Application of free temporoparietal fascial flap for recurrent neural adhesion of superficial radial nerve—A case report

Abstract

Because of its anatomical location, the superficial radial nerve is vulnerable to trauma as well as injury during various surgical procedures. Once the nerve adheres to surrounding scar tissue, radiating pain often occurs due to nerve traction caused by loss of smooth gliding. Since it has been reported that the success rate with neurolysis only is lower, additional preventive procedures for recurrent neural readhesion are recommended. In the current report, we describe our experience performing neurolysis followed by nerve coverage using a free temporoparietal fascial flap for recurrent neural adhesion of the superficial radial nerve. A 45-year-old male complained of motion pain of the left wrist and thumb joints caused by recurrent neural adhesion of the superficial radial nerve after a chain saw trauma and following multiple reconstructive procedures. The radiating pain completely disappeared after neurolysis performed by a previous surgeon; however, it recurred 4 weeks later. Four months after the previous neurolysis the patient underwent external neurolysis and covering of the nerve with a free temporoparietal fascial flap to prevent neural readhesion because local soft tissue could not be used due to the massive scar tissues on the forearm. One year after the secondary neurolysis, the symptoms of radiating pain during wrist and thumb motion were drastically improved. A free adipofascial flap such as a temporoparietal flap may be an option for prevention of neural readhesion after neurolysis of the superficial radial nerve in cases where a local flap cannot be used on the forearm.

The Double-Opposing Adipofascial Interposition Flap: A Novel Technique to Prevent Scar Tethering and Symptomatic Neuroma of the Superficial Radial Nerve After Trauma

“…The mechanisms thought to provide the clinical benefit of autologous flaps include improved nutrition from a highly vascularised flap bed, improved padding from external forces, separation of nerve from movement of adjacent tissue, superior gliding within the flap itself, physical restriction of axonal growth into surrounding tissue, and restriction of scar adhesion [5][6][7]17]. Protecting a nerve with a vascularised flap following nerve repair has been shown to improve regenerative outcomes.…”

“…Patients receiving well-vascularised soft tissue coverage for painful neuromas and chronically scarred nerves show significant improvement and symptom resolution. One case study of note by Yamamoto et al recruited a patient similar to our patient cohort [7]. The patient sustained wrist trauma from a chainsaw injury and underwent SRN repair, following which he developed persistent nerve pain.…”

“…There is reduced scar adhesion to nearby structures, and the flap provides padding along the injured nerve from external forces and prevents the nerve from resting in a vulnerable position close to the skin while creating a gliding layer for the nerve. Fascial flaps offer further benefits due to their truly plastic nature and low friction coefficient, with improved nerve protection and regeneration [6][7][8].…”

Medial Sural Perforator “Nerve through Flap”: Anatomical Study and Clinical Application

“…In some cases, ALT flap with femoral cutaneous nerve has been used in order to transfer a composite flap restoring both skin and nervous continuity, but in most cases this flap is quite thick compared to hand skin [1,2]. In other cases, just fascial free flaps have been used in order to reduce peripheral nerve scar tissue [25] without carrying any skin island. This way we tried to investigate the possibility to raise the sural nerve within the MSAP flap.…”

Temporoparietal Fascial Free Flap

“…Methods of application of the TPFF as a gliding surface continued to evolve with its usage as a nerve sheath, 46 first reported in 1998. Yamamoto et al 17 later published another case report detailing this application for recurrent neural adhesion of the superficial radial nerve. In this report, a 45-year-old patient with prior traumatic injury to the forearm underwent external neurolysis and resection of scar tissue surrounding the nerve followed by transfer of the FTPFF to cover the nerve trunk and all the branches.…”