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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3182402c37
Hand/Peripheral Nerve: Original Articles

Revision Surgery for Persistent and Recurrent Carpal Tunnel Syndrome and for Failed Carpal Tunnel Release

Jones, Neil F. M.D.; Ahn, Hee Chang M.D., Ph.D.; Eo, SuRak M.D., Ph.D.

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Author Information

Irvine, Calif.

From the University of California Irvine Center for Hand and Upper Extremity Surgery, University of California Irvine.

Received for publication May 4, 2011; accepted August 26, 2011.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Neil F. Jones, M.D.; University of California Irvine Medical Center, 101 The City Drive South, Pavilion III, Orange, Calif. 92868, nfjones@uci.edu

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Abstract

Background: Carpal tunnel release is one of the most frequently performed hand operations. However, persistent, recurrent, or completely new symptoms following carpal tunnel release remain a difficult problem.

Methods: A retrospective review of the surgical findings and outcomes of 50 consecutive patients who had undergone 55 revision carpal tunnel operations was performed.

Results: The initial carpal tunnel release was an endoscopic technique in 34 hands and an open technique in 21 hands. Thirty-four hands continued to have persistent symptoms, 18 hands had recurrent symptoms, and three hands had completely new symptoms. Reexploration revealed incomplete release in 32 patients. Circumferential fibrosis around the median nerve was found in all patients. Forty-six percent of patients with recurrent symptoms had slight palmar subluxation of the median nerve. External neurolysis was performed in 41, epineurectomy was performed in 15, synovial or hypothenar fat flap coverage was performed in eight, and radial forearm adipofascial flap coverage was performed in three hands. Symptomatic improvement following revision surgery after open carpal tunnel release was slightly better (90 percent) compared with after endoscopic carpal tunnel release (76 percent), but complete relief of symptoms following revision surgery was similar after open (57 percent) or endoscopic (56 percent) techniques. Ten patients (20 percent) showed no improvement and five patients required a third operation.

Conclusions: A small number of patients (1) continue to have persistent symptoms after carpal tunnel release because of incorrect diagnosis or incomplete release of the transverse carpal ligament; (2) develop recurrent symptoms caused by circumferential fibrosis; or (3) develop completely new symptoms, which usually implies iatrogenic injury to branches of the median nerve.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Since Learmonth performed the first surgical treatment for carpal tunnel syndrome in 1933, carpal tunnel release has become the most frequently performed hand operation in the United States.1 In addition to the classic open technique, newer endoscopic techniques have been introduced by Chow, Okutsu, Teo, and Agee.1,2 Although complications are not common after carpal tunnel release, a small number of patients may continue to experience persistent symptoms or may experience new and different symptoms in the postoperative period.

The persistence of preoperative symptoms may occur after either open or endoscopic carpal tunnel release and correlates with incomplete release of the transverse carpal ligament.3 On the contrary, recurrence is defined as “documented carpal tunnel syndrome in which the symptoms had resolved following surgical release, but then recurred, requiring a re-release of the carpal tunnel.”4 Although possible reasons for recurrent carpal tunnel syndrome have been hypothesized by some hand surgeons,4,5 its pathogenesis is still not clear. A retrospective review of 50 consecutive patients who required a second operation performed by the senior author (N.F.J.) for persistent or recurrent symptoms after initial carpal tunnel release in 55 hands was performed to analyze the surgical findings and patients' outcomes.

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MATERIALS AND METHODS

After institutional review board approval, medical records were analyzed to identify patients who had undergone revision carpal tunnel surgery performed by a single surgeon (N.F.J.) at the University of California, Los Angeles Medical Center over a 6-year period from March of 2001 through February of 2007. Documentation of preoperative symptoms, physical examination, and electrodiagnostic studies before the revision carpal tunnel operation were recorded. Associated systemic conditions and the technique of the initial carpal tunnel release were obtained from the chart review. Details of displacement of the median nerve, scarring, site of incomplete release, and visible injury to the median nerve were collected from the operative reports. Patients' outcomes at least 1 year postoperatively were documented as either complete, improved, or unchanged symptomatic relief.

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RESULTS

Fifty-five hands in 50 consecutive patients underwent a second operation after an initial carpal tunnel release over a 6-year period performed by a single surgeon. Forty-seven patients had their carpal tunnel release at another institution and three patients had been treated by other surgeons in our institution. Twenty-nine were men and 21 were women. The initial carpal tunnel release was an endoscopic technique in 34 hands and an open technique in 21 hands. The affected hand was the dominant hand in 46 of the 50 patients; there 14 left hands and 31 right hands, and five were affected bilaterally.

