What is the best course of action for a 62-year-old male patient with a history of ulcerative colitis (UC) in remission, who has radial styloid tenosynovitis and is experiencing recurrent pain and new numbness at the thumb base after initial conservative management, including bracing, heat application, and non-steroidal anti-inflammatory drugs (NSAIDs)?

Management of Recurrent Radial Styloid Tenosynovitis with New Neurological Symptoms

This patient requires immediate reassessment to rule out carpal tunnel syndrome or de Quervain's disease progression, followed by either a repeat corticosteroid injection or referral for surgical release, while carefully managing NSAID use given his ulcerative colitis history.

Immediate Diagnostic Considerations

The new onset of numbness at the thumb base with radiating pain up the arm represents a significant change from the initial presentation and warrants urgent re-evaluation 1. This symptom pattern suggests either:

• Progression of de Quervain's tenosynovitis with more severe compression
• Concurrent carpal tunnel syndrome (median nerve compression causing thumb numbness)
• Intersection syndrome (pain radiating proximally up the forearm)

Physical examination should specifically assess for Tinel's sign at the wrist, Phalen's test, and sensory distribution in the median nerve territory to differentiate these conditions 1.

Treatment Algorithm for Recurrent Disease

First-Line Approach: Repeat Corticosteroid Injection

A second corticosteroid injection is highly effective and should be offered as the next step 2. The evidence shows that steroid injection achieves complete pain relief in all treated patients compared to splinting alone (NNTB = 1) 2. The patient has already failed conservative management (bracing, heat, activity modification), making repeat injection appropriate 1.

Key technical points for injection success:

• Ensure accurate injection into the first extensor compartment 3
• Consider ultrasound guidance to identify anatomical variations and improve accuracy 3
• Use methylprednisolone with bupivacaine for optimal results 2

NSAID Management in Ulcerative Colitis Context

NSAIDs must be used with extreme caution or avoided entirely in this patient 4. The guidelines are clear on this critical safety issue:

• Short-term selective COX-2 inhibitors (celecoxib) for 2-4 weeks maximum are acceptable in patients with quiescent UC 1, 4
• Traditional non-selective NSAIDs significantly increase UC flare risk and should be avoided 4, 5
• Long-term NSAID use of any type is contraindicated in UC patients 4

Given his UC is in remission, a 2-4 week course of celecoxib could be considered for pain control if needed, but this should not be the primary treatment strategy 1.

Alternative Pain Management Options

For patients with UC who cannot tolerate NSAIDs:

• Acetaminophen/paracetamol provides pain relief without affecting UC activity 4
• Local corticosteroid injection (as discussed above) treats the source without systemic UC effects 1, 4
• Short-term systemic corticosteroids could bridge to definitive treatment if symptoms are severe 1

Surgical Referral Criteria

Surgery should be considered if conservative measures fail after 3-6 months 1. This patient is approaching that threshold with recurrent symptoms after initial treatment. Surgical release of the first extensor compartment is:

• Highly effective with high cure rates 6, 7
• Simple and straightforward procedure 7
• Recommended as definitive treatment for recalcitrant cases 1, 6
• The treatment of choice when conservative therapy fails 7

The presence of new neurological symptoms (numbness, radiating pain) strengthens the indication for surgical evaluation, as these may indicate more severe compression requiring decompression 1.

Critical Management Pitfalls to Avoid

Do not continue prolonged conservative management without reassessment 1. The patient has already failed initial conservative therapy, and the new neurological symptoms indicate disease progression 1.

Do not prescribe traditional NSAIDs given the UC history 4, 5. Even though his UC is in remission, conventional NSAIDs increase bleeding, diarrhea severity, and endoscopic inflammatory lesions in UC patients 5.

Do not ignore the possibility of concurrent carpal tunnel syndrome 1. The numbness at thumb base and radiating arm pain are not typical of isolated de Quervain's and require specific evaluation 1.

Recommended Action Plan

1. Immediate: Perform focused neurovascular examination to rule out carpal tunnel syndrome or other nerve compression 1

2. Next step: Offer repeat corticosteroid injection with consideration of ultrasound guidance for accuracy 3, 2

3. Pain management: Use acetaminophen as first-line analgesic; if inadequate, consider celecoxib 2-4 weeks maximum only 1, 4

4. Surgical referral: If symptoms persist after second injection or worsen, refer to hand surgery for definitive surgical release 1, 6, 7

5. Activity modification: Continue strict avoidance of triggering activities (guitar playing) during treatment 1