TeleEMG Patient Education Series
Series Editors: JF Jabre, MD and OS Shams, MD

Carpal Tunnel and Ulnar Neuropathy - Part II

Carpal tunnel surgery complications? Top

Question

I was diagnosed with bilateral carpal tunnel and "trigger thumb" and had surgery on right hand for the CT and TThumb on 1/3/01. I thought I would wait a few weeks and then have the carpal tunnel surgery on the left hand with the hopes I would be as good as new. However, I am in worse shape now than I was before I had the surgery on my right hand, and I don't dare have the other surgery because I am afraid it will turn out like this one. I am in more pain now than I was before I had the surgery. The pain is mostly in the wrist are and radiates up the arm almost to the elbow. My thumb is practically useless as I have very limited movement and cannot open doors, jars, or write. I could do all these things before the surgery. I have less strength in my hand than before. I have to change the gear shift in my car with my left hand and it is painful holding onto the steering wheel. I can barely hold my coffee cup. The pain is so bad at night that it wakes me up and I could cry. Needless to say, I am very depressed over my condition. I am going back to my surgeon this week and would like some advice on any tests I might request to see what is wrong. I have also developed a lump at the base of my thumb at the wrist area and a larger area on my arm right above the wrist. I talked with other people who have had this surgery and no one has had the problems I am having. So you can see why I can't risk having the CT surgery on the left hand at this time. Has anybody ever heard of anything like this before?

Answer

I can really understand and share with you the pain. It is not however, clear to me the exact cause. But the surgeon who did the operation should be able to tell you more about it. Perhaps repeat EMG to assess the position of the median nerve post operative would help. I hope you get better soon.

Possible double crush to ulnar nerve Top

Question

Two years ago this May 17th 2001. I was rear ended by a drunk driver to make a long story short I have had a long recovery and am still going threw treatment, My question:

After the accident and to date I've had neck pain and numbness in my little and ring fingers. I had very severe pain in my neck so bad that just riding in a car was like having no shocks, feeling jolts to my neck even gravel seamed like boulders, and I would get pains in my collar bone as if it was broken.

I went in and had Ulnar nerve surgery to help the numbness in my arm and fingers and in this area has helped, the perplexing thing is as I awoke in the recovery room I noticed a great improvement in my neck pain? and the pain in my collar bone has not returned, this is all on my left side.

I have been told that the Ulnar nerve should not effect the neck in this way, but, I know the relief I have gotten to the neck area since!

I still have damage at the C6,7, and T1 nerve areas. that I am going threw injections for at present but since the operation have been able to drive fairly well though turning of my neck becomes more painful the longer I do.

A friend of mine who has some knowledge in this area has suggested a "double pinch" of the ulnar nerve that she had heard of?
But I've been unable to find any information in this area of question.

Are there any answers? There must be? Is there any information I can be directed to?

I thank you sincerely for any help in this area.

Answer

The Double-Crush syndrome is well known and has been described by Upton and McComas in their landmark paper in 1973

TITLE: The double crush in nerve entrapment syndromes.
AUTHORS: Upton AR, McComas AJ
SOURCE: Lancet. 1973 Aug 18;2(7825):359-62

The basic premise is that when a nerve is injured proximally (or in this case close to the neck), it makes it more susceptible to injury distally (away from the neck).

What exactly happens to give pins and needles sensation? Top

Question

When you experience the sensation of "pins and needles" what exactly is taking place? Is it a result of the healing process of the nerve or is it a result of damage to the nerve. I know when your foot is "asleep", the pins and needles come after the numbness but before normalcy, as your foot recovers......so I am wondering if the sensation might indicate a reactivation of proper nerve impulses? I'm experiencing pins and needles in association with lyme disease and am wondering if this could be the reawakening of my damaged nerves and thus a good thing.....or does it result as my nerves are damaged, and thus a bad thing? Thanks. Ruth.

Answer

This is quite interesting question. Any or all of the sensory symptoms (pins and needles) and signs are considered diagnostic for a dysfunctional sensory nervous system or point that some thing going on with sensory nervous system. It could either occur at start or later in the process of nerve affection. Although pins and needles may get less with recovery. But does not basically or necessarily be a bad sign.

I have Left elbow pain. Is it necessary to have EMG? Top

Question

Do I really need this test? I have been treating what the doc thought was tennis elbow. But the cortisone shot I had didn't help that much. So he wants an EMG. I don't want it if it is not necessary! I have always had left neck and upper arm pain (I have Fibromyalgia and injuries from years ago) The main pain is in the elbow area and runs down the arm...It is different form my usual pain. Hurts to use the arm and hand...gripping and pulling mainly! Any advice out there? Sometimes the hand gets cold and tingles and turns bluish too. I still think it is a joint problem.

Answer

You are right. It sounds like a joint problem. However, only tingling suggests nerve problem. Therefore, EMG may be of help.

Comment

Thanks for the quick response. I am concerned that with the Fibro pain I already have that the test will make my pain worse so if I don't need it I don't want it. The arm is also sensitive to touch. Like skin surface pain...all this seems to lesson when I don't use it. That tells me it is a joint problem but the doc said since the marcaine took the pain away for 3 hours it could be nerve pain??????????? Any input here? It is set up for next Tuesday in the doctor’s office. (A neurologist) Wouldn't the marcaine take any pain away????????

