Surgical Management of Recurrent Carpal Tunnel Syndrome

Abstract

Recurrent symptoms after carpal tunnel release are a significant challenge to hand surgeons. Recurrent carpal tunnel syndrome (CTS) may occur from incomplete surgical release, recurrence of local compression, and/or neural scarring or adhesions in a suboptimal bed; all may be confounded by neuropathic or complex regional pain syndromes. Incomplete initial release and recurrence of local compression may be treated successfully with repeat decompression and is not discussed. This discussion reviews the more complicated scenario of median nerve scarring to surrounding structures. Concomitant treatment of associated neuropathic pain is not addressed directly. Conservative treatment for recurrent CTS may provide immediate, but transient, relief of symptoms, or may provide no benefit for underlying median nerve compression or irritation. Surgical management of recurrent CTS secondary to external perineural fibrosis involves neurolysis, changing the environment to minimize the effects of tenosynovitis, fibrous proliferation within the carpal tunnel, intraneural fascicular scarring, and adherence of the median nerve to the transverse carpal ligament, and early motion. This paper presents the techniques available to effectively treat recurrent CTS. Options include nerve wrapping, local autologous flaps, and pedicled flaps that provide a favorable local environment for the median nerve excursion. Key Words: Recurrent Carpal Tunnel Syndrome-Nerve wrapping-Local autologous flaps-Pedicled flaps.Carpal tunnel syndrome (CTS) is common and is treated with open or endoscopic carpal tunnel release (CTR) when nonoperative means fail. Unfortunately, persistence of symptoms or recurrence of CTS is frequent. Recurrent symptoms of CTS have been shown to occur in 0 to 20% of patients following CTR, with up to 12% requiring re-exploration. 4,6,11,12,30,35 The management of recurrent entrapment neuropathy is difficult and controversial. The results following reoperation have not been as successful as primary surgery, with up to 95% residual symptoms and 40% poor results. 42,57 Eighteen percent (18%) of workers' compensation patients improved after revision carpal tunnel surgery compared with 84% of those with conventional insurance. 24 Repeated nerve decompression, alone or accompanied with external or internal neurolysis, does not always relieve symptoms. 16 Multiple factors have been associated with poor results, including injury to the median nerve either from chronic compression or iatrogenic surgical injury, excessive scar formation preventing the nerve from gliding with wrist motion, subcutaneous atrophy of the palm, incomplete surgical release, and patient secondary gain factors. 6,12,22,25,66 In addition, neuropathic pain, manifested by excessive pain, autonomic dysfunction, trophic changes, and functional impairment may coexist.A thorough clinical evaluation, including a complete neurologic examination of the neck and the entire upper extremity, is essential to confirm the accuracy of the original diagnosis. The presence of anoth...

Proceedings of a workshop

“…The tubular collagen matrix permits nutrient exchange and accessibility of neurotrophic factors at the axonal growth zone during regeneration 58. Bush et al59 described their application of NeuraGen as a nerve wrapping material for the treatment of the recurrent carpal tunnel syndrome. Kim et al12 used type I highly purified collagen as a nerve coverage material (NeuraWrap™/Integra LifeSciences corporation, Plainsboro, NJ) after primary nerve repair in the rat sciatic nerve model and evaluated axonal regeneration.…”

Protective effect of biodegradable nerve conduit against peripheral nerve adhesion after neurolysis

“…Many nerve protective materials including silicone sheets, collagen tubes, gels, and fluids have been developed in recent years to overcome these drawbacks. 2,3,6,9,13,15,[19][20][21][23][24][25][26]29,31,[39][40][41]45,46,60,64 We previously developed a novel biodegradable nerve conduit composed of poly(L-lactide) (PLA) and poly(ecaprolactone) (PCL) to treat peripheral nerve injury and confirmed that axonal regeneration was induced within the conduit. 22,30,40,56,57 This nerve conduit comprises 2 layers: an outer layer composed of PLA multifilament fiber mesh and an inner layer composed of a PLA-and PCL-containing porous sponge with pores of 10 to 50 mm.…”

Complications of Surgery for Carpal Tunnel Syndrome

“…arpal tunnel syndrome (CTS) is the most common entrapment neuropathy, and its treatment prognosis is affected by many factors 1,2 . Open and endoscopic carpal tunnel release (CTR) are still widely used procedures when the nonoperative means fails 3 .…”

“…Unfortunately, despite of the success of open CTR, complications and failures have been shown to occur in some patients 2,4,5 . Persistent or recurrence of symptoms after CTR is frequent and are a significant challenge to the surgeons because the outcomes following reoperation have not been as successful as the primary surgery 1,5 . There are multiple factors associated with the poor results including injury to the median nerve or its branches excessive scar formation preventing the nerve gliding, incomplete surgical release, and injury to the other underlying neurovascular structures.…”

“…There are multiple factors associated with the poor results including injury to the median nerve or its branches excessive scar formation preventing the nerve gliding, incomplete surgical release, and injury to the other underlying neurovascular structures. Also patients with postoperative incisional pain "pillar pain" and finger stiffness have significantly more difficulty in recovery and returning to daily activities 1,[3][4][5][6] .…”