Treatment of Recurrent Compressive Neuropathy of Peripheral

Treatment of Recurrent Compressive
Neuropathy of Peripheral Nerves
in the Upper Extremity With
an Autologous Vein Insulator
Sokratis E. Varitimidis, MD, Dimitris G. Vardakas, MD,
Felix Goebel, MD, Dean G. Sotereanos, MD, Pittsburgh, PA
The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not
uncommon and its management is both challenging and difficult. Nineteen patients with
recurrent carpal tunnel and cubital tunnel syndrome were treated with the vein wrapping
technique using the autogenous saphenous vein. The average number of surgeries before
vein wrapping was 3.3. The mean patient age was 53 years (range, 28 –75 years) and the
mean follow-up period was 43 months (range, 24 –78 months). All patients reported
reduction in pain and the sensory disturbances secondary to the compression of the
median or ulnar nerve. Two-point discrimination and electrodiagnostic findings also
improved. (J Hand Surg 2001;26A:296 –302. Copyright © 2001 by the American Society
for Surgery of the Hand.)
Key words: Autologous vein wrapping, recurrent compressive neuropathy.
The gold standard for surgical treatment of entrapment neuropathy in the upper extremity is surgical
decompression of the entrapped nerve. Despite the
high success rates reported in the literature by most
investigators releasing the transverse carpal ligament
at the wrist for carpal tunnel syndrome and decompressing the ulnar nerve at the elbow for cubital
tunnel, the compression can recur.1–3 If the primary
decompression was adequate, cicatrix that develops
From the Department of Orthopaedics, University of Pittsburgh
Medical Center, Pittsburgh, PA.
Received for publication June 28, 2000; accepted in revised form
November 10, 2000.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Dean G. Sotereanos, MD, Department of Orthopaedics, University of Pittsburgh Medical Center, Kaufmann Bldg,
Suite 1010, 3471 Fifth Ave, Pittsburgh, PA 15213.
Copyright © 2001 by the American Society for Surgery of the Hand
0363-5023/01/26A02-0011$35.00/0
doi:10.1053/jhsu.2001.22528
296 The Journal of Hand Surgery
at the site of decompression surrounding the nerve is
generally the reason for failure.3
The management of recurrent entrapment neuropathy is difficult and controversial. Repeated
nerve decompression, alone or accompanied with
external or internal neurolysis, does not always relieve symptoms.
In an experimental study we used the femoral
vein to wrap the sciatic nerve of rats.4,5 Histologic
examination showed that no scar tissue developed
between the sciatic nerve and the intima of the
vein. Encouraged by the results of our experimental study, we applied the vein wrapping technique
to patients with recurrent compressive neuropathy.
Our preliminary results of a study of only 3 patients with recurrent compression neuropathy of
the median nerve were very encouraging.6 In this
report we discuss the results of autologous vein
wrapping of the median and ulnar nerve as a
treatment option for recurrent carpal and cubital
The Journal of Hand Surgery / Vol. 26A No. 2 March 2001 297
Table 1. Patients With Recurrent Carpal Tunnel Syndrome Treated With Autologous Saphenous Vein Wrapping
Two-Point
Discrimination (mm)
Pain
Case
No.
Age
(yr)
Length of
Follow-Up
(mo)
No. of
Previous
Procedures
Before
Surgery
After
Surgery
Before
Surgery
After
Surgery
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
46
34
53
61
41
61
28
48
56
59
51
75
64
58
44
78
66
60
53
52
49
44
41
38
32
31
31
29
27
24
5
3
4
2
3
4
3
3
4
3
3
3
2
3
3
7
7
6
8
9
6
8
7
6
6
6
8
7
7
8
2
3
3
3
6
2
4
3
3
2
2
5
3
2
3
12
9
15
10
12
10
9
8
12
14
15
12
14
10
9
8
8
12
6–8
8
7
6–8
8
8
10
10
9
10
8
6
tunnel syndrome in a larger group of patients with
a longer follow-up period.
