INTRODUCTION: The treatment of recurrent or persistent carpal tunnel syndrome is a rare but challenging problem to hand surgeons.1 Collagen nerve wraps have been used in revision surgery to help prevent the recurrence of scarring.2 Adipofascial flaps have been used to improve nerve gliding and promote neovascularization.3 Both modalities have been used separately with moderate success for revision carpal tunnel surgery. The outcomes of revision surgery for recurrent or persistent carpal tunnel syndrome may be improved by the novel use of both nerve wrapping and adipofascial flap.
METHODS: The records of patients with recurrent or persistent carpal tunnel syndrome treated with revision decompression, collagen nerve wrap, and adipofascial flap from a 4-year period were retrieved from the Computerized Patient Record System database. Each record was reviewed for pre-operative and post-operative visual-analog pain scale measurements, opioid usage, and severity of symptoms.
RESULTS: 22 patients were identified, with 22 revision surgeries for recurrent carpal tunnel syndrome and 3 revision surgeries for persistent carpal tunnel syndrome. The mean age of the patients was 67.8 years and ranged from 51 to 85 years. There was an average follow up of 52 weeks. The average pre-operative median motor nerve conduction velocity was 47.7 m/s. 80% of patients had hypertension as a comorbidity. 76% reported subjective resolution of their symptoms by most recent follow up. Post-operative average visual-analog pain score decreased to 0.20 from an average pre-operative average visual-analog pain score of 5 (p<0.001). Post-operative opiate medication use average decreased to 20% from an average pre-operative opioid average use of 36% (P=0.31). No patient required repeat decompression by latest follow up.
CONCLUSION: Revision decompression with collagen nerve wrap and adipofascial flap can successfully treat recurrent and persistent carpal tunnel syndromes. This means of treatment may currently be the optimal way to treat recurrent or persistent carpal tunnel syndrome and should be compared to treatments with isolated nerve wrapping or adipofascial flap for revision carpal tunnel treatment in future prospective studies.
Reference Citations:
1. Cobb TK, Amadio PC, Leatherwood DF, et al. Outcome of reoperation for carpal tunnel syndrome. YJHSU. 1996;21(3):347–356.
2. Soltani AM, Allan BJ, Best MJ, et al. Revision Decompression and Collagen Nerve Wrap for Recurrent and Persistent Compression Neuropathies of the Upper Extremity. Annals of plastic surgery. 2014;72(5):572–578.
3. Strickland JW, Idler RS, Lourie GM, et al. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. YJHSU. 1996;21(5):840–848.