Single-stage salvage for recurrent carpal tunnel syndrome and delayed Guyon’s canal syndrome following open release: a case report

Abstract

Introduction: Recurrent carpal tunnel syndrome (CTS) is commonly attributed to incomplete decompression or perineural scarring. However, delayed-onset ulnar nerve compression at Guyon’s canal after carpal tunnel release (CTR) is extremely rare and presents diagnostic and therapeutic challenges.

Case report: We report the case of a 50-year-old man who developed dual neuropathies, recurrent median nerve compression, and new-onset ulnar nerve entrapment, approximately one year after open CTR. He presented with diffuse hand paresthesia, weakness, ulnar digit clawing, and impaired thumb opposition. Electrodiagnostic studies revealed severe axonal damage in both the median and ulnar nerves. Surgical intervention was performed via a single palmar incision, including dual nerve decompression, epineurolysis, hypothenar fat pad grafting, and opponensplasty using the extensor indicis proprius (EIP) tendon. At one-year follow-up, the patient demonstrated full sensory recovery, regained thumb opposition, improved grip and pinch strength, and no recurrence of symptoms.

Conclusion: This case highlights the importance of comprehensive clinical and electrodiagnostic reassessment in patients with recurrent or evolving symptoms after CTR. A single-stage, integrated surgical approach may constitute a viable management option in carefully selected patients with complex dual nerve entrapments and is presented as an illustrative example for comparable challenging clinical situations.