Time scales of DCS symptoms?

[bluebanded goby]

A couple of years ago I developed numbness, tingling and pain in one hand and arm following a vacation dive, and was treated in a chamber. The symptoms seemed to go away during the treatment, and didn't recur on the plane ride home a few days later. However, they did come back a couple of weeks later. In the two years since then, the symptoms have come, stuck around for a couple of weeks, and then gone away for several months at a time. This has been exhaustively reviewed by several doctors, with lots of nerve tests, an MRI, etc, and the cause has never been pinned down with complete certainty. The general belief, however, is that it is probably a manifestation of some spinal nerve compression due to arthritis that isn't showing up on MRI.

After considering the above, my hyperbaric doctor back home said he didn't think it could have been DCS-related, due to the pattern of when and how symptoms have recurred and remitted. "I've seen DCS symptoms come and go on a time scale of a few hours within a single day, but never across time scales of weeks," he said. The fact that symptoms didn't recur during the plane flight is obviously notable.

So here's my question. I'm not particularly interested in asking for comment on my particular case, since it's been scrutinized pretty thoroughly by a number of M.D.s. But I'm interested in any reactions to the dive doctor's statement about the time scale of DCS symptoms. Would you view his statement as being correct -- that reemergence of symptoms after many weeks of remission argues strongly against it being DCS-related? Thanks for any reactions.

 

[pipedope]

And I don't play one on TV.

I think that the DCI can cause damage that can give you recuring symptoms. The DCI is long gone but it has left you a momento.

 

[rmediver2002]

Would you view his statement as being correct -- that reemergence of symptoms after many weeks of remission argues strongly against it being DCS-related? Thanks for any reactions.

I would consider this statement correct. I also feel it is correctly worded in that the diagnosis is not given as an absolute matter of fact but as an indicator that the injury is not DCS related.

Differential diagnosis is made with a combination of all available information. When no conclusive information is present in the case of diving injuries it is safer to treat the symptom as if it were a diving injury. (treating for worst case senario) When all the information is combined and considered, the diagnosis is still a best guess in most cases, not an absolute answer.

Many times only after the treatment is started and the symptom is rapidly resolved is it clear that the injury was diving related. Regardless of the nature of the injury the increase in ppO2 can be quite effective in aiding recovery...


Thank you for sharing the story.

Jeff Lane

 

[Dr Deco]

Dear BlueBanded:

Time Scale

The fact is a gas phase will not persist for a very long period of time in the body, and it will not grow without supersaturation. It is certainly possible for a gas phase to form now and again in certain places (spinal cord), but this is unconnected with DCS. In the cord, one has what is called the “vacuum phenomenon” that appears as a gas bubble between the disks on an x-ray. These are believed to originate from the pulling apart of the tissues during movement (called “viscous adhesion” or “Stephan adhesion”). They do not grow and cause problems mimicking DCS.

Any gas phase that is present will eventually disappear because:

The tissues are actually undersaturated , and
Surface tension increases the internal pressure and the gas exits the bubble.

In some cases, permanent damage to a nerve could result and one gets DCS with residuals; this could be considered as similar to a stroke in some cases. It does not remit and reappear, however

There are millions individuals who experience pains that come and go. The vast majority of them have never gone diving. Divers tend to associate these pains with their ding experience and will ruminate on this for months.

The physician who told you that the time scales did not match was correct.

Dr Deco :doctor:

 

[bluebanded goby]

Dr Deco once bubbled...
In some cases, permanent damage to a nerve could result and one gets DCS with residuals; this could be considered as similar to a stroke in some cases. It does not remit and reappear, however

Thanks, Dr. Deco. This was the specific point I guess I was getting at -- i.e. it didn't seem plausible to me that there would be any more gas than normal left in the tissue after this length of time, but the question rather would be whether permanent nerve damage from DCS could result in symptoms that remit and reappear on the time scales I described. Thanks for what sounds like a definitive word on that!

-- BBG
(whose hand/arm still kicks up sometimes, often after dives)

 

[DocVikingo]

Over the years I have developed a number of aches & pains that come and go and I definitely associate some of these with my "ding experiences."

Wink.

DocVikingo

 

[jplacson]

What are the known causes for delayed (more than 8 hours after a dive) DCS... and how do these bubbles form? I mean, if you're not hit within the first hour, how can these micro bubbles form fast enough or expand fast enough if your not flying or ascending above sea lever?

 

[wetnorm]

A couple of years ago I developed numbness, tingling and pain in one hand and arm following a vacation dive, and was treated in a chamber. The symptoms seemed to go away during the treatment, and didn't recur on the plane ride home a few days later. However, they did come back a couple of weeks later. In the two years since then, the symptoms have come, stuck around for a couple of weeks, and then gone away for several months at a time. ....

After considering the above, my hyperbaric doctor back home said he didn't think it could have been DCS-related, due to the pattern of when and how symptoms have recurred and remitted. "I've seen DCS symptoms come and go on a time scale of a few hours within a single day, but never across time scales of weeks," he said. The fact that symptoms didn't recur during the plane flight is obviously notable.

So here's my question. I'm not particularly interested in asking for comment on my particular case, since it's been scrutinized pretty thoroughly by a number of M.D.s. But I'm interested in any reactions to the dive doctor's statement about the time scale of DCS symptoms. Would you view his statement as being correct -- that reemergence of symptoms after many weeks of remission argues strongly against it being DCS-related? Thanks for any reactions.

Just to consider another "unifying" explanation that does not exclude DCS....

Perhaps there is an anatomical neurological location (whether abnormal, or even normal) such as a watershed arterial intersection where any blood borne debris may accumulate. This site may collect emboli whether they be gaseous, platelets, plaques, fatty emboli, etc. and produce your recurrent symptoms. In this case you are vulnerable to any emboli. The timeline of clinical recovery may be the differentiating element to point to the nature of the debris.

Also consider, vasospasm of a similar neurovascular site, not dependent on emboli.

Of course, the compressive neurological diagnoses can recur as well and should be considered as more probable. These may be relatively fleeting or persist for days/weeks and then subside w/o residua. Vulnerable bony sites include spinal foramina, first rib/clavicle, olecranon, and carpal tunnel; entrapment of nerve nearby or within muscle bodies found to be in acute or chronic spasm due to strains or injuries, such as scalenius, pectoralis, brachial, or brachioradialis may occur. Non-neurological but "radiating" pain occurs in myofascial pain syndromes and closely mimick nerve compression. Your physicians may be aware of specific provocative physical maneuvers to reproduce your pain, or if in pain, may be able to do a differential nerve/trigger point block to ablate the pain.

Sorry for the comments in your particular case, but one needs to consider all etiologies as well as the rationale for a "timeline" in a specific paradigm.

 

[jplacson]

What are the chances that DCS symptoms (aching shoulder, tingling) are DCS related 24 hours after a dive... assuming that no symptoms at all were present within the first 12 hours?

 

[Dr Deco]

Hello john:

Twenty-four hours later would give a small probability for DCS. It is not, however, impossible.

Dr Deco :doctor: