ic40-r: management of recalcitrant carpal tunnel syndrome
TRANSCRIPT
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IC40-R: Management of Recalcitrant Carpal
Tunnel Syndrome
Moderator: Alexander Lauder, MD
Faculty: Duretti T. Fufa, MD, Fraser J. Leversedge, MD and Suhail K. Mithani, MD
Session Handouts
SEPTEMBER 30 – OCTOBER 2, 2021
SAN FRANCISCO, CA
Duretti Fufa, MD
Fraser Leversedge, MD
Suhail Mithani, MD
• Conservative management
• Surgical management
• Revision neuroplasty
• Prevalence 3-10% (variations with region, sex, occupation)
• >500,000 CTR performed annually
• Economic impact >$2 billion
HAND 2012;7:242 PRS 2001;107:1830
Revision carpal tunnel release
• Up to 40% have unfavorable outcomes
JHS 2013;38:1530
• Diagnostic Considerations and Workup (Fufa)
• Surgical Management (Leversedge)
1 2
3 4
5 6
• Exam: + tinel median nerve prox. wrist crease, +compression, +phalen
• Repeat EDS: no significant change from pre-op exam
57 year old man
• oCTR 1 year ago
• Pain/dysesthesias over the palm of the hand
• Hypersensitivity
• Exam: + tinel at the FCR/wrist crease, neg compression, neg phalen
• Repeat EDS: conduction improvement along median nerve
Anatomy, pathophysiology, differential Alexander Lauder, MD
Disclosures
• None
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
13 14
15 16
17 18
Anatomy
Wrist/Hand
Anatomy
Leversedge, Goldfarb, Boyer, Primus manus 2010PLoS ONE 10(8): e0136477
Anatomic variations Carpal tunnel anatomy
• Volar: TCL
19 20
21 22
23 24
• Recurrent symptoms (after a period of symptomatic relief)
• New symptoms (different from preoperative symptoms)
Persistent
• Account for 43% of patients undergoing revision CTR
• Etiologies
JAAOS 2019 1;27(15):551
Other sites of compression 37% release of site • C-spine
• Brachial plexus
• Pectoralis minor
• Ligament Struthers
• Lacertus fibrosus
• Pronator teres
• FDS arch
• Anomalous muscles
Other sites of compression 37% release of site
Irreversible nerve pathology unknown symptomatic
• Review co-morbidities, age, duration of compression
• DM, thyroid disease, gout, RA → slower improvement
• Polyneuropathy, diabetic neuropathy, chemotherapy/radiation
Persistent symptoms - Differential
Other sites of compression 37% release of site
Irreversible nerve pathology unknown symptomatic
Inaccurate initial diagnosis 10-15% correct diagnosis Recurrent
After a period of symptomatic relief
31 32
33 34
35 36
• Incidence 4-57% (inconsistency in prior reporting)
• Etiologies
Recurrent symptoms
JAAOS 2019 1;27(15):551
• Reconstitution of the TCL unknown neurolysis
Orthopedics. 2015; 38(1):e72
• Reconstitution of the TCL unknown neurolysis
• Secondary Conditions ~20% optimize environment
New
• Etiologies
37 38
39 40
41 42
•
• 1. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ: Carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons 2007;15:537-548.
• 2. Louie D, Earp B, Blazar P: Long-term outcomes of carpal tunnel release: a critical review of the literature. Hand 2012;7:242-246.
• 3. Tung TH, Mackinnon SE: Secondary carpal tunnel surgery. Plastic and reconstructive surgery 2001;107:1830-1843; quiz 1844,1933.
• 4. Beck JD, Brothers JG, Maloney PJ, Deegan JH, Tang X, Klena JC: Predicting the outcome of revision carpal tunnel release. The Journal of hand surgery 2012;37:282-287.
• 5. Zieske L, Ebersole GC, Davidge K, Fox I, Mackinnon SE: Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes. The Journal of hand surgery 2013;38:1530-1539.
• 6. Leversedge FJ, Goldfarb CA, Boyer MI: A pocketbook manual of hand and upper extremity anatomy : primus manus . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2010, pp viii, 136 p.
• 7. Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K: Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures. The Journal of hand surgery 2016;41:841-844.
• 8. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M: Anatomy of the palmar cutaneous branch of the median nerve: clinical significance. The Journal of hand surgery 1996;21:639-643.
• 9. Roy J, Henry BM, PA PE, et al.: Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Muscle Nerve 2016;54:36-47.
• 10. Seiler JG, 3rd, Daruwalla JH, Payne SH, Faucher GK: Normal Palmar Anatomy and Variations That Impact Median Nerve Decompression. The Journal of the American Academy of Orthopaedic Surgeons 2017;25:e194-e203.
• 11. Lundborg G, Myers R, Powell H: Nerve compression injury and increased endoneurial fluid pressure: a "miniature compartment syndrome". J Neurol Neurosurg Psychiatry 1983;46:1119-1124.
• 12. Mackinnon SE: Pathophysiology of nerve compression. Hand clinics 2002;18:231-241.
• 13. Rempel DM, Diao E: Entrapment neuropathies: pathophysiology and pathogenesis. J Electromyogr Kinesiol 2004;14:71-75.
• 14. Reinke JM, Sorg H: Wound repair and regeneration. Eur Surg Res 2012;49:35-43.
• 15. Jones NF, Ahn HC, Eo S: Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plastic and reconstructive surgery 2012;129:683-692.
• 16. Stutz N, Gohritz A, van Schoonhoven J, Lanz U: Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period. Journal of hand surgery 2006;31:68-71.
• 17. Luria S, Waitayawinyu T, Trumble TE: Endoscopic revision of carpal tunnel release. Plastic and reconstructive surgery 2008;121:2029-2034; discussion 2035-2026.
• 18. Mimura T, Uchiyama S, Hayashi M, Uemura K, Moriya H, Kato H: Flexor carpi radialis brevis muscle: A case report and its prevalence in patients with carpal tunnel syndrome. J Orthop Sci 2017;22:1026-1030.
• 19. Keese GR, Wongworawat MD, Frykman G: The clinical significance of the palmaris longus tendon in the pathophysiology of carpal tunnel syndrome. Journal of hand surgery 2006;31:657-660.
• 20. Dailiana ZH, Bougioukli S, Varitimidis S, et al.: Tumors and tumor-like lesions mimicking carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2014;134:139-144.
• 21. Schmid AB, Coppieters MW: The double crush syndrome revisited--a Delphi study to reveal current expert views on mechanisms underlying dual nerve disorders. Man Ther 2011;16:557-562.
• 22. Wessel LE, Fufa DT, Canham RB, La Bore A, Boyer MI, Calfee RP: Outcomes following Peripheral Nerve Decompression with and without Associated Double Crush Syndrome: A Case Control Study. Plastic and reconstructive surgery 2017;139:119-127.
References
• Cagle PJ, Jr., Reams M, Agel J, Bohn D: An outcomes protocol for carpal tunnel release: a comparison of outcomes in patients with and without medical comorbidities. The Journal of hand surgery 2014;39:2175-2180.
• 24. Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, Rydevik B, Dimick M: Results of treatment of severe carpal-tunnel syndrome without internal neurolysis of the median nerve. The Journal of bone and joint surgery American volume 1987;69:896-903.
• 25. Nolan WB, 3rd, Alkaitis D, Glickel SZ, Snow S: Results of treatment of severe carpal tunnel syndrome. The Journal of hand surgery 1992;17:1020-1023.
• 26. Verdu E, Ceballos D, Vilches JJ, Navarro X: Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst 2000;5:191-208.
• 27. Kanatani T, Nagura I, Kurosaka M, Kokubu T, Sumi M: Electrophysiological assessment of carpal tunnel syndrome in elderly patients: one-year follow-up study. The Journal of hand surgery 2014;39:2188-2191.
• 28. Hattori Y, Doi K, Koide S, Sakamoto S: Endoscopic release for severe carpal tunnel syndrome in octogenarians. The Journal of hand surgery 2014;39:2448-2453.
• 29. Mosier BA, Hughes TB: Recurrent carpal tunnel syndrome. Hand clinics 2013;29:427-434.
• 30. Tollestrup T, Berg C, Netscher D: Management of distal traumatic median nerve painful neuromas and of recurrent carpal tunnel syndrome: hypothenar fat pad flap. The Journal of hand surgery 2010;35:1010-1014.
• 31. Sayegh ET, Strauch RJ: Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clinical orthopaedics and related research 2015;473:1120-1132.
• 32. Tapadia M, Mozaffar T, Gupta R: Compressive neuropathies of the upper extremity: update on pathophysiology, classification, and electrodiagnostic findings. The Journal of hand surgery 2010;35:668-677.
• 33. Schreiber JE, Foran MP, Schreiber DJ, Wilgis EF: Common risk factors seen in secondary carpal tunnel surgery. Annals of plastic surgery 2005;55:262-265.
• 34. Thoomes EJ, van Geest S, van der Windt DA, et al.: Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J 2017.
• 35. Hagert E: Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study. Hand 2013;8:41-46.
• 36. Unglaub F, Wolf E, Goldbach C, Hahn P, Kroeber MW: Subjective and functional outcome after revision surgery in carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2008;128:931-936.
• 37. Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell TD: Predicting the outcome of carpal tunnel release. The Journal of hand surgery 2003;28:255-261.
• 38. AAOS: Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline Accessed December 1, 2017.
• 39. Stutz NM, Gohritz A, Novotny A, Falkenberg U, Lanz U, van Schoonhoven J: Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome. Neurosurgery 2008;62:194-199; discussion 199
• 40. Amadio PC: Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release. The Journal of hand surgery 2009;34:1320-1322.
• 41. Opanova MI, Atkinson RE: Supracondylar process syndrome: case report and literature review. The Journal of hand surgery 2014;39:1130-1135.
• 42. Fowler JR, Cipolli W, Hanson T: A Comparison of Three Diagnostic Tests for Carpal Tunnel Syndrome Using Latent Class Analysis. The Journal of bone and joint surgery American volume 2015;97:1958-1961.
• 43. Fowler JR, Maltenfort MG, Ilyas AM: Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clinical orthopaedics and related research 2013;471:932-937.
• 44. Page MJ, Massy-Westropp N, O'Connor D, Pitt V: Splinting for carpal tunnel syndrome. The Cochrane database of systematic reviews 2012:CD010003.
• 45. Ballestero-Perez R, Plaza-Manzano G, Urraca-Gesto A, et al.: Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review. J Manipulative Physiol Ther 2017;40:50-59.
• 46. Griffin JW, Hogan MV, Chhabra AB, Deal DN: Peripheral nerve repair and reconstruction. The Journal of bone and joint surgery American volume 2013;95:2144-2151.
References
• Cho MS, Rinker BD, Weber RV, et al.: Functional outcome following nerve repair in the upper extremity using processed nerve allograft. The Journal of hand surgery 2012;37:2340- 2349.
• 48. Means KR, Jr., Rinker BD, Higgins JP, Payne SH, Jr., Merrell GA, Wilgis EF: A Multicenter, Prospective, Randomized, Pilot Study of Outcomes for Digital Nerve Repair in the Hand Using Hollow Conduit Compared With Processed Allograft Nerve. Hand 2016;11:144-151.
• 49. Pederson WC: Median nerve injury and repair. The Journal of hand surgery 2014;39:1216-1222.
• 50. Varitimidis SE, Vardakas DG, Goebel F, Sotereanos DG: Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator. The Journal of hand surgery 2001;26:296-302.
• 51. Abzug JM, Jacoby SM, Osterman AL: Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand 2012;7:23-29.
• 52. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity. Annals of plastic surgery 2014;72:572-578.
• 53. Strickland JW, Idler RS, Lourie GM, Plancher KD: The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. The Journal of hand surgery 1996;21:840-848.
• 54. Murthy PG, Abzug JM, Jacoby SM, Culp RW: The tenosynovial flap for recalcitrant carpal tunnel syndrome. Techniques in hand & upper extremity surgery 2013;17:84-86.
• 55. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plastic and reconstructive surgery 2013;132:114-121.
• 56. Wichelhaus A, Mittlmeier T, Gierer P, Beck M: Vascularized Hypothenar Fat Pad Flap in Revision Surgery for Carpal Tunnel Syndrome. J Neurol Surg A Cent Eur Neurosurg 2015;76:438-442.
• 57. Djerbi I, Cesar M, Lenoir H, Coulet B, Lazerges C, Chammas M: Revision surgery for recurrent and persistent carpal tunnel syndrome: Clinical results and factors affecting outcomes. Chir Main 2015;34:312-317.
• 58. O'Malley MJ, Evanoff M, Terrono AL, Millender LH: Factors that determine reexploration treatment of carpal tunnel syndrome. The Journal of hand surgery 1992;17:638-641.
43 44
45 46
Duretti Fufa, MD Associate Orthopaedic Surgeon Hospital for Special Surgery Associate Professor of Orthopaedic Surgery New York Presbyterian Hospital – Weill Cornell Medical College
ASSH 76th Annual Meeting 2021
Evaluation of Recalcitrant CTS
History and Physical Examination
• Electrodiagnostics?
• Worse -> surgical complication
• Ligament of Struthers
• FDS fibrotic arch
• Gantzer’s muscle
• Anomalous muscles in the distal forearm (palmaris profundis or FCR brevis)
Alternative Sites of Compression
compression
• Space occupying lesion
• Nerve injury
Confidential & Proprietary 7
• Counsel patients on feedback needed from injection
• % improvement and duration
Confidential & Proprietary 9
Summary of Evaluation and Findings for Distinct Causes of Recalcitrant CTS
Confidential & Proprietary 10
•No improvement
•Confirmatory diagnostic injection
•Symptoms worse postoperatively
compression, unrecognized anatomic variations, irreversible nerve pathology associated with chronic compression
neuropathy, perineural adhesions, conditions associated with secondary nerve compression, iatrogenic nerve injury, or
an inaccurate preoperative diagnosis. Understanding the pertinent surgical anatomy and pathophysiology is essential
towards developing an effective diagnostic and treatment strategy. A thorough clinical history and examination guide
a comprehensive diagnostic evaluation that includes serial examinations, neurophysiologic testing, and imaging
studies. Conservative treatment may provide symptomatic relief, however, surgical management involving revision
neuroplasty, neurolysis, nerve reconstruction, and/or local soft-tissue flap augmentation may be indicated in refractory
cases.
• Describe the prevalence and differential diagnosis for persistent and recurrent carpal tunnel syndrome (CTS).
• Understand the diagnostic evaluation with ultrasound, electrodiagnostic studies, and injection for workup of
recalcitrant CTS.
• Discuss options for the surgical management of recalcitrant disease and considerations for management of the
peineural environment.
• Understand the local options for flap coverage and their outcomes in recalcitrant CTS.
Confidential & Proprietary 12
Proximal Distal →
Transverse US images of the median nerve (blue arrows) across the carpal tunnel after carpal tunnel release. A segment of the transverse carpal ligament remains intact at the proximal carpal tunnel (orange arrows), with regional flattening of the nerve. The transverse carpal ligament is visibly released distally (white arrows).
13
7/21/2021
1
www.cuortho.org
advanced neuropathy IC40: Management of recalcitrant carpal tunnel syndrome
Fraser J. Leversedge, MD
Department of Orthopedic Surgery
University of Colorado www.cuortho.org
Axogen - Dr. Leversedge receives fees for consulting and educational activities
Axogen – Dr. Leversedge has received institutional support for research studies
Wolters Kluwer – Dr. Leversedge receives royalties for publications
www.cuortho.org
• surgical history • perioperative history • gains / deficits
www.cuortho.org
• diagnostic imaging ultrasound
• FUNCTIONAL ASSESSMENT
• NCS / EMG • ULTRASOUND
• FUNCTIONAL ASSESSMENT
ANATOMIC CLUES …
Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K. Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures. J Hand Surg Am. 2016;41:841-4.
Case: 52yo s/p ORIF Distal Radius
NORMAL
1. DECOMPRESS NERVE • direct compression • tethering associated with
adhesions / scar
• expose MN to normal tissue planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
7 8
9 10
11 12
www.cuortho.org
www.cuortho.org
*
• expose MN to normal tissue planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
13 14
15 16
17 18
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
Neuroplasty + ________ ?
www.cuortho.org
from Dy CJ, et al. JHS-Am 2018
1. minimal or no chance of rejection or inflammatory rxn 2. sufficient porosity to facilitate diffusion of nutrients
without allowing axonal escape 3. avoidance of scar induced ischemia 4. promote nerve gliding 5. minimal or no donor site morbidity 6. minimal cost or supply restraints
www.cuortho.org
Influencing the Perineural Environment
Barriers to nerve adhesions
• local tissue flap (adipofascial or muscle) • distant tissue transfer (free flap) • autologous vein • biologic wraps
• Type 1 collagen • Porcine small intestinal mucosa • Hyaluronic acid – carboxymethylcellulose (Seprafilm) • Hyaluronic acid – alginate (Versawrap)
www.cuortho.org
BIOLOGIC WRAPS
• there are no meaningful clinical trials that compare outcomes of revision / severe median neuroplasty at the wrist with vs without biologic ‘wrap’
• possible benefit following neurolysis where SIS may serve as an ecm “scaffold” for damaged epineurium
www.cuortho.org
• HYPOTHENAR FAT PAD FLAP • PALMARIS BREVIS FLAP • TENOSYNOVIAL FLAP • FOREARM ADIPOFASCIAL FLAP
19 20
21 22
23 24
• modified by senior author • 62 pts / 66 hands
www.cuortho.org
Techniques in Hand & Upper Extremity Surgery Volume 17, Number 2, June 2013
• retrospective review of 45 procedures in 41 pts • follow up / methodology limited
www.cuortho.org
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
• mature wound, straight line of pull, one function
Restore Function
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
Danoff, et al. JHS-Eur 2014 • outcomes survey in 14 pts • exam for 7 pts • mean follow up = 2.8 yrs
• ALL pts able to palmar abduct • 71% able to oppose to SF base
Ring Finger FDS Transfer
SUMMARY
• Assess functional deficit(s)
• Surgical principles • zone of ‘injury’, optimize perineural environment
• Post-operative rehabilitation
31 32
33 34
35 36
Suhail K. Mithani, MD
Duke University Medical Center
• Options
• Wraps
Persistent
• Local Conditions
• Postoperative Infection
• Postoperative Hematoma
Why Flap or Wrap after Revision CTR?
Multiple studies have shown perineural adhesion at the time of revision CTR
J Hand Surg Am 2013;38:1530-1539J Hand Surg 2006;31:68-71.
Indications for Flap or Wrap after Revision CTR
• Idiopathic Recurrent Carpal Tunnel
• Mucopolysaccharoidosis
• Amyloidosis
• Provide a barrier between the nerve and its environment
• Implants/Grafts
• “Tennis racket” wrap of saphenous vein
• Improved Nerve Conduction velocity after recurrent CTR
J Hand Surg Am 2001;26:296-302.
Vein Wrapping Outcomes
15 patients: Retrospective Review
velocity with 43 month followup
J Hand Surg Am 2001;26:296-302.
Biologic Wrapping for Recurrent CTR
• In conjunction with extensile CTR ± tenosynovectomy/Neurolysis
• Wrapping of median nerve with biologic conduit
• Porcine
• Collagen
JHS. 2018 Apr;43(4):360-367
• Open Extensile
• Blood supply: Segmental
Surgery10(3):150-156, September 2006.
Surgery10(3):150-156, September 2006.
Synovial Flap
• Tenosynovium is elevated from flexor tendon while preserving its ulnar attachements
• Transposed over median nerve and sutured to radial leaflet
Techniques in Hand & Upper Extremity
Surgery17(2):84-86, June 2013.
