What treatment is recommended for a patient with worsening right wrist pain, weakness, and constant aching pain, with a history of carpal tunnel repair, currently taking meloxicam (meloxicam) 7.5mg daily and gabapentin (gabapentin) 300mg at bedtime?

Management of Recurrent Wrist Pain After Prior Carpal Tunnel Surgery

Your current approach with splinting and gabapentin 300mg at bedtime is reasonable, but you should optimize the meloxicam dosing first, obtain wrist radiographs to rule out structural pathology, and consider that gabapentin has limited evidence for carpal tunnel syndrome specifically. 1, 2

Immediate Medication Optimization

Increase meloxicam to 15mg daily (the standard therapeutic dose) rather than continuing the subtherapeutic 7.5mg dose she's been taking. 3 NSAIDs are recommended as part of multimodal analgesia for chronic pain conditions, though they have limited efficacy for nerve compression specifically. 3, 1

Critical Caveat About Gabapentin

• Recent high-quality evidence shows gabapentin probably does NOT improve carpal tunnel symptoms compared to placebo (moderate certainty evidence). 2
• The benefit was only 0.08 points on the BCTQ scale (far below the 1.14-point minimal clinically important difference). 2
• Gabapentin causes significant adverse effects: it probably causes more fatigue (RR 1.67) and may cause more dizziness (RR 1.96) compared to placebo. 2
• Despite this, gabapentin may provide minor benefits for neuropathic pain symptoms and sleep quality in post-surgical residual symptoms, particularly nocturnal symptoms. 4

Essential Diagnostic Workup

Obtain wrist radiographs immediately - this is the best initial imaging examination for chronic wrist pain and is essential before proceeding with further treatment. 3

If Radiographs Are Normal or Nonspecific:

• Order MRI without IV contrast to evaluate for:
  • Recurrent median nerve compression or scarring 3
  • Scapholunate ligament tears (radial-sided pain) 3
  • TFCC tears (if ulnar-sided component) 3
  • Occult fractures or stress fractures 3
  • Kienböck's disease 3

Consider Ultrasound Evaluation

• Ultrasound can measure median nerve size and identify incomplete decompression or post-surgical complications. 1
• This is particularly useful for evaluating persistent symptoms after prior carpal tunnel surgery. 1

Treatment Algorithm Based on Findings

If Recurrent Carpal Tunnel Syndrome Is Confirmed:

Conservative management should be attempted for 4-6 weeks before surgical re-exploration: 1

1. Continue nighttime wrist splinting (already initiated - appropriate first-line treatment) 1, 5

2. Optimize pain management with multimodal approach:

   • Increase meloxicam to 15mg daily 3
   • Consider acetaminophen 1000mg TID-QID (up to 4g/day) as it's safer and more effective than NSAIDs alone when used in combination 3
   • Discontinue gabapentin if no improvement after 2-4 weeks given the strong evidence against its efficacy and significant adverse effect profile 2

3. Physical therapy focusing on:

   • Optimal postural alignment 1
   • Normal movement patterns 1
   • Strategies to reduce muscle overactivity 1
   • Avoid prolonged immobilization as it can worsen symptoms 1

4. Consider corticosteroid injection if conservative measures fail, but NOT within 3 months of any planned surgery (increases infection risk). 1

If Surgical Intervention Is Needed:

Surgical decompression provides the strongest evidence for moderate to severe carpal tunnel syndrome and is the most effective treatment when conservative management fails. 1

• Patients with shorter symptom duration (<1 year) have better surgical outcomes. 1
• At 15 years post-initial surgery with only 1 year of worsening symptoms, she falls into a favorable prognostic category. 1

Critical Pitfalls to Avoid

• Do not rely on meloxicam 7.5mg or gabapentin alone as adequate conservative treatment - these do not address median nerve compression. 1, 2
• Do not proceed to surgery without attempting optimized conservative management including proper splinting and multimodal analgesia. 1
• Avoid excessive splinting beyond nighttime use, as it may prevent restoration of normal movement and function. 1
• Do not ignore the possibility of alternative diagnoses - her radial-sided pain with weakness could represent scapholunate ligament pathology, not just recurrent carpal tunnel syndrome. 3

Additional Considerations

Screen for reversible causes of neuropathy if symptoms don't improve with conservative management: 1

• HbA1c (diabetes)
• TSH (thyroid dysfunction)
• Vitamin B12 level
• Consider inflammatory markers if systemic disease suspected

The nocturnal pain pattern (6/10 baseline, 8/10 at night) is classic for carpal tunnel syndrome, but the constant aching and weakness suggest possible additional pathology requiring imaging evaluation. 3, 5