Recurrent and persistent carpal tunnel syndrome: "Triple-therapy approach"

Abstract

Background: Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018. Our surgical plan in all the patients involved a combination of these three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra LifeSciences or Axoguard Nerve Protector, AxoGen Inc), and hypothenar fat flap.

Materials and methods: A total of 30 patient records were identified. The index surgery was performed by a variety of surgeons at varied private institutions as well as the VA hospital. However, all of the revision interventions in this series were performed by the senior author (Z.J.P.). Demographic data (age, sex, hand dominance, comorbidities, alcohol, and smoking history) were collected. Preoperative and postoperative symptoms were recorded for all patients, including: subjective outcomes, need for additional surgery and complications. Mean VAS preoperatively and postoperatively were compared using a paired t-test. All statistical analyses were performed with SPSS 20 (IBM, Chicago, IL).

Results: Patient reported measures of resolution of symptoms and VAS scores documented at 3 months. Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (P < .0001).

Conclusion: Our study demonstrates that a combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap should be considered in patients presenting with recurrent or persistent carpal tunnel syndrome.

Keywords: Hand treatment; Hypothenar flap; Median neuropathy; Nerve conduit; Nerve wrap; Neurolysis; Recurrent and persistent carpal tunnel syndrome; Redo carpal tunnel release; Secondary procedure.

Fig. 1

Figure 1a. Exposure of the median nerve. Note the hourglass deformity from chronic compression. Figure 1b. Placement and inset of the nerve conduit wrap around the median nerve. Figure 1c. Hypothenar fat pad flap. The vascularized flap is sutured to the cut end of the retinaculum with interrupted absorbable sutures.

Fig. 2

Pre and post-operative visual analogue scale (VAS) reports.