Comparison of Various Techniques
Meta Analysis
Most consistent success with revision open
CTR and hypothenar fat flap
Conclusions
• Idiopathic recurrent CTS is typically associated with fibrosis and
adherence of the median nerve to the radial leaflet of the TCL
• In addition to revision CTR and neurolysis, some type of “protection” for
the median should be considered
• Vascularized soft tissue transposition may be superior to wrapping with
autologous vein or biologic conduit
13 14
15 16
17 18
IC40-R: Management of Recalcitrant Carpal
Tunnel Syndrome
Moderator: Alexander Lauder, MD
Faculty: Duretti T. Fufa, MD, Fraser J. Leversedge, MD and Suhail K. Mithani, MD
Session Handouts
SEPTEMBER 30 – OCTOBER 2, 2021
SAN FRANCISCO, CA
Duretti Fufa, MD
Fraser Leversedge, MD
Suhail Mithani, MD
• Conservative management
• Surgical management
• Revision neuroplasty
• Prevalence 3-10% (variations with region, sex, occupation)
• >500,000 CTR performed annually
• Economic impact >$2 billion
HAND 2012;7:242 PRS 2001;107:1830
Revision carpal tunnel release
• Up to 40% have unfavorable outcomes
JHS 2013;38:1530
• Diagnostic Considerations and Workup (Fufa)
• Surgical Management (Leversedge)
1 2
3 4
5 6
• Exam: + tinel median nerve prox. wrist crease, +compression, +phalen
• Repeat EDS: no significant change from pre-op exam
57 year old man
• oCTR 1 year ago
• Pain/dysesthesias over the palm of the hand
• Hypersensitivity
• Exam: + tinel at the FCR/wrist crease, neg compression, neg phalen
• Repeat EDS: conduction improvement along median nerve
Anatomy, pathophysiology, differential Alexander Lauder, MD
Disclosures
• None
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
Anatomy
Forearm
13 14
15 16
17 18
Anatomy
Wrist/Hand
Anatomy
Leversedge, Goldfarb, Boyer, Primus manus 2010PLoS ONE 10(8): e0136477
Anatomic variations Carpal tunnel anatomy
• Volar: TCL
19 20
21 22
23 24
• Recurrent symptoms (after a period of symptomatic relief)
• New symptoms (different from preoperative symptoms)
Persistent
• Account for 43% of patients undergoing revision CTR
• Etiologies
JAAOS 2019 1;27(15):551
Other sites of compression 37% release of site • C-spine
• Brachial plexus
• Pectoralis minor
• Ligament Struthers
• Lacertus fibrosus
• Pronator teres
• FDS arch
• Anomalous muscles
Other sites of compression 37% release of site
Irreversible nerve pathology unknown symptomatic
• Review co-morbidities, age, duration of compression
• DM, thyroid disease, gout, RA → slower improvement
• Polyneuropathy, diabetic neuropathy, chemotherapy/radiation
Persistent symptoms - Differential
Other sites of compression 37% release of site
Irreversible nerve pathology unknown symptomatic
Inaccurate initial diagnosis 10-15% correct diagnosis Recurrent
After a period of symptomatic relief
31 32
33 34
35 36
• Incidence 4-57% (inconsistency in prior reporting)
• Etiologies
Recurrent symptoms
JAAOS 2019 1;27(15):551
• Reconstitution of the TCL unknown neurolysis
Orthopedics. 2015; 38(1):e72
• Reconstitution of the TCL unknown neurolysis
• Secondary Conditions ~20% optimize environment
New
• Etiologies
37 38
39 40
41 42
•
• 1. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ: Carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons 2007;15:537-548.
• 2. Louie D, Earp B, Blazar P: Long-term outcomes of carpal tunnel release: a critical review of the literature. Hand 2012;7:242-246.
• 3. Tung TH, Mackinnon SE: Secondary carpal tunnel surgery. Plastic and reconstructive surgery 2001;107:1830-1843; quiz 1844,1933.
• 4. Beck JD, Brothers JG, Maloney PJ, Deegan JH, Tang X, Klena JC: Predicting the outcome of revision carpal tunnel release. The Journal of hand surgery 2012;37:282-287.
• 5. Zieske L, Ebersole GC, Davidge K, Fox I, Mackinnon SE: Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes. The Journal of hand surgery 2013;38:1530-1539.
• 6. Leversedge FJ, Goldfarb CA, Boyer MI: A pocketbook manual of hand and upper extremity anatomy : primus manus . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2010, pp viii, 136 p.
• 7. Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K: Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures. The Journal of hand surgery 2016;41:841-844.
• 8. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M: Anatomy of the palmar cutaneous branch of the median nerve: clinical significance. The Journal of hand surgery 1996;21:639-643.
• 9. Roy J, Henry BM, PA PE, et al.: Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Muscle Nerve 2016;54:36-47.
• 10. Seiler JG, 3rd, Daruwalla JH, Payne SH, Faucher GK: Normal Palmar Anatomy and Variations That Impact Median Nerve Decompression. The Journal of the American Academy of Orthopaedic Surgeons 2017;25:e194-e203.
• 11. Lundborg G, Myers R, Powell H: Nerve compression injury and increased endoneurial fluid pressure: a "miniature compartment syndrome". J Neurol Neurosurg Psychiatry 1983;46:1119-1124.
• 12. Mackinnon SE: Pathophysiology of nerve compression. Hand clinics 2002;18:231-241.
• 13. Rempel DM, Diao E: Entrapment neuropathies: pathophysiology and pathogenesis. J Electromyogr Kinesiol 2004;14:71-75.
