Background

This paper reviews the signs and symptoms of recurrent or persistent carpal tunnel syndrome and examines some of the causes of failed primary carpal tunnel release.

Methods

A retrospective review of the surgical findings and outcomes of 29 consecutive patients who underwent 30 revision carpal tunnel operations was performed. Patient outcomes were recorded at a minimum of 1 year postoperatively.

Results

Thirty hands in 29 consecutive patients underwent a second operation by a single surgeon. The average time interval from the first carpal tunnel release to the revision surgery was 5.7 years. Twenty-three patients experienced recurrent symptoms, and 7 had persistent symptoms. On preoperative examination, 77% demonstrated abductor pollicis brevis muscle weakness, 67% demonstrated a positive Phalen sign, and 63% demonstrated ring finger "sensory splitting." Incomplete release of the transverse carpal ligament and circumferential fibrosis were the most common intraoperative findings, totaling 20 cases each; intact antebrachial fascia (8 cases), volar subluxation of the median nerve (5 cases), compression of the median nerve by palmaris longus (4 cases), flexor tenosynovitis (4 cases), and aberrant anatomy (1 case) were also observed. Nine patients (34%) had complete resolution of symptoms after the revision carpal tunnel release. Fifteen patients (58%) had improvement in symptoms, and 2 patients did not report improvement.

Conclusions

We have found the Phalen sign, comparison of the strength of the abductor pollicis brevis muscle, and subjective "splitting" of the ring finger sensation to be the most helpful findings in establishing the diagnosis. Persistent carpal tunnel syndrome is almost always secondary to incomplete division of the transverse carpal ligament.

Background

Laminectomy with fusion (LF) and laminoplasty (LP) are common posterior decompression procedures used to treat multilevel degenerative cervical myelopathy (DCM). There is debate on their relative efficacy and safety for treatment of DCM. The goal of this study is to examine outcomes and costs of LF and LP procedures for DCM.

Methods

This is a retrospective review of adult patients (<18) at a single center who underwent elective LP and LF of at least 3 levels from C3-C7. Outcome measures included operative characteristics, inpatient mobility status, length of stay, complications, revision surgery, VAS neck pain scores, and changes in radiographic alignment. Oral opioid analgesic needs and hospital cost comparison were also assessed.

Results

LP cohort (n=76) and LF cohort (n=59) reported no difference in neck pain at baseline, 1, 6, 12, and 24 months postoperatively (p>.05). Patients were successfully weaned off opioids at similar rates (LF: 88%, LP: 86%). Fixed and variable costs respectively with LF cases hospital were higher, 15.7% and 25.7% compared to LP cases (p=.03 and p<.001). LF has a longer length of stay (4.2 vs. 3.1 days, p=.001). Wound-related complications were 5 times more likely after LF (13.6% vs. 5.9%, RR: 5.15) and C5 palsy rates were similar across the groups (LF: 11.9% LP: 5.6% RR: 1.8). Ground-level falls requiring an emergency department visit were more likely after LF (11.9% vs. 2.6%, p=.04).

Conclusions

When treating multilevel DCM, LP has similar rates of new or increasing axial neck pain compared to LF. LF was associated with greater hospital costs, length of stay, and complications compared to LP. LP may in fact be a less morbid and more cost-effective alternative to LF for patients without cervical deformity.