A 55-year-old female patient was admitted to our hospital because of numbness in her right hand for 10 years, and the pain get worse for two years. The initial symptoms were paresthesia and nocturnal numbness of the right middle finger without pain. Later, the numbness developed in in the median nerve distribution. Over the past 10 years, the symptoms recurred and the numbness gradually increased. Two years ago, the patient developed pain in the right hand, which was radiation-like pain. The pain radiates down the elbow joint extremity to the fingers. There was no shoulder and neck pain, dizziness, headache, and no range of motion disorder. The patient has no history of trauma. In the past two years, total six corticosteroid injections were performed in her wrist, and the symptoms did not relief significantly and become worse. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score was 55. Electromyography revealed: the median nerve injured, conformed severe carpal tunnel syndrome. Ultrasound of wrist revealed: The right median nerve was significantly thicker than the left side, the echo was low, no interruption was seen, and the transverse carpal ligament was thickened(Figure1). A cervical spine MRI examination revealed: C3/4, C4/5, C5/6 intervertebral discs herniated, C6/7 discs bulge with mild protrusions, degeneration, and cervical degeneration. A right wrist MRI examination revealed: The median nerve is thickened, and slightly higher signal in T2WI（Figure2）. Ultrasound-guided pulsed radiofrequency of the cervical spinal nerve root + posterior branch block + epidural steroid injection (ESI) were performed. The symptoms did not improve significantly. There was no significant atrophy of the thenar. She had a positive Tinel ’s sign and Phalen’s test on her right wrist.
The patient underwent general anesthesia for the surgery. We made the double mini-incisions. A distal incision was made for the transverse carpal ligament resection and another proximal incision for the median nerve release. It was found that the transverse carpal ligament was thickened. The distal median nerve epineurium thickened, and the scar of proximal median nerve epineurium was obvious. The nerve epineurium was excised and the fascicular membrane was released. The median nerve was completely released(Figure3). Sodium hyaluronate was injected into the neural trunk. Postoperative the patient’s numbness and pain relieved
significantly, and The BCTQ score was 24 three weeks after surgery. Postoperative MRI examination revealed: The thickened median nerve became normal thickness(Figure4). Oral methylcobalamin tablets (0.5 mg every 8 h; Eisai Co, Ltd Japan) were taken for six months. There was no difference in the daily life of the patients during the one-year follow-up.