• 14. Reinke JM, Sorg H: Wound repair and regeneration. Eur Surg Res 2012;49:35-43.
• 15. Jones NF, Ahn HC, Eo S: Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plastic and reconstructive surgery 2012;129:683-692.
• 16. Stutz N, Gohritz A, van Schoonhoven J, Lanz U: Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period. Journal of hand surgery 2006;31:68-71.
• 17. Luria S, Waitayawinyu T, Trumble TE: Endoscopic revision of carpal tunnel release. Plastic and reconstructive surgery 2008;121:2029-2034; discussion 2035-2026.
• 18. Mimura T, Uchiyama S, Hayashi M, Uemura K, Moriya H, Kato H: Flexor carpi radialis brevis muscle: A case report and its prevalence in patients with carpal tunnel syndrome. J Orthop Sci 2017;22:1026-1030.
• 19. Keese GR, Wongworawat MD, Frykman G: The clinical significance of the palmaris longus tendon in the pathophysiology of carpal tunnel syndrome. Journal of hand surgery 2006;31:657-660.
• 20. Dailiana ZH, Bougioukli S, Varitimidis S, et al.: Tumors and tumor-like lesions mimicking carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2014;134:139-144.
• 21. Schmid AB, Coppieters MW: The double crush syndrome revisited--a Delphi study to reveal current expert views on mechanisms underlying dual nerve disorders. Man Ther 2011;16:557-562.
• 22. Wessel LE, Fufa DT, Canham RB, La Bore A, Boyer MI, Calfee RP: Outcomes following Peripheral Nerve Decompression with and without Associated Double Crush Syndrome: A Case Control Study. Plastic and reconstructive surgery 2017;139:119-127.
References
• Cagle PJ, Jr., Reams M, Agel J, Bohn D: An outcomes protocol for carpal tunnel release: a comparison of outcomes in patients with and without medical comorbidities. The Journal of hand surgery 2014;39:2175-2180.
• 24. Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, Rydevik B, Dimick M: Results of treatment of severe carpal-tunnel syndrome without internal neurolysis of the median nerve. The Journal of bone and joint surgery American volume 1987;69:896-903.
• 25. Nolan WB, 3rd, Alkaitis D, Glickel SZ, Snow S: Results of treatment of severe carpal tunnel syndrome. The Journal of hand surgery 1992;17:1020-1023.
• 26. Verdu E, Ceballos D, Vilches JJ, Navarro X: Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst 2000;5:191-208.
• 27. Kanatani T, Nagura I, Kurosaka M, Kokubu T, Sumi M: Electrophysiological assessment of carpal tunnel syndrome in elderly patients: one-year follow-up study. The Journal of hand surgery 2014;39:2188-2191.
• 28. Hattori Y, Doi K, Koide S, Sakamoto S: Endoscopic release for severe carpal tunnel syndrome in octogenarians. The Journal of hand surgery 2014;39:2448-2453.
• 29. Mosier BA, Hughes TB: Recurrent carpal tunnel syndrome. Hand clinics 2013;29:427-434.
• 30. Tollestrup T, Berg C, Netscher D: Management of distal traumatic median nerve painful neuromas and of recurrent carpal tunnel syndrome: hypothenar fat pad flap. The Journal of hand surgery 2010;35:1010-1014.
• 31. Sayegh ET, Strauch RJ: Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clinical orthopaedics and related research 2015;473:1120-1132.
• 32. Tapadia M, Mozaffar T, Gupta R: Compressive neuropathies of the upper extremity: update on pathophysiology, classification, and electrodiagnostic findings. The Journal of hand surgery 2010;35:668-677.
• 33. Schreiber JE, Foran MP, Schreiber DJ, Wilgis EF: Common risk factors seen in secondary carpal tunnel surgery. Annals of plastic surgery 2005;55:262-265.
• 34. Thoomes EJ, van Geest S, van der Windt DA, et al.: Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J 2017.
• 35. Hagert E: Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study. Hand 2013;8:41-46.
• 36. Unglaub F, Wolf E, Goldbach C, Hahn P, Kroeber MW: Subjective and functional outcome after revision surgery in carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2008;128:931-936.
• 37. Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell TD: Predicting the outcome of carpal tunnel release. The Journal of hand surgery 2003;28:255-261.
• 38. AAOS: Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline Accessed December 1, 2017.
• 39. Stutz NM, Gohritz A, Novotny A, Falkenberg U, Lanz U, van Schoonhoven J: Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome. Neurosurgery 2008;62:194-199; discussion 199
• 40. Amadio PC: Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release. The Journal of hand surgery 2009;34:1320-1322.
• 41. Opanova MI, Atkinson RE: Supracondylar process syndrome: case report and literature review. The Journal of hand surgery 2014;39:1130-1135.
• 42. Fowler JR, Cipolli W, Hanson T: A Comparison of Three Diagnostic Tests for Carpal Tunnel Syndrome Using Latent Class Analysis. The Journal of bone and joint surgery American volume 2015;97:1958-1961.
• 43. Fowler JR, Maltenfort MG, Ilyas AM: Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clinical orthopaedics and related research 2013;471:932-937.
