Treatment Options for Recurrent Carpal Tunnel Syndrome: Local Flaps

Abstract

Idiopathic carpal tunnel syndrome (CTS) has become one of the most common peripheral neuropathies of the upper extremity in the United States, and carpal tunnel release is one of the most commonly performed surgeries of the hand. Primary surgical release of median nerve compression at the wrist usually affords good symptomatic relief, but a small but significant number of surgical failures exist. Before committing to surgery, aggressive nonsurgical management should be exhausted. Significant benefits from splinting, ultrasound, nerves gliding exercises, and carpal bone mobilization have been obtained in mild to moderate primary carpal tunnel, and similar therapy may prove beneficial for a patient with recurrent symptoms. If refractory to aggressive conservative management and objective evidence exists to support recurrent CTS, then the etiology of recurrent carpal tunnel syndrome may include incomplete release of the transverse carpal ligament, fibrous proliferation, and recurrent tenosynovitis. Many techniques are available to treat the condition. Treatment can range from a simple strait forward approach to a complex constellation of procedures including external and internal neurolysis and vascularized flap coverage. The purpose of this chapter is to describe the etiology of recurrent CTS lending support for an appropriate treatment plan to address the pathology. In all cases, the objective is to provide a favorable environment for the median nerve in which normal excursion is possible.

Palmaris longus interposition in revision surgery for recurrent and persistent carpal tunnel syndrome: a case series

“…Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity and affects approximately 10% of the population [1][2][3][4]. Although various conservative treatment options are available, patients often need a surgical procedure to provide decompression of the median nerve.…”

“…It is considered technically undemanding and generally very successful. Nevertheless, a group of patients remains symptomatic after primary release with a reported incidence up to 30% [1,3,[6][7][8][9]. The presence of postoperative symptoms is commonly described as recalcitrant CTS [1,2,10].…”

“…In general, persistent symptoms can be attributed to an incomplete release of the flexor retinaculum or in rare cases to double crush syndrome or incorrect diagnosis, and the current concept of recurrence is that symptoms mostly result from perineural fibrosis and tethering of the median nerve within the carpal tunnel. Symptoms may also recur in the context of proliferative tenosynovitis or neuromas of the palmar cutaneous branch of the median nerve, although the latter is identifiable on thorough examination [1][2][3]5,6,8].…”

“…Recalcitrant CTS necessitates revision surgery in 5-10% of the patients, for which repeated decompression with external or internal neurolysis have been reported as the standard technique [3,4,6]. However, this approach is often insufficient to prevent recurrent perineural adhesions.…”

“…However, this approach is often insufficient to prevent recurrent perineural adhesions. Many different surgical techniques are available for enveloping the median nerve with vascularized tissue to provide coverage to prevent recurrent scarring and to create a gliding plane for the nerve [2,3,6,8]. Coverage can be achieved by using synovium [5,10], fascia flaps [5,9], fat flaps [2,8], muscle flaps [11,12], free flaps [13,14], vein wraps [15,16] or synthetic implants [7,17].…”