Materials and Methods
Nineteen patients with recurrent compressive neuropathy of the median or ulnar nerve were treated
with autologous saphenous vein wrapping between
January 1993 and June 1997. Fifteen patients had
recurrent carpal tunnel syndrome and 4 had recurrent
cubital tunnel syndrome (Tables 1,2). There were 8
men and 11 women. The mean age was 53 years
(range, 28 –75 years). The involved extremity was
dominant in 14 of the 19 patients.
The mean number of previous procedures was 3,
with a minimum of 2 and a maximum of 5 for each
patient. For the median nerve these procedures included simple nerve decompression, tenosynovec-
tomy, internal neurolysis, hypothenar fat pad flap,
and local flaps. For the ulnar nerve they included in
situ decompression with or without medial epicondylectomy, subcutaneous, submuscular, and intramuscular transposition of the ulnar nerve.
The average follow-up period was 43 months
(range, 24 –78 months). Each patient had both subjective and objective evaluation. For the subjective
evaluation the patient was given an identical questionnaire both before and after surgery that asked
about pain, numbness, and overall satisfaction. Patients were asked to rate their level of pain on a scale
of 10 and to state whether their preoperative numbness had improved after surgery (sensation). They
also were asked whether they were satisfied with the
outcome. The objective evaluation included the measurement of 2-point discrimination (sensibility) and
Table 2. Patients With Recurrent Cubital Tunnel Syndrome Treated
With Autologous Saphenous Vein Wrapping
Two-Point
Discrimination (mm)
Pain
Case
No.
Age
(yr)
Length of
Follow-Up
(mo)
No. of
Previous
Procedures
Before
Surgery
After
Surgery
Before
Surgery
After
Surgery
1
2
3
4
30
54
42
48
24
44
36
34
4
3
5
4
8
6
6
7
3
2
2
3
NM
15
15
12
6–8
6
6–8
8–10
NM, not measurable.
298 Varitimidis et al / Autologous Vein Wrap for Compressive Neuropathy
Figure 1. The technique used for vein wrapping of scarred nerves. (A) The saphenous vein is harvested from the ipsilateral
or contralateral leg, (B) is split longitudinally, and (C) is opened to form a rectangle. (D) The saphenous vein is wrapped
around the scarred portion of the nerve in a spiral pattern with its intima on the surface of the nerve. Each ring of the vein
is tacked to the adjacent rings with a 7– 0 or 8 – 0 nylon stitch. (E) The entire scarred portion of the nerve is covered with
the saphenous vein.
grip strength. Grip strength was measured with a
Jamar dynamometer (Preston Corp, Clifton, NJ). All
patients had electrodiagnostic studies before surgery
and 10 patients had electrodiagnostic studies after
surgery for comparison with their preoperative values.
Operative Procedure
The standard approach used for the primary procedure is also used for the revision surgery, but the
incision is slightly extended both proximally and
The Journal of Hand Surgery / Vol. 26A No. 2 March 2001 299
Figure 2. The median nerve has been exposed at the wrist. Internal neurolysis has been performed and the saphenous vein
is tacked distally. The intimal surface of the vein is facing the surface of the nerve.
distally because the compressed nerve must first be
exposed in an unscarred environment. The procedure
is done under general anesthesia because 2 operating
fields (1 in the upper extremity and 2 in the lower
extremity) co-exist. The median nerve is identified
and lysed from the surrounding scar tissue. Dissec-
Table 3. Patients With Recurrent Carpal Tunnel
Syndrome Treated With Autologous Saphenous
Vein Wrapping
tion is done under ⫻3.5 magnification. Internal neurolysis is performed only if indicated. Indications
included severe compression and thinning of the
nerve, lack of epineural vascularity, and muscle
wasting.
