Physician Performs Unnecessary Procedure on Patient with Carpal Tunnel Syndrome

This case involves a young Caucasian female who presented to her physician with Carpal Tunnel Syndrom (CTS), derived from a workplace environment with below-standard ergonomics. The patient presented with right wrist pain and paresthesias in the fingers bilaterally, right to left. On the initial visit, the doctor treated the patient conservatively with a night splint and medications, NSAID. The patient contacted her physician again as the symptoms persisted for another 2 months and the doctor rescheduled the surgery to perform a right wrist flexor synovectomy, a carpal tunnel release and an ulnar nerve decompression. After the procedure, the patient noted a decrease in paresthesias; however, the wrist and finger pain persisted. The patient continually followed up with the orthopedist until she decided to order an MRI on the affected wrist. At a later date, the surgeon performed an open right reconstruction with capsulodesis, a right wrist radical extensor tenosynovectomy, a right wrist TFC repair, and a right wrist distal radioulnar joint arthrotomy with synovectomy. The patient received no relief in symptoms from the additional procedures. Care under this physician continued for another 6 months.

Question(s) For Expert Witness

1. What are the necessary procedures for Carpal Tunnel Syndrome?

Expert Witness Response

The above case is a perfect example of unnecessary procedures. CTS is a very common disease in the USA. The management is aimed at treating this conservatively. First, the patient is typically advised to seek physical therapy/occupational therapy consults. Night splinting and NSAIDs are another preliminary step in management. More invasive measures such as steroid injection and surgery are indicated if the above is not effective. Patients whose condition does not improve following conservative treatment and patients who initially are in the severe carpal tunnel syndrome (CTS) category (as defined by electrophysiologic testing) should be considered for surgery. Surgical release of the transverse ligament provides high initial success rates (greater than 90%), with low rates of complication; however, it has been suggested that the long-term success rate may be much lower than previously thought (approximately 60% at 5 y). Success rates also are considerably lower for individuals with normal electrophysiologic studies. Due to the moderate cure rate by the procedure, it's typically done as a last resort. There were multiple other conservative measures that could have been taken with the above patient. Additional procedures were not necessary and the patient will have life-long complications as a result.