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ORIGINAL ARTICLE

Recurrent Carpal Tunnel Syndrome Treated By Autograft Vein Wrapping

*Ignacio R. Proubasta,  Laura T. Trullols, Claudia G Gomez,  Joan P. Itarte,

*Hand Surgery Unit, Orthopaedic Department, Hopital Sant Pau, Barcelona (Spain)

Address for Correspondence

Ignacio R. Proubasta, PhD.
Hand Surgery Unit, Orthopaedic Department, Hopital Sant Pau,
Barcelona (Spain)
E-mail: iproubastasop.santpau.es

Abstract

Carpal tunnel release has become one of the most frequent and successful operative procedures performed on the hand. However, complications and treatment failures have been shown to occur in 3% to 19% in large clinical series, needing re-exploration in up to 12% of open carpal tunnel release 1.  Common causes of unrelieved symptoms or recurrence are diverse and include incomplete release of the transverse carpal ligament, reformation of the flexor retinaculum, postoperative adhesions, fibrous proliferation, scarring within carpal tunnel, recurrent inflammatory flexor tenosynovitis, entrapment of the palmar cutaneous branch, laceration or neuroma of median nerve or palmar cutaneous branch, incorrect diagnosis, double crush syndrome, etc 2. Of these the most common pathologic finding was epineural scarring at the site of decompression surrounding the nerve 3. When this occurs, multiple surgical procedures have been advocated to diminish adherence of the median nerve, including reincision of the transverse carpal ligament, scar debridement, epineurolysis, internal neurolysis, placement of local muscle flaps or fat pads over heavily scarred areas, and application of barrier material to prevent recurrence of adhesions 2.

We present an alternative method to treat this complication. This method of treatment called “Vein wrapping” constitutes a simple surgical technique that causes minimal complications in the donor area. In addition, the donor vein is readily available and harvesting is easy.

 

J.Orthopaedics 2006;3(2)e9

Material and Methods :

We treated two female patients with recurrent compressive neuropathy of the median nerve by means vein wrapping. Our first patient was a 42 year-old woman diagnosed of carpal tunnel syndrome of her right hand 2 years before. She has been operated previously twice but symptoms reappeared each time after few months of clinical improvement. She had diabetes mellitus type 1 and penicillin allergy.   The second patient was a 51 year-old woman operated in other centre of carpal tunnel syndrome of her right hand 1 year before. Following carpal tunnel release she was free of symptoms for 2 months but the numbness gradually recurred. She suffered from cardiac pathology, hypercalcemia, chronic venous insufficiency, cervix cancer resection and she also had penicillin allergy.

  The average follow-up period was 12 months. Each patient had both subjective and objective evaluation. For the subjective evaluation the patient was given an identical questionnaire both before and after surgery that asked about pain, numbness, and overall satisfaction. Patients were asked to rate their level of pain on a scale of 10 and to state whether their preoperative numbness had improved after surgery. They also were asked whether they were satisfied with the outcome. The objective evaluation included the measurement of 2-point discrimination and grip strength by means a Jamar dynamometer. No electrodiagnostic studies were performed after surgery.

Surgical Technique :

Under general anaesthesia the ipsilateral or contralateral lower extremity is used for haversting the internal saphenous vein. A longitudinal incision is made anterior to the medial malleolus (Fig. 1). However the vein graft can be haversted by means a vein stripper to minimize the length of the incision and the morbidity of the donor site. The required length of the vein is 3 to 4 times the scarred length of the nerve (aprox 25 to 30 cm).  The remaining internal saphenous vein is ligated both proximally and distally before the excision of the graft. With the help of sutures or skin hooks the graft is held straight and is incised longitudinally, using a pair of sharp scissors, to form a rectangle (Fig 2).

    

 Figure 1. Preparation of the saphenous vein graft. A) Skin incision.                   B) Visualization of the vein. C) Dissection of the vein.

                       

Figure 2. Preparation of the vein graft.

With respect to the wrist, we performed the standard surgical approach for carpal tunnel release, but slightly extended proximally and distally, to expose the median nerve in an unscarred environment. In both cases a great fibrous proliferation was found constricting the nerve proximally just to the palmar cutaneous branche, and distally just at the level of the distal carpal tunnel in which the nerve divides into lateral and medial portions under the palmar aponeurosis and the superficial palmar arch  (Fig. 3). The involved nerve is first decompressed and separated from all the scarred soft tissues. After then, the vein intima was placed next to the nerve, and circumferential wrapping distal to proximal is performed.

Figure 3. Scar tissue around the median nerve.

One end of the vein graft is tacked distal to the scarred portion of the nerve on a tissue that is not mobile, generally in one of the lips of the opened transverse carpal ligament (Fig. 4), while the other end of the vein graft is tacked proximal to the scarred segment of the nerve on unscarred tissue, generally immediately distal to the exit of the palmar cutaneous branch (Fig. 5).  

Figure 4. Distal attachment of the graft in one of the lips of the opened TCL.

The vein-to-vein junctures were sutured carefully with 6/0 non-absorbable monofilament.

Figure 5.  Vein graft wrapping completed. Observe that the sapheonus vein covers the entire portion of the nerve.

