Treatment of Recurrent Compressive Neuropathy of Peripheral
Transcription
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. References 1. Cobb TK, Amadio PC, Leatherwood DF, Schleck CD, Ilstrup DM. Outcome of reoperation for carpal tunnel syndrome. J Hand Surg 1996;21A:347–356. 2. 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. J Bone Joint Surg 1987;69A:896 –903. 3. Hunter JM. Recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy. Hand Clin 1991; 7:491–504. 4. Xu J, Sotereanos DG, Moller AR, et al. Nerve wrapping with vein grafts in a rat model: a safe technique for the treatment of recurrent chronic compressive neuropathy. J Reconstr Microsurg 1998;14:323–328. 5. Xu J, Varitimidis SE, Fisher KJ, Tomaino MM, Sotereanos DG. The effect of wrapping scarred nerves with autogenous vein graft to treat recurrent chronic nerve compression. J Hand Surg 2000;25A:93–103. 6. Sotereanos DG, Giannakopoulos PN, Mitsionis GI, Xu J, Herndon JH. Vein-graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery 1995;16:752–756. 7. Masear VR, Colgin S. The treatment of epineural scarring with allograft vein wrapping. Hand Clin 1996;12:773–779. 8. Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median nerve for severe carpaltunnel syndrome. J Bone Joint Surg 1985;67A:253–256. 9. Urbaniak JR. Complications of treatment of carpal tunnel syndrome. In: Gelberman RH, ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991:967– 979. 10. Gould JS. Treatment of the painful injured nerve in-continuity. In: Gelberman RH, ed. Philadelphia: JB Lippincott, 1991:1541–1549. 11. Botte MJ, von Schroeder HP, Abrams RA, Gellman H. Recurrent carpal tunnel syndrome. Hand Clin 1996;12: 731–743. 12. Rose EH, Norris MS, Kowalski TA, Lucas A, Flegler EJ. Palmaris brevis turnover flap as an adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1991;16A: 191–201. 13. Nashold BS Jr, Goldner JL, Mullen JB, Bright DS. Longterm pain control by direct peripheral-nerve stimulation. J Bone Joint Surg 1982;64A:1–10. 14. Monsivais JJ, Monsivais DB. Managing chronic neuropathic pain with implanted anesthetic reservoirs. Hand Clin 1996;12:781–786.
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