PLEASE ONLY COMMENT ON THIS CASE IF YOU ROUTINELY PERFORM CARPAL TUNNEL SURGERY.
62 year old female has severe carpel tunnel issues: her hands were very numb; they were cramping up. she was having issues straightening her fingers. She was having a hard time grabbing things. She sees a physician who is allegedly a fellowship trained sports medicine physician, but his residency was in family practice not orthopedics. He recommends an ultrasound guided carpel tunnel release. When he does the procedure, he transects the median nerve. He does not recognize the injury therefore by the time it is diagnosed the nerve ends have retracted. A cadaver nerve was utilized to bridge the gap (3 to 3.5 CM after debridement) the patient and has only enjoyed a minimal success.
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Do you believe there might have been medical error?
Ultrasound guided carpal tunnel release surgery is a new technology and has now been adopted by non-surgical physicians. This has been promoted by the company Sonex who owns and sells the technology/device and has been selling and training non-surgical physicians to perform the procedure. The standard of care is certainly not to transect the median nerve, regardless of the technique used. Most orthopedic hand surgeons are performing open carpal tunnel release or endoscopic carpal tunnel release. No matter how the procedure is performed, the expectation is that the median nerve should not be injured. If the median nerve was transected, there was obviously a medical error/complication. The goal of the procedure is to decompress and release the pressure off of the nerve, but not to transect the nerve.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
From the above history, it seems it’s clear there is causation. Prior to the procedure. The patient had a chronically compressed, median nerve at the wrist, consistent with carpal tunnel syndrome, but following the procedure, the median nerve was subsequently found to be transected. It’s clear that the procedure led to the nerve injury.
What makes you a good expert for this case?
I am orthopedic surgery trained, hand surgeon, and who has completed a hand surgery fellowship and is board certified in both orthopedic surgery and hand surgery. Carpal tunnel release surgery is my number one most frequently performed surgery. I have personally trial the ultrasound guided carpal tunnel release in the lab. I prefer endoscopic carpal tunnel release. I am very familiar with carpal tunnel release surgery and outcomes
How often do you encounter cases similar to this one in your practice?
Thankfully, I have not personally ever had this complication. I have had colleagues who have seen this injury as a second opinion.
Do you believe there might have been medical error?
Unqualified physician doing procedure out of his scope of practice. Ultrasound guided CTR is not good standard and not widely accepted as safe. Transected median nerve is a complication, higher likelihood with that procedure. Medical error was failure to recognize complication and failure to appropriately treat said complication. He is unable to treat the complications of said procedure and therefore should not be performing procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Medical error and failure to recognize and treat complication caused permanent damage to median nerve which is unable to be fully recovered at this point. Permanent and severe nerve damage that is irreparable.
What makes you a good expert for this case?
Board certified orthopedic hand surgeon who has performed endoscopic carpal tunnel and median nerve surgeries for more than 15 years. Highly experienced with tertiary referrals for median nerve repairs after carpal tunnel surgery complications.
How often do you encounter cases similar to this one in your practice?
I treat median nerve cases like this monthly.
Do you believe there might have been medical error?
Transection of the median nerve is a catastrophic complication of carpal tunnel release. The consequences are magnified when the injury is not immediately recognized. The standard of care was most likely breached with this complication and delayed reconstruction. However, I would refrain from saying anything definitive without the ability to review the specific details of the case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The median nerve transection is almost always a direct consequence of improper positioning of the knife, inadequate visualization, inadequate anatomical familiarity, or any combination of those factors. However, I would refrain from saying anything definitive without the ability to review the specific details of the case.
What makes you a good expert for this case?
I am a Board-Certified, fellowship-trained hand surgeon with experience reviewing cases of carpal tunnel complications. I am the Clinical Director of Hand Surgery in an area medical center. Carpal tunnel release is the most common surgical procedure that I perform.
How often do you encounter cases similar to this one in your practice?
Thankfully, a complication of this magnitude is uncommon. However, I have encountered nerve transection cases as a second opinion surgeon approximately once per year.
Do you believe there might have been medical error?
First of all the physician performing the surgery was not either an orthopedic surgeon or orthopedic specialist or Plastic Surgeon fellowship trained in hand. The surgery is never done under ultrasound guidance. The physician did not understand the anatomy and unfortunately cut the median nerve.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The transaction of the median nerve was definitively caused during the time of the surgery. This is basically an irreversible injury, despite the fact that the graft was used to try to improve the function of the median nerve. This patient will permanently have numbness and tingling in the median nerve distribution along with weakness in grip strength, ability to turn a key or knob, right etc..
What makes you a good expert for this case?
I have been in practice for over 25 years. I have performed multiple carpal tunnel releases over the years.
How often do you encounter cases similar to this one in your practice?
I have never heard of a case where the median nerve was completely transected. I have heard of cases where the motor branch of the median nerve was transected, but not the median nerve in its entirety at the carpal tunnel.
Do you believe there might have been medical error?
A graft was used to reconstruct the nerve. It also seems that the error was missed by the initial treating physician
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The presence of a nerve laceration requiring repair following previous surgery in proximity of the nerve can only be explained by an intraoperative event unless another injury occurred soon afterward (example a knife injury). All the presented signs point to a complication.
What makes you a good expert for this case?
I am an experienced hand surgeon with expertise in US carpal tunnel surgery
How often do you encounter cases similar to this one in your practice?
This particular complication- never. Carpal tunnel surgery- very common.
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