Improper performance of carpal tunnel surgery

Presentation

A 56-year-old man with a history of fibromyalgia and depression went to his primary care physician due to sensory changes in his upper arms. The patient was referred to an orthopedic surgeon.

Physician action

Orthopedic Surgeon A saw the patient and ordered nerve conduction studies, which confirmed a diagnosis of bilateral carpal tunnel syndrome. The surgeon also ordered night splints for the patient’s wrists.

One week later, Orthopedic Surgeon A operated and completed a carpal tunnel repair surgery on the patient’s right side. All appropriate consent forms were signed and the procedure went as planned. The patient attended his postoperative appointments and was noted as having great results.

A second carpal release surgery was performed six months later to repair the patient’s left side. Again, the surgery was noted to be successful and without incident.

During the follow-up visit two weeks later, the patient stated that his left-hand fingers were still numb and he was experiencing elevated pain—at a “9/10 level.”

Orthopedic Surgeon A reasoned that some compression neuropraxia of the median nerve might be present. The patient agreed to wait six weeks to see if the condition improved; if not, a nerve conduction study would be completed.

Within two weeks, the patient returned reporting continued numbness and pain in the left hand. Orthopedic Surgeon A treated the patient with injections of lidocaine, bupivacaine, and methylprednisolone. The surgeon also referred the patient to a pain management specialist.

The pain management specialist noted symptoms of “constant, severe, burning and tingling in the [left] index and middle finger and thumb and along his palm and wrist….aggravated by touch.” The specialist noted that the patient exhibited early signs of complex regional pain syndrome (RSD).

A referral was made to another orthopedic surgeon for evaluation. Orthopedic Surgeon B performed a nerve conduction study and noted that the test showed complete resolution of the carpal tunnel syndrome on the right, but progression of the condition on the left. Orthopedic Surgeon B documented that the patient had a left hand and wrist median nerve injury, possibly precipitated by the surgery.

Subsequent studies confirmed pain and sensory deficits to the left hand. During surgery to explore and repair the left median nerve, Orthopedic Surgeon B found a large amount of scar tissue inside the carpal canal attached to the median nerve.

Orthopedic Surgeon B worked to free the nerve, revealing an atypical Y appearance in the field with two apparent extensions proximally to the one distally, consistent with injury. At the time of this surgery, the patient’s medications were levothyroxine; hydrocodone-acetaminophen 5,500 mg; and gabapentin 300 mg.

Orthopedic Surgeon B informed the patient that the injury was likely due to the previous surgery. The patient continued to have pain in subsequent follow-up visits, ranging anywhere between 6 and 10. The patient requested additional physician opinions and testing.

Approximately nine months later, a new physician, Orthopedic Surgeon C, took the patient to surgery to redo the left carpal tunnel release. He discovered “profound scarring of the median nerve throughout the previous operative site.”

He was able to fully mobilize the nerve; dissect the median nerve along with its distal branches; and mobilize the ulnar median nerve with subcutaneous fat. The patient experienced temporary relief from pain and improved range of motion, but the severe pain returned.

Allegations

The patient filed a lawsuit against Orthopedic Surgeon A, alleging negligence when performing the left carpal tunnel release and injuring the left median nerve. The surgeon’s group was also named in the suit for vicarious liability.

Legal implications
Multiple orthopedic surgeons reviewed this case and agreed that laceration of the median nerve may have occurred during the first surgery; however, nerve injury is a known complication of carpal tunnel surgery.

Disposition

This case was settled on behalf of Orthopedic Surgeon A, due to the seeming permanence of the patient’s condition.

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