Revision carpal tunnel decompression and application of Polyganics Vivosorb membrane surgical technique
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Carpal tunnel results from compression of the median nerve on the volar aspect of the wrist. Decompression is a successful operation when performed for the appropriate indication, when the nerve is completely released and when there is no impairment of nerve glide in the post-operative period.
Persistent carpal tunnel symptoms are associated with incomplete decompression and recurrent symptoms after an interval of 3 months or more are usually associated with a degree of scar formation causing further compression or resulting from nerve tether. The rate of failed primary carpal tunnel decompression is approximately 1:20. This figure includes those with significant persistent symptoms or new symptoms after surgery, incorrect diagnosis, contributing concomitant cervical radiculopathy and a failure to manage the patient’s expectations when there is severe nerve dysfunction. The rate of recurrent carpal tunnel syndrome requiring revision decompression within 10 years of the primary procedure is an additional 1:20. Recurrence rates are higher in diabetic patients due to nerve susceptibility to compression and a tendency to develop thickened chronic tenosynovium around the flexor tendons within the carpal canal. Recurrence is also common in women with low body mass index, possibly due to the decreased subcutaneous adipose tissue that otherwise fills the void left after flexor retinaculum (FR) release. The post operative healing in such cases includes rapid reforming of the FR which results in the recurrent compression. Patients with Hereditary Neuropathy with sensitivity to Pressure Palsies (HNPP), a genetic condition, are prone to multiple peripheral nerve compressions and recurrent compression after release. Patients with complications from primary surgery including infection may have impaired nerve glide and develop persistent or recurrent symptoms after primary release.
One of the causes of failed carpal tunnel decompression (CTD) is scarring of the median nerve paraneurium that impairs physiological nerve glide. Revision CTD may require the use of an adjunct barrier to prevent scar formation resulting in recurrent nerve tether. There are a number of biological and synthetic alternatives. The Vivosorb is a bioresorbable polymer layer that can be sutured loosely around a scarred nerve to prevent scar tether in the surgical bed, maintain nerve gliding and prevent recurrence of compression.
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Author: Dominic Power MA MB BChir(Cantab) FRCSEd, FRCSLon, FRCS(Tr & Orth) Consultant Hand and Peripheral Nerve Surgeon Honorary Senior Clinical Lecturer, University of Birmingham, UK
Institution: West Midlands Peripheral Nerve Injury Service, Birmingham Hand Centre, UK.
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