The patient presented with intense pain and loss of sensitivity in her right hand after surgical release of the flexor retinaculum.
The patient presented after surgical release of the flexor retinaculum because of with carpal tunnel syndrome of the right hand. She complained of intense pain and loss of sensitivity in her right hand. The symptoms of persistent median neuropathy despite previous surgically carpal tunnel release were explored by magnetic resonance imaging (MRI).
The imaging protocol included axial and sagittal T1-weighted, T2-weighted and GE STIR images without administration of paramagnetic contrast. The patient was placed in the supine position with the arm extended along the body, taking care to ensure perfect alignment between the forearm and the hand. The MRI examination showed a larger transversal median nerve section than normal with marked hyperintensity of the nerve in the T2 and GE-STIR images. MRI also demonstrated the presence of an extended oedema of the flexor tendons with signs of tenosynovitis. Moreover the images showed a tenosynovitis of the extensor tendons, indicated by hyperintensity on T2 and GE STIR images of the sheath of the tendons. A fluid effusion of the radio-carpal joint was also present. These findings suggested the presence of surgical median nerve damage and an EMG examination confirmed this suspicion.
The carpal tunnel syndrome is the most common neuropathy of the upper extremities. Following failure of conservative therapy, treatment consists of surgical release of the flexor retinaculum. Complications of surgical release for carpal tunnel syndrome include: inadequate release of the transverse carpal ligament, post-operative scarring around the median and ulnar nerves, damage to the superficial palmar arch, damage to flexor tendons, iatrogenic nerve complications. The most common complication is failure to completely release the flexor retinaculum. Damage due to sectioning of motor branches of the median nerve is less common. The result morbidity is persistent paresthesia and pain.
The contribution of MRI to the assessment of complications of surgical carpal tunnel release appears to be useful. MRI, therefore, allows reliable detection of the severity of nerve damage to the ulnar or median nerves and the completeness of release of the flexor retinaculum. So we think MRI is a useful exam especially in some particular cases as like as persistent simptoms after surgical release of flexor retinaculum. .
Surgical damage of the median nerve.
Based on the provided MRI sequence images, the local soft tissue structures around the carpal tunnel display the following characteristics:
1. In the postoperative area, suspected scar tissue is visible, showing slightly high or mixed signal intensity (possibly more evident on T2-weighted images).
2. Abnormal tissue density or signals can be observed around the median nerve region, suggesting potential fibrosis or inflammatory changes during the postoperative repair process.
3. No clearly intact and continuous flexor retinaculum (i.e., flexor retinaculum or transverse carpal ligament) is seen, indicating possible incomplete release or residual fibrous bands causing traction.
4. There is no clear evidence of fracture or bony destruction on the images; however, minor local bony or joint changes (such as long-term arthritic changes) cannot be ruled out.
5. At the indicated site (arrow shown), there is an abnormal signal shadow adjacent to the nerve, possibly representing local adhesion, scar tissue, or a suspected neural sheath involvement.
Overall, the main issue in the operative region appears to be focused around the proximal or distal area near the median nerve. Further evaluation should incorporate clinical symptoms alongside these imaging findings.
Combining imaging results with the patient’s medical history, the following should be considered as primary diagnostic or differential diagnoses:
1. Incomplete Release of the Flexor Retinaculum: Scar tissue or an incomplete surgical cut at this site may continue to mechanically compress or pull on the median nerve; imaging may reveal remnants of the transverse carpal ligament.
2. Postoperative Scar Adhesion or Perineural Inflammatory Reaction: In some patients, excessive scar formation or fibrosis after surgery may cause persistent or new compression on the median and/or ulnar nerve regions. On imaging, such tissue may exhibit higher-than-normal signal intensity or appear as irregular band-like structures.
3. Iatrogenic Nerve Injury: Although the incidence is low, surgical damage to branches of the median nerve or adjacent tissues is possible, presenting as an abnormally thickened nerve sheath or altered signal intensity; patients often continue to experience pain or sensory disturbances.
4. Other Irreversible Changes in the Wrist Joint: Such as degenerative changes of small joints in the wrist, worsening tenosynovitis, or localized cartilage or ligament damage. These are less likely but should be considered if indicated by imaging or clinical findings.
Considering the patient’s age (60 years), continued severe hand pain and sensory loss post-surgery, and MRI findings of irregular signal shadows around the median nerve or in the carpal tunnel area — including suspected residual or proliferative fibrous bands — the most likely diagnosis is: incomplete release of the flexor retinaculum post-surgery accompanied by local scar adhesion.
If clarification of the degree of nerve dysfunction is needed, electromyography (EMG) and nerve conduction velocity (NCV) testing may be considered. If there is still significant evidence of nerve compression on examination and imaging, repeat surgical exploration or release may be required.
Treatment Strategies:
1. Conservative Treatment: For mild symptoms or moderate pain and sensory disturbances, initial management can include local immobilization, physical therapy (e.g., ultrasound, physiotherapy), and oral non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief.
2. Nerve Nutrition and Pain Desensitization: If necessary, nerve nutrition supplements (e.g., B vitamins) or medications for neuropathic pain (e.g., gabapentin, pregabalin) may help alleviate postoperative nerve pain.
3. Injection Therapy: In cases of significant scar formation with inflammatory or adhesive components, image-guided local injections (e.g., corticosteroids) into the soft tissue may help reduce the inflammatory response.
4. Second Surgical Release: If conservative measures fail and electrodiagnostic and imaging findings confirm persistent nerve compression, a second surgical exploration may be considered to thoroughly release any residual or newly formed scar and ligamentous tissue.
Rehabilitation and Exercise Prescription (FITT-VP Principle):
1. Initial Phase:
• Frequency: Approximately 3 times per week, with a 1–2 day interval for rest.
• Intensity: Light intensity, tolerable to mild pain; avoid forceful flexion or heavy load training.
• Time: 10–15 minutes per session focusing on basic wrist activities, such as gentle joint movement and finger gripping after warm water immersion.
• Type: Active exercises of the fingers and wrist, including wrist extension, wrist flexion, fist making, and finger extension; supplemented by local massage or rehabilitation devices.
• Progression: If the patient’s pain gradually decreases, the session can be extended to 20–30 minutes, with possible mild resistance training for the hand (e.g., using a light handgrip device).
2. Intermediate Phase:
• Increase training frequency by one session per week (up to 4 sessions/week), based on pain level and improvement.
• Use light-to-moderate resistance bands or small handgrip devices for progressive resistance training, extending to 20–30 minutes per session; emphasize wrist flexion, extension, and forearm rotation exercises.
3. Maintenance Phase:
• Continue at 3–4 sessions per week, gradually increasing intensity according to recovery, aiming to meet daily functional requirements.
• Focus on functional training, such as correct lifting techniques and sustaining grip strength, to consolidate hand and wrist joint function.
Safety Tips: If severe pain, local redness, or a marked decline in function occurs, stop the exercises immediately and seek medical evaluation to rule out secondary injury or postoperative complications.
Disclaimer:
This report is based solely on the available information and is provided for reference only. It does not replace in-person consultation or a professional medical opinion. If you have any questions or if your condition changes, please seek timely medical attention or consult a qualified healthcare professional.
Surgical damage of the median nerve.
