RECURRENT CARPAL TUNNEL SYNDROME: INADEQUATE PROXIMAL RELEASE

Abstract

A prospective assessment of the cause and results of surgery for recurrent carpal tunnel syndrome.

All patients undergoing revision carpal tunnel surgery over a five year period in a specialist hand surgery unit were reviewed. The physical signs, symptoms, ENIG, operative findings and operative outcome were recorded prospectively.

The selection criteria for surgery included an appropriate history, positive neurophysiology and one or more positive physical signs (Tinel’s, Phalen’s or pressure signs). Patients with normal neurophysiology results only underwent open release if the signs and symptoms were clear-cut, typically with at least 2 out of 3 positive signs.

Twenty-two patients (twenty-four wrists, mean age 55, range 33 to 91) underwent revision surgery. The mean time to re-operation was 7 years. 20 wrists had a positive Tinel’s test, 18 had a positive Phalen’s test, 19 had a positive pressure test and 18 had positive neurophysiology.

At operation, 20 wrists were noted to have compression proximally, 3 mid-retinacular and 3 distally. The proximal end of the primary wound scar was 1 cm or more from the distal wrist crease in 9 patients.

All patients reported some benefit. Significant or complete relief of symptoms were reported in 19 wrists. Better results were achieved in patients who had noted some improvement after primary surgery that had lasted for at least 4 months before relapse.

1. Most papers report inadequate distal release as the most common cause of re-operation but this study found inadequate proximal release to be more common. Less experienced surgeons may be apprehensive about performing an adequate closed proximal release but should be encouraged to take the scar to the distal wrist crease and if in doubt, incise across it in a standard manner.

2. Our results compare with the best reported in the literature and may be attributable to the selection criteria used.