I am sure you all would have come across the elderly patient with very severe carpal tunnel syndrome with muscle wasting and a complete lack of sensations.
I operated on such a case recently and the patient feels worse after the operation.
She has now dysaesthesia compared to the complete lack of sensations.
On the basis of that experience, I tried to counsel the next patient about the possibility of worsening symptoms after release.
The patient wanted to know whether I would advise to leave it alone?
It is a difficult situation. What would you advise?
I think this problem is poorly understood and is an important part of the consent process. In my experience the greatest risk is in the severe compression case and typically also associated with diabetic neuropathy. The consequence is that there is some reperfusion and “awakening” of fibres with conduction block within a severely compressed nerve and as you say the resultant dysaesthesia is unpleasant and can be painful. In such cases the differential is an incomplete release with an unhappy nerve and repeat neurophysiology may demonstrate that there is some improvement in conduction. I try to reassure patients that there will be some improvement with time. It is not possible to predict preoperatively which patients will benefit from release and which may be at risk of this complication. I would urge caution in the minimally symptomatic patient with diabetes and severe compression as this is the highest risk group and the group with least to gain from decompression. Desensitisation exercises, mirror therapy, scar massage and functional hand integration with hand therapy are the mainstays of managing the new symptoms and this is one situation where I would use neuromodulator medications.