Thirty-four hands in 30 patients had persistent symptoms after primary carpal tunnel release (Table 1). Reexploration revealed incomplete release of the flexor retinaculum distally in 18 hands and intact antebrachial fascia proximally at the wrist in 14 hands (Table 2). Two patients had “double-crush” syndrome caused by pronator syndrome. Eighteen hands in 17 patients developed recurrent symptoms after initial relief of their original symptoms following primary carpal tunnel release an average of 21 months after the initial operation (range, 7 months to 8 years). Three patients developed completely different symptoms after their initial carpal tunnel release. One patient presented with weakness of thumb abduction and thenar atrophy after the primary carpal tunnel release, and one patient presented with numbness and paresthesias down the ulnar aspect of the long finger and the radial aspect of the ring finger after the primary carpal tunnel release.

Table 1
Table 1
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Table 2
Table 2
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The average interval between the first carpal tunnel release and the second operation was 1 year 5 months (range, 3 months to 8 years) (Fig. 1). All patients presented with both clinical symptoms and signs and electrodiagnostic criteria of compromised median nerve function.

Fig. 1
Fig. 1
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Systemic diseases or associated conditions are summarized in Table 3. Trigger thumb developed in three hands after the primary carpal tunnel release. Other nerve compression syndromes, including the “double-crush” phenomenon, occurred in three patients.

Table 3
Table 3
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The most common intraoperative finding at surgical reexploration was incomplete release of the flexor retinaculum in 32 hands (58 percent) (Fig. 2). Obviously, incomplete release was associated with persistent symptoms. In 18 hands (32.7 percent), the distal few millimeters of the transverse carpal ligament had not been completely released, and in 14 hands (25.5 percent), the antebrachial fascia at the wrist crease remained intact. The location of the incomplete release did not correlate with the original endoscopic or open technique. Circumferential fibrosis of the median nerve within the carpal tunnel was seen in all cases, including patients with persistent, recurrent, and new symptoms. Severe scarring of the palmaris longus tendon over the median nerve was observed in four hands (7.3 percent). Severe synovial proliferation was found in four hands (7.3 percent), and rice bodies, amyloid deposits, and calcinosis were found in one hand each. Two ganglions were discovered at the second carpal tunnel release. Reexploration of two of the three patients who had developed completely new symptoms after their initial carpal tunnel surgery revealed transection of the motor branch of the median nerve after open carpal tunnel release and a neuroma-in-continuity (Fig. 3) of the common digital nerve to the long/ring finger web space after an endoscopic carpal tunnel release. There were no specific abnormal intraoperative findings to explain the symptoms in three patients (5.5 percent). Five patients underwent an ancillary procedure such as cubital tunnel, radial tunnel, or pronator syndrome release.

Fig. 2
Fig. 2
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Fig. 3
Fig. 3
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Formal external neurolysis was performed in 41 hands, neurolysis under the operating microscope was performed in 18 hands, and epineurectomy was performed in 15 hands (Fig. 4 and Table 4). Coverage of the median nerve was performed using a synovial or hypothenar fat flap in eight patients (Fig. 5) and a reverse radial forearm adipofascial flap in three patients.

Fig. 4
Fig. 4
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Table 4
Table 4
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Fig. 5
Fig. 5
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Postoperatively, abductor pollicis brevis strength, evaluated by the senior surgeon on a five-point scale, was improved in 24 patients (48 percent). Pain, numbness, and paresthesias resolved completely or improved in 40 patients (80 percent) and 45 hands after reoperation, but remained unchanged in 10 patients (20 percent), five of whom (10 percent) required a third operation. Eight of these 10 patients underwent second carpal tunnel surgery for recurrent symptoms and two patients underwent second carpal tunnel surgery for persistent symptoms. Operative findings associated with a poor result included severe circumferential fibrosis around the median nerve, proliferative tenosynovitis, and amyloidosis. Workers' compensation insurance and a painful hypersensitive incisional scar before the second operation were also associated with a worse prognosis.

