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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
•
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Nerv Syst 2000;5:191-208.
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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.
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clinics 2013;29:427-434.
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traumatic median nerve painful neuromas and of recurrent carpal
tunnel syndrome: hypothenar fat pad flap. The Journal of hand
surgery 2010;35:1010-1014.
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release: a meta-analysis of randomized controlled trials. Clinical
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the upper extremity: update on pathophysiology, classification, and
electrodiagnostic findings. The Journal of hand surgery
2010;35:668-677.
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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.
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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.
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Clinical Practice Guideline Accessed December 1, 2017.
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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
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surgery 2009;34:1320-1322.
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carpal tunnel syndrome. The Cochrane database of systematic reviews
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Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome:
A Systematic Review. J Manipulative Physiol Ther
2017;40:50-59.
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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