Failed carpal tunnel surgery

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

There are multiple reasons for surgical failure in carpal tunnel syndrome.

The first is the assumption that overuse is the underlying cause of the syndrome without a careful approach to the diagnosis of other underlying conditions.

It is important to look for other conditions associated with CTS such as obesity, diabetes mellitus, thyroid disease, connective tissue disorders such as rheumatoid arthritis, osteoarthritis, inflammatory back pain, psoriasis, gout, and inflammatory bowel disease. Symptoms such as unusual fatigue, fever, night sweats, hair loss, sun sensitivity, skin rashes, eye inflammation, Raynaud's phenomenon, or unexplained changes in weight could point towards an autoimmune or metabolic cause.

An evaluation for arthritis or peripheral neuropathy should be done. This includes symptoms such as prolonged morning stiffness, true swelling of joints or soft tissues, musculoskeletal pain in areas other than the hands, numbness and tingling outside the median nerve distribution of the hands or involving the legs. Ask whether the patient ever has undergone carpal tunnel surgery that failed to relieve symptoms. Finally, consider pregnancy. About 20% of pregnant women describe symptoms of CTS due to fluid retention, generally beginning in the third trimester and resolving spontaneously following delivery.

On physical exam, check for signs of inflammation such as swelling, redness, and joint "crunching." Check for joint pain or limited movement in the lower extremities, pain radiating from the spine, or widespread tenderness in the soft tissues next to joints. Neurologic abnormalities outside the median nerve distribution of the hands would be unusual. Examining the skin for evidence of Raynaud's phenomenon, livedo reticularis, or psoriasis is a good idea.

The most common cause for misdiagnosis of CTS is referred pain from a cervical radiculopathy which leads to discomfort in the thumb, index and middle fingers. Median nerve entrapment in the forearm can also mimic carpal tunnel syndrome.

Magnetic resonance imaging (MRI) is recommended for more precise evaluation of carpal tunnel anatomy and other abnormalities that might be causing the carpal tunnel problem.

Laboratory studies are important in the work-up. Test results suggestive of metabolic disorders include elevated blood sugar, an abnormal TSH level, elevated blood calcium, abnormal liver function studies, or kidney problems. Inflammatory diseases are suggested by anemia, abnormal platelet count, low white blood cells, elevated sedimentation rate, increased C-reactive protein level, and positive rheumatoid factor or antinuclear antibody tests.

Nerve conduction studies may be useful. They are an essential part of the pre-surgical evaluation. An electromyogram (EMG) may be ordered to check for nerve problems occurring at the elbow or in the neck.

Initially, patient discomfort may be alleviated with simple measures such as wrist splints and non-steroidal anti-inflammatory agents. Ultrasound-guided corticosteroid injections into the carpal tunnel can relieve pain and numbness and, in some cases, may eliminate the need for surgery. However, studies suggest that pain and other symptoms return within six months of injection in about 50% of patients.

Treatment of an underlying metabolic or inflammatory disease may alleviate CTS manifestations. However, patients with significant arthritis may continue to experience discomfort and should be considered candidates for carpal tunnel release if conventional measures fail. In patients with median nerve deficit but no evidence of systemic illness, surgery has a good success rate.

For patients who fail surgery, an MRI may help point to the reason why. In addition to incomplete release of the flexor retinaculum, postoperative MRI changes in failed carpal tunnel surgery include excessive fat within the carpal tunnel, neuromas, scarring, and persistent neuritis.

A newer technique, called ultrasound-guided percutaneous needle release is a minimally invasive method for carpal tunnel release and may may make surgical approaches, whether endoscopic or open, obsolete. For more information about this technique, contact the Arthritis Treatment Center at (301) 694-5800 or go to

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