Of the 34 primary endoscopic carpal tunnel releases, symptoms improved in 26 hands (76 percent); symptoms were relieved completely in 19 (56 percent) and unchanged in eight hands (24 percent). Of the 21 primary open carpal tunnel releases, symptoms improved in 19 hands (90 percent), 12 (57 percent) had complete relief of their symptoms, but there was no improvement in two hands (9.5 percent) (Table 5). Five hands required a third operative procedure.

Table 5
Table 5
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DISCUSSION

Carpal tunnel release has become one of the most common and successful hand surgery procedures performed, regardless of the various surgical techniques used—the original open method,6 endoscopic techniques,1,4,6,7 and the limited mini-incision techniques.8 However, complications and failures have been shown to occur in 3 to 19 percent in large series,3,9 necessitating reexploration in up to 12 percent.5,10

Tung and Mackinnon11 classified the indications for secondary carpal tunnel surgery into three general types: persistent, recurrent, and new symptoms. Symptoms may persist after surgery, with little or no improvement. Although Proubasta et al.12 described the “fat pad” and “little finger pulp” signs to confirm complete release of the transverse carpal ligament intraoperatively, incomplete release of the transverse carpal ligament is the most common cause of persistent symptoms after carpal tunnel release, with a reported incidence of 7 to 20 percent.3,13 The most distal portion of the transverse carpal ligament and the proximal antebrachial fascia are the most likely sites of ongoing compression because of the difficulty of adequate exposure in endoscopic and limited mini-incision techniques. However, it has been difficult to determine the true contribution of incomplete release, because many patients have also been found to have other contributing factors such as fibrous proliferation or tenosynovitis.14 In addition, compression of the median nerve more proximally in the forearm (pronator syndrome) or in the neck may lead to a misdiagnosis of carpal tunnel syndrome, and persistent symptoms may be caused by a “double-crush” syndrome.5,15 It is imperative that surgeons consider an incorrect diagnosis as the cause of persistent symptoms rather than automatically assuming incomplete release.

Recurrent carpal tunnel syndrome implies that there has been significant improvement or complete relief of the patient's symptoms that lasts for a definite period of time after the initial carpal tunnel release. Eventually, however, similar symptoms develop again. We have defined recurrent carpal tunnel syndrome as symptoms recurring after a minimum of 6 months of complete relief of the original symptoms after the primary carpal tunnel release. Epineurial fibrosis, interstitial scar, and soft-tissue adhesions to the nerve are common causes of recurrence after carpal tunnel release.1618 Pizzillo et al.19 and Hunter20 described traction neuropathy when the epineurial surface of the median nerve is surrounded by scar tissue that is irritated by repetitive wrist and finger flexion and extension. Proliferation of fibrous scar tissue may form directly around the median nerve and either externally compress the nerve or “spot-weld” the nerve to surrounding structures (Fig. 6, above), preventing normal nerve gliding and leading to traction neuritis of the nerve whenever the wrist or digits are flexed or extended. Contributing factors may include poor hemostasis, prolonged immobilization, and overzealous physical therapy.

Fig. 6
Fig. 6
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Finally, completely new symptoms may develop following primary carpal tunnel release that are quite distinct from the patient's initial complaints. Neuropathic pain out of all proportion to the surgery, or new areas of numbness or paresthesias, or marked weakness of the thenar muscles implies iatrogenic injury to the median nerve or its branches, usually the palmar cutaneous branch or the thenar motor branch after open carpal tunnel release, or the common digital nerve to the long/ring finger web space after endoscopic carpal tunnel release. Vascular injury to the superficial palmar arch or a common digital artery, “pillar” pain, a painful incisional scar, and trigger finger are infrequently encountered after carpal tunnel surgery.11

Evaluation of a patient with an unfavorable result following carpal tunnel surgery begins with a detailed history, specifically regarding whether the patient's symptoms are similar to those preoperatively or whether they are new symptoms such as pain, numbness, or paresthesias. Iatrogenic injury to the median nerve or its branches should always be suspected in the presence of pain out of all proportion to the carpal tunnel surgery. Examination should include the position and length of the previous carpal tunnel incision, tenderness or a Tinel sign over the incision, Phalen sign, weakness of the abductor pollicis brevis muscle compared with the contralateral normal thumb, or atrophy of the thenar muscles. Two-point discrimination and Semmes-Weinstein monofilament testing of each of the digital nerves within the median nerve distribution and the palmar cutaneous branch of the median nerve should be performed. We have found the Phalen sign, comparison of the strength of the abductor pollicis brevis muscle, and subjective “splitting” of the ring finger sensibility to be the most informative signs on physical examination. The possibility of pronator syndrome should be excluded by examining for tenderness or a Tinel sign over the median nerve in the proximal third of the forearm; weakness of the flexor pollicis longus and flexor digitorum profundus muscles to the index and long fingers; and several provocative maneuvers including the pronator compression test, resisted flexion of the proximal interphalangeal joint of the long finger, the resisted pronation test and the elbow flexion test.

