controlled will not bend mor than 10 degrees.  The ortho guys says probaly scar tissue binnding the flexor tendon.

Seems like I am going in circles and not getting better.  Any suggestions?  Thanks for your time and input.

 

As a neurophysiologist I am wondering what the nerve conduction studies actually showed, as opposed to what anyone said they thought the problem was. I like to have some objective results to work with. Do you have copies of the NCS?

Yes, I have copies of the first emg done in sept 2015.  The emg conducted this past thursday is not available yet.  I dont have a scanner and would have to wait until monday to get scanned.  Although may be able to provide info if you talk me through

Will attempt to give u the data:

Nerve Conduction

Amplitude (mvor mu)              

Median Sensory

Wrist Index  R=25.0  L =31

Ulnar Sensory

Wrist 5th R=18

Median Motor

Wrist  Thenar=4.5

Elbow Thenar=3.5

Ulnar Motor

Wrist Hypothen = 10.2

B Elbow=9.0

A Elbow=7.6

Latency(ms) (will follow same locations as Nerve Stimulate Record)

R= 4.2 L = 3.4

R=3.7

R=4.9

R=3.0

Conductor Velocity (m/sec)

From to

Wrist to Index R=43.7 L=51.9

Wrist to 5th  R=45.7

Elbow to Wrist R=51.0

B Elbow Wrist R=50.0

A Elbow B Elbow 52.6

EMG/Insertional/Spontaneous (ins)(p wave)(fib)(fasc)(other)

R-Deltoid

R-Biceps Brachi

R-Triceps

R-Ext Digitorum Communis

R- Flexor Carp Ulanris

R-FDI (hand)

R-Abd Pollicsis Brevis

L-FDI- Hand

All normal except;

R-FDI (hand) = 1+ (fib)

R-Abd Pollicsis = 1+(fib)

Both of the above were sustained in p wave

Both Elevated arrow for ins

VOLUNT MOTOR POTENTIAL

Same location as above

eff= all normal

recrt = Deltoid normal

others decrease arrow 1+

2+

1+

1+

1+

1+

AMP (same location as above)

NN

then 4K,5K,4K,4K,4K

the poly is Elevated arrow 1+ (flexor carpi)

Intrepretation says abnormal study evidence of mild active deervation in the right C8 distribution

Thats alot of data hope you can understand if not i can take a picture.  Thanks for all your time and help.

 

I can make sense of most of that. Median sensory conduction across the carpal tunnel is slightly slow in the right hand - 43.7 m/sec compared to 51.9 m/sec on the left side. The ulnar nerve studies are normal showing no focal conduction slowing or significant conduction block at the elbow. More detailed testing would probably have revealed a very slight right carpal tunnel syndrome but that may be of little relevance to the symptoms. There is no obvious ulnar nerve problem at the elbow. The needle EMG sampling on the other hand was thought to show mild abnormalities in the small hand muscles and sometimes elswhere - a few fibrillations, a few polyphasic motor units, increased insertional activity and slightly reduced voluntary activity - all taken as evidence of injury to the nerve roots supplying motor nerve fibres to those muscles - mostly the C8 nerve root.

The neurophysiologial evidence does therefore favour cervical root problems rather than peripheral nerve entrapment but NCS are not infallible diagnostically. I would not generally recommend surgery on either the elbow or the wrist with results like that myself. Even if the results are a false negative and there really are entrapments present there is no hurry to treat these lesions surgically when other, less aggressive things can be tried first. Alternatively the neurologist could well be right, these are then not false negative but true negative results, and treatment would be better directed to the neck. My guess would be that the new set of results will be very similar except that the median sensory conduction velocity wil be quicker - we'll see.

Thank you for your time.  Your statements correspond the those made by the neurologist last week during the second emg.  Its seems that I jumped the gun with the 3 surgeries I had and an paying the price.  It is upsetting that the orthopedic surgeon who read these results, overlooked or ignored and went ahead with surgery that may or may not have been necessary.  A neurosurgeon suggested to try the elbow in an effort to relieve pain  symptoms and be conservative with neck surgery. 

I understand that looking at a video is not as conclusive as the emg, however, I did see loss of vascular supply and surrounding tissue had become like "tuna fish" not healthy. 

The latest emg conducted last week suggested the same results as the first, C8 root.  Therefore, the atropy of my hand muscles and claw deformity may be a progression of the C8 nerve root problems.

