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Background: Carpal tunnel syndrome is the most common compression neuropathy and carpal tunnel release is one of the most frequently performed hand operations. However persistent, recurrent or new symptoms following carpal tunnel release remain a vexing clinical problem.

Methods: A retrospective review of 50 consecutive patients who had undergone revision carpal tunnel surgery by the senior author between 2001 and 2007 was performed. Surgical findings and outcomes were analyzed.

Results: Of the 55 hands in the 50 patients, 34 hands continued to have persistent symptoms, 18 hands had recurrent symptoms and 3 hands had completely new symptoms. The initial carpal tunnel release had been performed by an open technique in 34 hands and by an endoscopic technique in 21 hands. All secondary carpal tunnel surgeries were performed by open carpal tunnel release. Re-exploration revealed incomplete release in 34 patients, either intact antebrachial fascia just proximal to the wrist or undivided flexor retinaculum distally. Circumferential fibrosis around and within the median nerve was found in all patients, synovial proliferation within the carpal tunnel was seen in 4 patients and a separate synovial cavity between the median nerve and the flexor tendons was found in 6 patients (18%). All 50 patients were treated by extensive decompression as well as external neurolysis in 41, epineurectomy in 15, synovial or fat flap coverage in 8, and radial forearm fascial flap coverage in 3 patients. Symptoms resolved completely or improved in 40 patients (80%), but were unchanged in 10 patients (20%) and five patients required a third operative procedure. Improvement after revision surgery for patients who had originally undergone endoscopic carpal tunnel release was slightly better (86%) compared with patients who had originally undergone open carpal tunnel release (76%).

Conclusion: Despite carpal tunnel surgery being a simple procedure, there is still a small number of patients who continue to have persistent symptoms because of incomplete release of the transverse carpal ligament; or who develop recurrent symptoms usually due to associated systemic conditions; or who develop completely new symptoms which usually implies iatrogenic injury to the median nerve.