• 44. Page MJ, Massy-Westropp N, O'Connor D, Pitt V: Splinting for carpal tunnel syndrome. The Cochrane database of systematic reviews 2012:CD010003.
• 45. Ballestero-Perez R, Plaza-Manzano G, Urraca-Gesto A, et al.: Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review. J Manipulative Physiol Ther 2017;40:50-59.
• 46. Griffin JW, Hogan MV, Chhabra AB, Deal DN: Peripheral nerve repair and reconstruction. The Journal of bone and joint surgery American volume 2013;95:2144-2151.
References
• Cho MS, Rinker BD, Weber RV, et al.: Functional outcome following nerve repair in the upper extremity using processed nerve allograft. The Journal of hand surgery 2012;37:2340- 2349.
• 48. Means KR, Jr., Rinker BD, Higgins JP, Payne SH, Jr., Merrell GA, Wilgis EF: A Multicenter, Prospective, Randomized, Pilot Study of Outcomes for Digital Nerve Repair in the Hand Using Hollow Conduit Compared With Processed Allograft Nerve. Hand 2016;11:144-151.
• 49. Pederson WC: Median nerve injury and repair. The Journal of hand surgery 2014;39:1216-1222.
• 50. Varitimidis SE, Vardakas DG, Goebel F, Sotereanos DG: Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator. The Journal of hand surgery 2001;26:296-302.
• 51. Abzug JM, Jacoby SM, Osterman AL: Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand 2012;7:23-29.
• 52. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity. Annals of plastic surgery 2014;72:572-578.
• 53. Strickland JW, Idler RS, Lourie GM, Plancher KD: The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. The Journal of hand surgery 1996;21:840-848.
• 54. Murthy PG, Abzug JM, Jacoby SM, Culp RW: The tenosynovial flap for recalcitrant carpal tunnel syndrome. Techniques in hand & upper extremity surgery 2013;17:84-86.
• 55. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plastic and reconstructive surgery 2013;132:114-121.
• 56. Wichelhaus A, Mittlmeier T, Gierer P, Beck M: Vascularized Hypothenar Fat Pad Flap in Revision Surgery for Carpal Tunnel Syndrome. J Neurol Surg A Cent Eur Neurosurg 2015;76:438-442.
• 57. Djerbi I, Cesar M, Lenoir H, Coulet B, Lazerges C, Chammas M: Revision surgery for recurrent and persistent carpal tunnel syndrome: Clinical results and factors affecting outcomes. Chir Main 2015;34:312-317.
• 58. O'Malley MJ, Evanoff M, Terrono AL, Millender LH: Factors that determine reexploration treatment of carpal tunnel syndrome. The Journal of hand surgery 1992;17:638-641.
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Duretti Fufa, MD Associate Orthopaedic Surgeon Hospital for Special Surgery Associate Professor of Orthopaedic Surgery New York Presbyterian Hospital – Weill Cornell Medical College
ASSH 76th Annual Meeting 2021
Evaluation of Recalcitrant CTS
History and Physical Examination
• Electrodiagnostics?
• Worse -> surgical complication
• Ligament of Struthers
• FDS fibrotic arch
• Gantzer’s muscle
• Anomalous muscles in the distal forearm (palmaris profundis or FCR brevis)
Alternative Sites of Compression
compression
• Space occupying lesion
• Nerve injury
Confidential & Proprietary 7
• Counsel patients on feedback needed from injection
• % improvement and duration
Confidential & Proprietary 9
Summary of Evaluation and Findings for Distinct Causes of Recalcitrant CTS
Confidential & Proprietary 10
•No improvement
•Confirmatory diagnostic injection
•Symptoms worse postoperatively
compression, unrecognized anatomic variations, irreversible nerve pathology associated with chronic compression
neuropathy, perineural adhesions, conditions associated with secondary nerve compression, iatrogenic nerve injury, or
an inaccurate preoperative diagnosis. Understanding the pertinent surgical anatomy and pathophysiology is essential
towards developing an effective diagnostic and treatment strategy. A thorough clinical history and examination guide
a comprehensive diagnostic evaluation that includes serial examinations, neurophysiologic testing, and imaging
studies. Conservative treatment may provide symptomatic relief, however, surgical management involving revision
neuroplasty, neurolysis, nerve reconstruction, and/or local soft-tissue flap augmentation may be indicated in refractory
cases.
• Describe the prevalence and differential diagnosis for persistent and recurrent carpal tunnel syndrome (CTS).
• Understand the diagnostic evaluation with ultrasound, electrodiagnostic studies, and injection for workup of
recalcitrant CTS.
• Discuss options for the surgical management of recalcitrant disease and considerations for management of the
peineural environment.
• Understand the local options for flap coverage and their outcomes in recalcitrant CTS.
Confidential & Proprietary 12
Proximal Distal →
Transverse US images of the median nerve (blue arrows) across the carpal tunnel after carpal tunnel release. A segment of the transverse carpal ligament remains intact at the proximal carpal tunnel (orange arrows), with regional flattening of the nerve. The transverse carpal ligament is visibly released distally (white arrows).