Answer

Marcaine should work as local or regional anesthesia and analgesia for pain of any kind, as you said. However, The EMG study should not worsen your pain, although it does cause little pain by itself, which is quite tolerable. EMG is a diagnostic test only.

Rate of false negative and false positive results of electrodiagnosis in CTS Top

Question

What is the percentage of negative results on a positive finding? Also, what is the percentage of a positive result of a negative finding?
I've gone through 5 nerve conduction tests previously, and finally was diagnosed with carpel tunnel. The neurologists said it was because of my small boned structure that gave a negative result when it was actually positive. When I received the tunnel releases, it was very tight and surgeon was surprised that it didn't show up earlier. I now have possible ulnar nerve problems, but again my conduction test shows negative. Please give me some information as why this happens.

Answer

The pick up of carpal tunnel or ulnar neuropathies by nerve conductions is fairly easy so the false negatives there are very low. For pinched nerves however (root lesions) the number of false negatives is higher, sometimes up to 30 or 40%.

Ulnar nerve entrapment Top

Question

One month ago I had an EMG on my left arm. The results indicated an ulnar nerve entrapment, and recommended elbow surgery. I had
continual pain in my arm and hand before the EMG. The pain greatly increased immediately after the test, and has persisted continuously to date. I understand this is not normal. What could be the cause? Has anyone had a similar experience?

Answer

The nerve stimulation itself does not cause any lasting damage and usually the pain and discomfort resolve within 24 hours. In some instances however, nerve irritation during the test can cause an inflammation around it, especially if the nerve is already irritated because of the damage to it. In those instances, anti-inflammatory such as Aspirin or Motrin might help by reducing the inflammation. If they don't something else is going in and it is best to seek a consultation for that.

Comment from another patient

I would suggest caution on this one. I had numbness/tingling symptoms and a specialist (with good recommendations) diagnosed Ulnar Nerve problems. I had a release & transposition on one elbow and a year or so later on the second. It turns out that more than likely the source of the problem was c4-5-6 problems, not the nerve. I did have an EMG to rule out the neck but my guess is the results were inconclusive or false. This syndrome (from my research) is not that common. Feel free to mail me for more specifics

EMG in CTS and double crush syndrome Top

Question

Hi, I have had an EMG results show carpal tunnel. I also have cervical radiculopathy from disc bulge and spurs impinging on nerve at C5-6 and C6-7.My neurologist does not believe in the "double crush" theory and states that even if he did, I did not have impingement of the C7 nerve. He obviously did not even look at my MRI report, which clearly states this. He also said that because he tested my median nerve at the wrist and it showed compression this proved only Ct. This is not my understanding of the process. My question is; if it were indeed double crush would the testing of the wrist median nerve still show entrapment? Thank you very much

Answer 1

I would say that neurologists are evenly split on the existence (or lack thereof) of the double-crush syndrome. Let me quickly explain it. The double-crush theory says that if your nerve is compromised proximally (up high near the neck) it is more likely than not to be also damaged distally (below near the hand), meaning that the existence of a proximal lesion makes the nerve more susceptible to damage distally. So in answer to your question, if you are a double-crush believer, the testing of the median nerve at the wrist will show entrapment.

Answer 2

The concept of double crush syndrome is known for many years. I think from seventies. It means, there are 2 lesions along one nerve course, i.e. patients with one peripheral nerve lesion did in fact have a second lesion elsewhere and they implied that both lesions were contributing to the symptoms or on another way, somewhat include symptoms which result from a combination of two separate, local lesions at different anatomical sites in the same nerve, whether or not one actually contributes to the causation of the other. Practically, a patient may have carpal tunnel syndrome (distal) and another lesion (proximal) of plexus/root in addition. So, yes, EMG could show a carpal tunnel syndrome (to answer your question), which is fairly easy to diagnose by such method.

CTS and EMG questions Top

Question

I recently had and EMG done and was referred to an orthopedic surgeon for surgery on both wrists. While having both parts of the EMG done, the doctor tried to explain what he was seeing to me. I guess what I am not clear about is how bad this is. I mean, I know it's bad because he insists on surgery and the pain; numbness and burning are more than I can handle... He mentioned that when he did the shock down by my wrist that it was a " 2 " and a " 6 " up by my elbow on my right arm. And " 1 " and " 8 " on my left arm. What does this all mean? Can you refer me to any pages to help me understand this more? What are bad results?? Semi bad??? What can you get by on without having surgery?

Answer

Me too, I am not familiar with these numbers, perhaps further information would help. Generally, a "bad" CTS depends on the clinical picture and EMG findings. However, the presence of muscle wasting and/or abnormal EMG spontaneous discharges are bad signs. It is important to follow the advice of the surgeon, as without surgery the symptoms would persist. The wasting or atrophy will develop, if it is not yet happened. At advanced stage the surgery would not actually help to recover the nerve, but it would anyway save what is left.