The ipsilateral or contralateral lower extremity is
used for harvesting of the greater saphenous vein. A
longitudinal incision is made 1 cm anterior to the
medial malleolus. The required length of the vein is
3 to 4 times the scarred length of the nerve. A vein
Nerve Conduction Velocity (m/s)
Before Surgery
After Surgery
Case
No.
Motor
Sensory
Motor
Sensory
2
3
6
7
8
10
12
14
43.2
36.2
39
43.1
38.8
44.8
36.9
42.7
36.8
31.4
42.6
40.2
39.1
33
41.1
Not available
45.9
40.8
42.1
44.2
41.3
45.8
39.5
44.8
39.9
Not available
46.7
44
43.8
37.2
45.5
44.1
Table 4. Patients With Recurrent Cubital Tunnel
Syndrome Treated With Autologous Saphenous
Vein Wrapping
Nerve Conduction Velocity (m/s)
Case
No.
3
4
Before Surgery
After Surgery
Motor
Sensory
Motor
Sensory
43.2
44.8
41.5
43
47.1
46.9
Not available
46.7
300 Varitimidis et al / Autologous Vein Wrap for Compressive Neuropathy
Figure 3. Wrapping the nerve with the saphenous vein proceeds circumferentially according to the technique described by
Masear et al.
length of 25 to 30 cm usually is needed and the
incision is made accordingly. A vein stripper has
been recently used to minimize the length of the
incision. After the saphenous vein is harvested it is
incised and opened longitudinally (Fig. 1). One of
the ends of the vein graft is tacked distal to the
scarred portion of the nerve on a tissue that is not
mobile, with the intima against the nerve, using a
7– 0 or 8 – 0 nylon stitch (Fig. 2). The wrapping
proceeds circumferentially as described by Masear at
al (Masear VR, Tulloss JR, St Mary E, Meyer RD.
Venous wrapping of nerves to prevent scarring.
J Hand Surg 1990;15A:817– 818 [abstr]) from distal
to proximal, while care is taken not to make the wrap
too snug and thus constrict the nerve (Fig. 3). After
each complete circle of the vein on the nerve, the
vein is stabilized with a loose 7– 0 or 8 – 0 nylon
stitch to the adjacent ring of vein. The other end of
the vein graft is tacked proximal to the scarred segment of the nerve on unscarred tissue (Fig. 4). The
coverage of the scarred nerve segment must be complete to prevent recurrent compression.7
For the median nerve the wrist is immobilized
after surgery for 1 week in slight extension. Active
and passive motion exercises are started immediately
after the splint is removed. For the ulnar nerve the
elbow is not immobilized and active and passive
motion starts immediately.
Results
On a scale of 10 all 19 patients rated their pain
between 2 and 6; their preoperative pain had been
rated between 6 and 9. Sensation improved in all
patients, although 16 of the 19 patients had residual
numbness. One patient stated that he was not satisfied with the result, although he reported that his pain
had decreased. This patient was involved in an active
workers’ compensation litigation case. The remaining 18 patients stated that they would undergo the
procedure again had they known the outcome in
advance. Two-point discrimination improved from
an average of 12 (range, 8 –15) before surgery to 8
(range, 6 –10) after surgery (Tables 1,2). Sixteen of
the 19 patients demonstrated more than 2 mm im-
The Journal of Hand Surgery / Vol. 26A No. 2 March 2001 301
Figure 4. The saphenous vein covers the entire portion of the nerve where internal neurolysis has been performed.
provement in 2-point discrimination in comparison
to the preoperative values. Grip strength increased
from an average of 27 kg (range, 24 –36 kg) before
surgery to 38 kg (range, 28 – 46 kg) after surgery.