During the wrapping procedure, care is taken to avoid nerve traction or suturing of the vein to the median nerve (Fig. 6).

Figure 6. A soft tissue-elevator could be passed easily between the wrapping vein.

The skin was closed with 5/0 monofilament and wrist was immobilized in 20 degrees of neutral position with antebrachial splint for 2 weeks. Active and passive motion exercises are started immediately after the splint is removed.

Results :

Six months after surgery, all patients reported a reduction in pain and the sensory disturbances secondary to the compression of the median nerve. On a scale of 10, both patients rated their pain between 2 and 3; their preoperative pain had been rated between 8 and 9. Sensation improved in both patients. Two-point discrimination improved from 10 and 13 respectively before surgery to 5 and 7 after surgery. Grip strength increased from 15 and 20 Kg respectively before surgery to 22 and 30 after surgery. However, the patients reported discomfort at the saphenous vein donor site that resolved at approximately 4 weeks after the procedure. There are no infection case.

Discussion :

Despite a high rate of success following an initial carpal tunnel release, there are subsets of patients who report persistent or recurrent symptoms and needed secondary carpal tunnel surgery. Although some risk factors which may also contribute to the need for secondary surgery as diabetes mellitus or hypertension associated with medical therapy with b-blockers 4, the main reason for failure is the scar tissue that develops at the site of decompression surrounding the nerve. The risk factors for development fibrous proliferation following carpal tunnel release remain unknown, but poor hemostasis and hematoma formation, prolonged postoperative immobilization, inadequate range-of motion exercises and therapy have been implicated. In these circumstances, revision carpal tunnel release followed by internal neurolysis has a high rate of persistent symptoms and poor results 5. For this reason numerous methods of operative treatment for recurrent entrapment neuropathy have been described, fundamentally local muscle flaps or fat pads over heavily scarred areas, and application of barrier material to prevent recurrence of adhesions. Therefore, small local flaps, such as the abductor digiti minimi, the palmaris brevis, and the pronator qadratus, also have been used 6,7,8,9,10,11,12,13,14,15,16. However, the dissection of these flaps is not always ease, because vascular pedicles have limited mobility, nerve coverage is sometimes inadequate, and skin closure problems may occur.

  The primary indication for a vein wrap following the neurolysis is the presence of significant epineural scarring that can prevent nerve gliding.   The technique of vein wrapping was first described by Gould 17 for treatment of painful neuroma in-continuity, but was Masear et al. 18 which first reported the successful use of a vein graft for recurrent symptoms secondary to scarring of the nerve. Six years after, Masear and Colgin 19 to report clinical results with the use of a vein wrapping for recurrent median nerve compression. Koman et al. 20 used allograft umbilical vein for median nerve dysfunction with good results and Soteranos et al. 21,22 reported significant pain relief in patients with recurrent carpal tunnel syndrome after treatment with vein wrapping.

Our results were comparable with others series in the sense that the autogenous vein wrapping technique is effective in the treatment of a compression neuropathy secondary to scar. However, the exact mechanism of its effect remains uncertain. In this aspect, in an experimental study                Xu et al. 23,24 used the femoral vein to wrap the sciatic nerve of rats and found that no scar tissue developed between the epineurium of the wrapped sciatic nerve and the intimal surface of the vein. Vardakas et al. 25 report a case which provides clinical intraoperative evidence in human of the lack of scar tissue between the intimal surface of the vein and the epineurium of ulnar nerve wrapped two years before for recalcitrant cubital tunnel syndrome.

In conclusion, the use of autogenous vein wrapping technique is a good alternative for treatment of recurrent median neuropathy secondary to scarring of the nerve.                                                                                            

Reference:

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  17. Gould JS. Treatment of the painful injured nerve in-continuity. In: Gelberman RH, ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991: 1541-9.

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  21. Soteranos DG, Giannakopoulos PN, Mitsionis GI, Xu J, Herndon JH. Vein-graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery 1995; 16: 752-6.

  22. Soteranos DG, Xu J. Vein-wrapping for the treatment of recurrent carpal tunnel syndrome. Tech Hand Upper Extremity Surg 1997; 1: 35-40.

  23. Xu J, Soteranos DG,Moller AR, Jacobsohn J, Tomaino MM, Fisher KJ, Herndon JH. Nerve wrapping with vein grafts in a rat model: a safe technique for the treatment of recurrent chronic compressive neuropathy. J Reconstr Microsurg 1998; 14: 323-30.

  24. Xu J, Varatimidis SE, Fisher KJ, Tomaino MM, Soteranos DG. The effect of wrapping scarred nerves with autogenous vein graft to treat recurrent chronic nerve compression. J hand Surg 2000; 25 A: 93-103.

  25. Vardakas DG, Varatimidis SE, Soteranos DG. Findings of exploration of a vein-wrapped ulnar nerve: Report of a case. J Hand Surg 2001; 26 A: 60-3.

This is a peer reviewed paper 

Please cite as :Ignacio R. Proubasta: Recurrent Carpal Tunnel Syndrome Treated By Autograft Vein Wrapping

J.Orthopaedics 2006;3(2)e9

URL: http://www.jortho.org/2006/3/2/e9

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