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7/21/2021
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www.cuortho.org
advanced neuropathy IC40: Management of recalcitrant carpal tunnel syndrome
Fraser J. Leversedge, MD
Department of Orthopedic Surgery
University of Colorado www.cuortho.org
Axogen - Dr. Leversedge receives fees for consulting and educational activities
Axogen – Dr. Leversedge has received institutional support for research studies
Wolters Kluwer – Dr. Leversedge receives royalties for publications
www.cuortho.org
• surgical history • perioperative history • gains / deficits
www.cuortho.org
• diagnostic imaging ultrasound
• FUNCTIONAL ASSESSMENT
• NCS / EMG • ULTRASOUND
• FUNCTIONAL ASSESSMENT
ANATOMIC CLUES …
Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K. Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures. J Hand Surg Am. 2016;41:841-4.
Case: 52yo s/p ORIF Distal Radius
NORMAL
1. DECOMPRESS NERVE • direct compression • tethering associated with
adhesions / scar
• expose MN to normal tissue planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
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www.cuortho.org
www.cuortho.org
*
• expose MN to normal tissue planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
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• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
Neuroplasty + ________ ?
www.cuortho.org
from Dy CJ, et al. JHS-Am 2018
1. minimal or no chance of rejection or inflammatory rxn 2. sufficient porosity to facilitate diffusion of nutrients
without allowing axonal escape 3. avoidance of scar induced ischemia 4. promote nerve gliding 5. minimal or no donor site morbidity 6. minimal cost or supply restraints
www.cuortho.org
Influencing the Perineural Environment
Barriers to nerve adhesions
• local tissue flap (adipofascial or muscle) • distant tissue transfer (free flap) • autologous vein • biologic wraps
• Type 1 collagen • Porcine small intestinal mucosa • Hyaluronic acid – carboxymethylcellulose (Seprafilm) • Hyaluronic acid – alginate (Versawrap)
www.cuortho.org
BIOLOGIC WRAPS
• there are no meaningful clinical trials that compare outcomes of revision / severe median neuroplasty at the wrist with vs without biologic ‘wrap’
• possible benefit following neurolysis where SIS may serve as an ecm “scaffold” for damaged epineurium
www.cuortho.org
• HYPOTHENAR FAT PAD FLAP • PALMARIS BREVIS FLAP • TENOSYNOVIAL FLAP • FOREARM ADIPOFASCIAL FLAP
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• modified by senior author • 62 pts / 66 hands
www.cuortho.org
Techniques in Hand & Upper Extremity Surgery Volume 17, Number 2, June 2013
• retrospective review of 45 procedures in 41 pts • follow up / methodology limited
www.cuortho.org
• EXTERNAL v INTERNAL neurolysis • IDENTIFY: PCBMN + motor br. • EPINEURIUM: evaluate integrity • ASSESS: perineural environment • Reconstruction options
www.cuortho.org
• mature wound, straight line of pull, one function
Restore Function
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
Danoff, et al. JHS-Eur 2014 • outcomes survey in 14 pts • exam for 7 pts • mean follow up = 2.8 yrs
• ALL pts able to palmar abduct • 71% able to oppose to SF base
Ring Finger FDS Transfer
SUMMARY
• Assess functional deficit(s)
• Surgical principles • zone of ‘injury’, optimize perineural environment
• Post-operative rehabilitation
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Suhail K. Mithani, MD
Duke University Medical Center
• Options
• Wraps
Persistent
• Local Conditions
• Postoperative Infection
• Postoperative Hematoma
Why Flap or Wrap after Revision CTR?
Multiple studies have shown perineural adhesion at the time of revision CTR
J Hand Surg Am 2013;38:1530-1539J Hand Surg 2006;31:68-71.
Indications for Flap or Wrap after Revision CTR
• Idiopathic Recurrent Carpal Tunnel
• Mucopolysaccharoidosis
• Amyloidosis
• Provide a barrier between the nerve and its environment
• Implants/Grafts
• “Tennis racket” wrap of saphenous vein
• Improved Nerve Conduction velocity after recurrent CTR
J Hand Surg Am 2001;26:296-302.
Vein Wrapping Outcomes
15 patients: Retrospective Review
velocity with 43 month followup
J Hand Surg Am 2001;26:296-302.
Biologic Wrapping for Recurrent CTR
• In conjunction with extensile CTR ± tenosynovectomy/Neurolysis
• Wrapping of median nerve with biologic conduit
• Porcine
• Collagen
JHS. 2018 Apr;43(4):360-367
• Open Extensile
• Blood supply: Segmental
Surgery10(3):150-156, September 2006.
Surgery10(3):150-156, September 2006.
Synovial Flap
• Tenosynovium is elevated from flexor tendon while preserving its ulnar attachements
• Transposed over median nerve and sutured to radial leaflet
Techniques in Hand & Upper Extremity
Surgery17(2):84-86, June 2013.
Comparison of Various Techniques
Meta Analysis
Most consistent success with revision open
CTR and hypothenar fat flap
Conclusions
• Idiopathic recurrent CTS is typically associated with fibrosis and
adherence of the median nerve to the radial leaflet of the TCL
• In addition to revision CTR and neurolysis, some type of “protection” for
the median should be considered
• Vascularized soft tissue transposition may be superior to wrapping with
autologous vein or biologic conduit
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