Abnormal nerve conduction velocities were found in
all patients in their preoperative electrodiagnostic
studies. The motor nerve conduction velocity improved from an average of 41 m/s (range, 36 – 44
m/s) before surgery to 43 m/s (range, 39 – 47 m/s)
after surgery in the 10 patients who had both preoperative and postoperative values available. The sensory nerve conduction velocity improved from an
average of 39 m/s (range, 33– 43 m/s) before surgery
to 43 m/s (range, 37– 46 m/s) after surgery in the 7
patients who had both preoperative and postoperative
values available (Tables 3,4).
No patient had a complication due to harvesting of
the greater saphenous vein. The patients reported
some pain and discomfort at the donor site that
resolved at approximately 4 months after the procedure; however, 1 patient had local swelling for 1 year
after surgery.
Discussion
Surgical decompression of entrapped peripheral
nerves is generally efficacious. Some patients, however, do not experience good long-term results with
this treatment.
Multiple incisions and approaches can create scar
tissue, which further compresses the nerve. The result is a chronic neuropathy, called a “traction neuropathy,”3 and the optimal treatment may be a combination of procedures. Mobilization of the nerve
followed by internal neurolysis cannot alleviate these
problems due to recurrent scar.8 Most investigators
agree that soft tissue coverage is necessary to prevent
this phenomenon and several options have been suggested.9 –13 For recurrent carpal tunnel syndrome the
hypothenar fat pad flap can produce good results and
is uncomplicated in most cases.9 Pedicle or free
flaps, including the groin flap, lateral arm flap, and
posterior interosseous flap, provide excellent protection of the nerve, but the technique is complex and
the result is not always satisfying.9,10 Small local
302 Varitimidis et al / Autologous Vein Wrap for Compressive Neuropathy
flaps, such as the abductor digiti minimi, the palmaris
brevis, and the pronator quadratus, also have been
used.11,12 The dissection of these flaps, however, is
not always easy, nerve coverage is sometimes inadequate, and skin closure problems may occur. The
use of implanted peripheral nerve stimulators has
been suggested to relieve pain resulting from compressed or injured peripheral nerves,13,14 but failures
have been reported in many cases because of complications such as nerve injuries, skin problems, and
early formation of scar tissue due to silicone.10,13
Masear et al first reported the successful use of a
vein graft for recurrent symptoms secondary to scarring of the nerve. Koman et al (Koman LA, Neal B,
Santichen J. Management of the postoperative painful median nerve at the wrist. Orthop Trans 1995;18:
765 [abstr]) and Gould10 also have shown that the
vein graft wrapping technique can improve the recovery of nerve function in patients with chronic
refractory nerve symptoms secondary to cicatrix.
Our experimental studies4,5 have shown that the
autogenous vein wrapping technique is effective in
the treatment of a compression neuropathy secondary
to scar. The mechanism of its effect, however, remains uncertain. Based on etiology, pathology, and
pathophysiology of chronic nerve compression, we
believe that the procedure works by insulating the
peripheral nerve from surrounding scar tissue,
thereby preventing adhesion between the nerve trunk
and the surrounding tissue. In addition, the formation
of scar tissue within the peripheral nerve trunk is
minimized after decompression, possibly owing to
properties of endothelial cells that line the inner
surface of the vein. Perhaps the vein graft also functions by preventing adhesions between the vein and
the nerve. In addition, the autogenous vein graft with
its smooth inner surface should improve the gliding
function of the nerve trunk during motion of the
relevant joint, avoiding the possible damage induced
by gliding friction of the trunk.
Our patients reported that their pain, which was
their principal complaint before surgery, subsided
considerably. Sensation and 2-point discrimination
also improved. Follow-up nerve conduction studies
in several patients revealed improvement in nerve
conduction velocity.
The use of autogenous vein graft wrapping as a
supplementary technique to treat chronic nerve compression secondary to cicatrix has many advantages.
It is a simple technique that causes minimal compli-
cations in the donor area. In addition, the donor vein
is readily available and harvesting is easy. Based on
our results we believe that vein wrapping is an efficacious adjuvant procedure for the treatment of recurrent neuropathy secondary to scarring of the nerve.
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