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Contributors: Jonathan Isaacs and Amy Kite
Median nerve autogenous vein wrapping for revision carpal tunnel release due to traction neuritis.
DOI: http://dx.doi.org/10.17797/lr0euenlv3
Editor Recruited By: David Bozentka, MD
The majority of patients achieve high rates of success with carpal tunnel release but a small percentage result in recurrence of symptoms due to scar tissue. Clinical results of allograft vein wrapping for recurrent median nerve compression were first reported by Masear and Colgin in 1996 (1), but were popularized by Vardakis, Varitimidis, and Sotereanos (2). The technique was evaluated by several other authors and the use of vein autograft was found to decrease adherence to the median nerve (3,4,5), although both allograft and autograft vein demonstrate successful outcomes (6). Multiple commercially available scar barriers demonstrate successful results and are marketed for this application, but limited published clinical data limits its regular use (7).
erve wrapping of the median nerve is indicated for recurrent nerve compression due to scar tissue formation resulting in neuroma formation, perineural fibrosis and traction neuritis.
This procedure is contraindicated in situations where there is concern for infection.
The patient is positioned supine with the operative extremity on a hand table. To assist with harvest of the saphenous vein a bump can be placed under the contralateral hip to assist with access to the medial aspect of the lower extremity.
A thorough history and physical examination is the initial step for analysis of recurrent median nerve compression at the carpal tunnel. Close attention to the patients symptoms before and after each surgical intervention will clue the surgeon to whether the patient achieved any relief and then had a recurrence or whether the patients symptoms never improved. Additional review of the previous operative notes and analysis of pre and post operative nerve testing is essential as the previous surgery might have had complications not elicited by the history from the patient. The use of ultrasound to assess for scarring and incomplete decompression can assist in the preoperative workup to look for specific areas of concern.
The previous operative incision is used for access to the median nerve and this is extended both proximal and distally. To protect the neuromuscular structures dissection is begun outside of the area of the previous procedure proximally and then carried into the area of scarring. Slow and careful dissection with tenotomy scissors and scalpel is carried down to the median nerve which is circumferentially released from the surrounding tissue. Perineural and intraneural fibrosis is assessed and if needed intraneural neurolysis is performed.
The use of a more extensile approach for revision of a median nerve release at the carpal tunnel exposes the patient to the possibility of additional scarring in the operative field. This is considered an acceptable risk as the addition of the vein wrap will isolate the median nerve from the surrounding hypertrophic tissue. The disadvantage is the length of the incision and moderate possibility of recurrence of symptoms. Outside of these disadvantages, the use of vein wrap for recurrent nerve compression offers a relatively low risk operation for patients with a difficult and often debilitating problem.
With careful dissection and meticulous surgical technique the operative field must have excellent hemostasis to prevent the formation of a post operative hematoma. Post operatively the surgeon must be vigilant for infection, hematoma formation, and complex regional pain syndrome.
With careful dissection and meticulous surgical technique the operative field must have excellent hemostasis to prevent the formation of a post operative hematoma. Post operatively the surgeon must be vigilant for infection, hematoma formation, and complex regional pain syndrome.
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1. Masear, V. R., & Colgin, S. (1996). The treatment of epineural scarring with allograft vein wrapping. Hand clinics, 12(4), 773-779.
2. Vardakas, D. G., Varitimidis, S. E., & Sotereanos, D. G. (2001). Findings of exploration of a vein-wrapped ulnar nerve: report of a case. The Journal of hand surgery, 26(1), 60-63.
3. Sotereanos, D. G., Giannakopoulos, P. N., Mitsionis, G. I., Xu, J., & Herndon, J. H. (1995). Vein-graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery, 16(11), 752-756.
4. Koman, L. A., Neal, B., & Santichen, J. (1995). Management of the postoperative painful median nerve at the wrist. Orthop Trans, 18(765), 752-756.
5. Ruch, D. S., Spinner, R. M., Koman, L. A., Challa, V. R., O'Farrell, D., & Levin, L. S. (1996). The histologic effect of barrier vein wrapping of peripheral nerves. Journal of reconstructive microsurgery, 12(05), 291-295.
6. Masear, V. R. (2011). Nerve wrapping. Foot and ankle clinics, 16(2), 327-337.
7. Isaacs, J., & McMurtry, J. (2014). Different nerve grafting and wrapping options in upper extremity surgery. Current Orthopaedic Practice, 25(5), 456-461.�
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