Nerve conduction studies should be repeated and compared with any preoperative nerve conduction study to determine whether they are the same, have improved, or are worse. If the repeated nerve conduction studies are worse or electromyography shows signs of denervation of the thenar muscles, this implies either injury to the median nerve or its branches and provides objective evidence to proceed with surgical reexploration. If the repeated nerve conduction study is the same or slightly improved compared with the initial nerve conduction study, this does not really help in determining whether to perform reexploration. Repeated nerve conduction studies may potentially detect other compression neuropathies or other diagnoses that may have been missed on the initial, possibly less detailed, nerve conduction study. Ultrasound and magnetic resonance imaging may help define pathologic anatomy,14 but absolute indications for their use have not been defined. The operative report from the initial carpal tunnel release should be obtained and reviewed for any hints of difficulty, poor visualization, or excessive bleeding.

Patients with both persistent and new symptoms are usually treated conservatively with scar massage, hand therapy, and a removable wrist splint for 9 months after the initial carpal tunnel release operation, unless objective signs and nerve conduction studies are suspicious for an iatrogenic injury to the median nerve or its branches, in which case early reexploration is indicated. A protective padded glove and scar-modifying gels may be appropriate for patients with complaints of painful or hypersensitive scars. Occasionally, a steroid injection just proximal to the wrist crease in patients with persistent or recurrent symptoms may be diagnostic if it results in a temporary improvement in the patient's symptoms.

Our approach to reexploration has been to extend the previous incision both proximally and distally. For patients who have previously undergone an Agee endoscopic carpal tunnel release, the transverse endoscopic incision can be extended distally from one end of the transverse limb and proximally from the opposite end of the transverse limb. The median nerve is identified in normal tissues proximal to the previous incision and traced in a proximal-to-distal direction. Similarly branches of the median nerve are identified in normal tissues in the palm and traced in a distal-to-proximal direction.

The surgeon should look specifically for remaining intact transverse fibers of the distal end of the transverse carpal ligament that had not been released at the initial carpal tunnel release, or intact antebrachial fascia proximally at the level of the wrist crease (Fig. 2). The palmaris longus tendon may be found acting as a secondary site of compression, passing either in a radial-to-ulnar or ulnar-to-radial direction across the median nerve, in which case it should be resected. The median nerve may be displaced radially beneath the radial leaf of the transverse carpal ligament and should be mobilized gently into a more direct central course. We have observed in 46 percent of patients with recurrent symptoms after previous open carpal tunnel releases that there is a separate synovial layer beneath the median nerve with a cavity between this synovial layer and the underlying flexor tendons (Fig. 6, center and below). Although Henry et al.21 implied that there is little therapeutic benefit to splinting after carpal tunnel release, our findings suggest that the median nerve may sublux slightly palmar with respect to the flexor tendons, possibly as a result of not splinting the wrist in extension immediately after the initial carpal tunnel release.

Although intuitively it would seem that a patient with persistent symptoms would simply require identification and release of the remaining site of incomplete release, unfortunately, these patients develop varying amounts of scar tissue around the median nerve in the interval between the primary carpal tunnel operation and the second operation (average, 17 months; minimum, 3 months). Therefore, the median nerve has to be dissected from scar tissue, and this usually requires a formal external neurolysis under loupe magnification. Especially in patients with recurrent symptoms, areas of significant epineurial scarring may require external neurolysis under the operating microscope and occasionally even epineurectomy. However, internal neurolysis of the median nerve is contraindicated.

If one of the common digital nerves is found to have been transected, either a secondary nerve repair or nerve graft or nerve conduit can be performed. If a neuroma of the palmar cutaneous branch of the median nerve is found, the neuroma can be translocated or, if both ends of the nerve can be identified, a nerve graft performed. If the motor branch of the median nerve is found to have been transected, direct nerve repair can occasionally be performed; otherwise, an opposition tendon transfer is performed either at the same time or at a later stage.

