Revision Carpal Tunnel Release in a Case of Persistent Symptoms and Incomplete Release

Failure to resolve symptoms of carpal tunnel syndrome following a release of the flexor retinaculum can occur for a number of reasons. Failed carpal tunnel can be classified into three categories and include (1) persistent symptoms, (2) recurrent symptoms, and (3) new symptoms. Persistent symptoms of median nerve dysfunction can imply an incomplete release and/or wrong initial diagnosis with other associated problems, which can include proximal median nerve compression and/or cervical disc disease. Revision surgery is appropriate for patients with an incomplete release. In this case, the patient presented with a loss of median motor/sensory function immediately after surgery and pain in the territory of the palmar cutaneous branch of the median nerve. Provocative tests revealed findings comparable with an incomplete release of the carpal tunnel. Revision surgery was elected and an incomplete proximal release of the flexor retinaculum was found. Additionally, this patient had a palmar cutaneous branch with an aberrant course through the flexor retinaculum into the territory of the first incision. This branch was managed with a proximal transposition.

Standard 131115

Extended 131115

POSITION

Supine.

INCISION

Ulnar incision from thenar crease, Brunner’s incision over wrist crease, and proximal forearm incision.

REFERENCES

Zieske L, Ebersole GC, Davidge K, Fox I, Mackinnon SE. Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes. J Hand Surg Am. 2013 Aug;38(8):1530-9. PMID: 23809470.

Colbert SH, Mackinnon SE. Nerve compressions in the upper extremity. Mo Med. 2008 Nov-Dec;105(6):527-35. Review. PMID: 19052017.
Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am. 2008 Nov;33(9):1518-24. PMID: 18984333.
Ellis RA, Novak CB, Mackinnon SE, Cheng CJ. Workers’ compensation, return to work, and patient satisfaction after carpal tunnel decompression. Am J Orthop (Belle Mead NJ). 2007 Apr;36(4):E63-6. PMID: 17703269.
Wiesman IM, Novak CsB, Mackinnon SE, Winograd JM. Sensitivity and specificity of clinical testing for carpal tunnel syndrome. Can J Plast Surg. 2003 Summer;11(2):70-2. PMID: 24222987.
Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002 May;18(2):231-41. Review. PMID: 12371026.
Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann Plast Surg. 2002 Mar;48(3):269-73. PMID: 11862031.
Tung TH, Mackinnon SE. Secondary carpal tunnel surgery. Plast Reconstr Surg. 2001 Jun;107(7):1830-43; quiz 1844,1933. PMID: 11391209.
Mackinnon SE, Novak CB, Landau WM. Clinical diagnosis of carpal tunnel syndrome. JAMA. 2000 Oct 18;284(15):1924-5; author reply 1925-6. No abstract available. PMID: 11035883.
Hudson AR, Wissinger JP, Salazar JL, Kline DG, Yarzagaray L, Danoff D, Fernandez E, Field EM, Gainsburg DB, Fabi RA, Mackinnon SE. Carpal tunnel syndrome. Surg Neurol. 1997 Feb;47(2):105-14. No abstract available. PMID: 9040809.
Watchmaker GP, Weber D, Mackinnon SE. Avoidance of transection of the palmar cutaneous branch of the median nerve in carpal tunnel release. J Hand Surg Am. 1996 Jul;21(4):644-50. PMID: 8842959.
Deune EG, Mackinnon SE. Endoscopic carpal tunnel release. The voice of polite dissent. Clin Plast Surg. 1996 Jul;23(3):487-505. Review. PMID: 8826685.
Strasberg SR, Novak CB, Mackinnon SE, Murray JF. Subjective and employment outcome following secondary carpal tunnel surgery. Ann Plast Surg. 1994 May;32(5):485-9. PMID: 8060072.
Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg. 1992 Jul;29(1):8-11. PMID: 1497301.
Cartotto RC, McCabe S, Mackinnon SE. Two devastating complications of carpal tunnel surgery. Ann Plast Surg. 1992 May;28(5):472-4. PMID: 1622022.
Novak CB, Mackinnon SE, Brownlee R, Kelly L. Provocative sensory testing in carpal tunnel syndrome. J Hand Surg Br. 1992 Apr;17(2):204-8. PMID: 1588205.
Mackinnon SE, McCabe S, Murray JF, Szalai JP, Kelly L, Novak C, Kin B, Burke GM. Internal neurolysis fails to improve the results of primary carpal tunnel decompression. J Hand Surg Am. 1991 Mar;16(2):211-8. PMID: 2022828.
Mackinnon SE. Secondary carpal tunnel surgery. Neurosurg Clin N Am. 1991 Jan;2(1):75-91. Review. PMID: 1821736.
Mackinnon SE, Dellon AL. Anatomic investigations of nerves at the wrist: I. Orientation of the motor fascicle of the median nerve in the carpal tunnel. Ann Plast Surg. 1988 Jul;21(1):32-5. Review. PMID: 304818.