I currently have less pain in my arm since the decompression surgery so that somewhat corrected a problem.  Unsure of the future.  The neurologist who works daily with the neurosurgeon will discuss the latest emg and the potential of neck surgery.  A MRI taken last week does reveal bulging of a disc(what is left) pressing the root near a foramina and could be the cause of the ulnar palsy I am experiencing.  Will take a VERY conservative route this time around.  Somewhat odd to me that I have never had pain from neck to upper arm, only from tricep to hand and 4th 5th digits. Still perplexed by the index finger situation. 

Thank you for your time and investigation into the results of the emg.  I will keep you posted and if you like send you the latest emg results when received.

I would like to hear how it eventually turns out. The lack of pain from neck to upper arm is not too surprising as sensation in the upper arm and neck is served by other nerve roots - C5 for the upper outer aspect of the arm, T1 for the inner aspect of the upper arm and higher levels still for the neck. It's easy enough to look up a dermatome map on the web to see how the roots map to peripheral territories. Which digit was triggering?

The middle finger was "the trigger finger" which had presented itself for a couple of years.  The surgery to release seems successful at this time.

My right index finger functioned perfectly prior to surgery.  24 weeks post -op the finger bends only slightly.  I have been going to a hand therapist since March 2 x per week.  With minimal results.  My mind tells it to bend and it won't.  Ortho says could be scar tissue from CTS binding the flexor tendon.I wear a compression glove at night to help with swelling.

Another question.  Since surgery I have gained about 15 lbs of grip strength in the operative hand.  That includes index finger participation because it doesnt bend.

The claw deformiity is still very present.

Will the ulnar palsy get better with more exercise and time?  Or does the potentially chronic condition at C8 nerve root prevent healing to occur.  Have people with Ulnar Palsy gotten better without further surgery?  I am not intersted in neck surgery at this time however I would like to regain as much use of my hand as possible.  Again thanks for your time and expertise.  Is a neurophysist  similar to a neurologist?

The index finger is interesting if that was not the triggering digit to start off with. I guess surgery for both the triggering middle digit and the CTS at the same time might have produced enough adhesions to fix the index finger tendons and interfere with finger flexion, or in the worst case scenario one of the tendons might have ruptured - which joint of the index finger will not bend - the 'knuckle' is the MCP (metacarpophalangeal) joint, and then the two joints in the finger are the proximal (nearest the knuckle) and distal (nearest the fingertip) interphalangeal joints (PIP and DIP respectively)

As I'm not sure there is an ulnar palsy I'm not going to predict what mght happen to it but almost anything can get better without surgery if you are lucky - the human body is remarkably good at self-repair given a chance.

In the UK clinical neurophysiology is a separate speciality from neurology. That is not true everywhere. In the USA most of the work I do is done by neurologists and physiatrists (a speciality which we don't really have here)

Dr. Bland,

I want to thank you for all the time you have spent reviewing my case.  I sincerely appreciate your time.  My knuckle will bend slightly.  The ortho and hand therapist think its scar tissue also.  I have been rubbing, mashing, doing what ever to break up.  May get a steroid shot no surgery for scar tissue i dont want to fuel the fire so to speak. Thanks again for all your advise.  Will keep you posted.

Dr. Bland,

Providing an update.  I have received the EMG report done 9 June 2016.  Should I upload as a photo or send to you via private email if interested.  Scheduled for a laminoforaminotomy in a few weeks.  I need the use of my hand back as the wasting continues to progress without any sign of improvement.  I appreciate your comment regarding giving body time to heal, however, my MD took my case to the weekly neuro/spine board and all agreed this would be the best effort they could provide.  I am afraid that if I wait another 6 months I will subject my muscles to further atrophy and they will not come back.  Appreciate any thought you have to offer.

Happy to look at the NCS if you want to email them to me. I'll comment then. Regards, Jeremy Bland

Don't have an email addrss.  Uncomfortable sending report with nameand other personal information.  Let me know best way to get the report to you.  Thanks, Cleve

meant don't have email address for you. 

It's in 'contacts' at carpal-tunnel dot net JB

Thanks for those - I've replied by email. JB

Further to that my email reply seems to have been blocked by your spam filter. If you can add my email address to your whitelist I'll try again. JB