After external neurolysis of the median nerve, controversy exists as to whether a biological barrier should be interposed between the median nerve and the overlying skin or the underlying flexor tendons. If a definitive cause for the patient's persistent symptoms is discovered at the second operation, such as incomplete release of the transverse carpal ligament, or if the median nerve can be easily mobilized from surrounding scar tissue, or if the median nerve can be relocated from a palmarly displaced position back into its normal position, coverage of the nerve is probably unnecessary. If the carpal tunnel is heavily scarred with fibrous proliferation around the median nerve, several authors have suggested that soft-tissue coverage is necessary to prevent recurrent scarring of the anterior surface of the median nerve to the radial and ulnar leaves of the transverse carpal ligament or to the palmar skin. Local muscle flaps including abductor digiti minimi,22 pronator quadratus,23 and palmaris brevis24; the hypothenar fat flap25; a synovial flap (Fig. 5)26; a dermal graft27; and more recently synthetic membranes have all been advocated for coverage of the anterior surface of the median nerve. More complex pedicled flaps and free flaps have also been described, including the reverse radial forearm adipofascial flap,28 free omental transfer,29 and small free muscle and fascial flaps.30,31 For the very severely scarred median nerve that has undergone multiple operations, Jones30 introduced the concept of “circumferential wrapping” the median nerve to insulate the median nerve from both the underlying flexor tendons and the overlying skin, to allow gliding of the previously scarred nerve, and to revascularize the ischemic nerve, analogous to the insulation of an electrical cable. Circumferential wrapping of a scarred median nerve with the intimal surface of a vein graft has also been described,19,32,33 although the vein graft is itself a dead piece of tissue that needs to become revascularized and may produce additional fibrous scar tissue.

According to Hulsizer et al.,10 patients with persistent or recurrent symptoms following a prior endoscopic carpal tunnel release have a better chance of improvement or resolution of their symptoms compared with patients who had a prior open carpal tunnel release. However, our results suggest slightly better improvement after open carpal tunnel release (90 percent) compared with 76 percent after endoscopic carpal tunnel release, although patients achieving complete relief of their symptoms are similar after open (57 percent) or endoscopic (56 percent) release. Only 25 percent of patients who undergo reoperation for a failed carpal tunnel release seem to be completely satisfied without any residual symptoms after the second carpal tunnel operation, with the incidence of residual symptoms ranging from 41 to 90 percent16,3437 and 20 percent of patients require a third operation. Although the description “residual symptoms” in the literature is not synonymous with our criteria of “no improvement,” 56 percent of our patients had complete relief of their symptoms after the second operation and only 10 percent went on to require a third operation. Poor outcomes after a second carpal tunnel release have been associated with workers' compensation insurance, normal nerve conduction studies before the second operation, and symptoms within the ulnar nerve distribution.34 Because carpal tunnel syndrome is occupationally related in 42 percent of patients,20 these patients appear to have higher recurrence rates and poorer outcomes.

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CONCLUSIONS

The results of both open and endoscopic carpal tunnel release are generally good, but not all patients obtain complete and long-lasting relief. Persistent, recurrent, or new different symptoms following carpal tunnel release remain a vexing problem for both hand surgeons and patients. Based on our series, incorrect diagnosis and incomplete release of the transverse carpal ligament were the main causes of persistent symptoms. Fibrous proliferation and subtle palmar subluxation of the median nerve compounded by repetitive motion were the main causes of recurrent symptoms. Revision carpal tunnel surgery should be avoidable by reducing technical errors during the primary carpal tunnel release, ensuring complete release of the transverse carpal ligament and avoiding iatrogenic injury to the median nerve.

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CODING PERSPECTIVE

This information prepared by Dr. Raymund Janevicius is intended to provide coding guidance.

* Release of the transverse carpal ligament is reported with code 64721. This code is reported for both primary and recurrent carpal tunnel surgery.

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* Code 64721 includes epineurectomy and external neurolysis.

* Internal neurolysis using the operating microscope is reported with code 64727. If fascicular groups are dissected using loupe magnification, code 64727 is not to be used.

* Code 64727 is an add-on code and never stands alone. It must be used with a primary neuroplasty code, in this case, 64721.

* A hypothenar fat flap is an adjacent tissue transfer and is reported with code 14040.

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