Reoperative Options for Compressive Neuropathies of the Upper Extremity

  • Jason R. Kang
  • Ranjan GuptaEmail author


In addressing failed surgery for compressive neuropathies about the arm, it is important to distinguish between what would truly be called recurrence vs. those who have a failure to improve in their symptoms. Evaluation of these patients does require some time in both obtaining a thorough history as well as performing a detailed clinical exam. Electromyographic and neural conduction velocity testing is helpful. In these cases, the surgeon needs to think both proximal and distal; that is, could the symptoms be coming from the neck or could there be areas of further compression proximally or distally about the peripheral nerve? Reoperating on previously operated nerve tissue can be quite stressful as the nerve tissue is frequently less forgiving than other soft tissue structures commonly encountered in the scar bed. The use of a microscope can sometimes be helpful in visualizing the tissue planes and/or nerve tissue. If mechanical reasons are found to explain the patient’s continued symptoms, then these points of compression can be surgically addressed if the patient is willing to accept the potential risks of nerve injury and further scarring, which sometimes precludes the patient from improving as much as both doctor and patient were hoping.


Carpal Cubital Radial Tunnel Syndrome Recurrence 


  1. 1.
    AAOS. Carpal Tunnel Syndrome. American Academy of Orthopaedic Surgeons Website. Accessed 16 July 2009.
  2. 2.
    Botte MJ, et al. Recurrent carpal tunnel syndrome. Hand Clin. 1996;12(4):731–43.PubMedGoogle Scholar
  3. 3.
    Gupta R, Steward O. Chronic nerve compression induces concurrent apoptosis and proliferation of Schwann cells. J Comp Neurol. 2003;461(2):174–86.PubMedCrossRefGoogle Scholar
  4. 4.
    Gupta R, et al. Local down-regulation of myelin-associated glycoprotein permits axonal sprouting with chronic nerve compression injury. Exp Neurol. 2006;200(2):418–29.PubMedCrossRefGoogle Scholar
  5. 5.
    Gray M, et al. Macrophage depletion alters the blood-nerve barrier without affecting Schwann cell function after neural injury. J Neurosci Res. 2007;85(4):766–77.PubMedCrossRefGoogle Scholar
  6. 6.
    Ludwin SK, Maitland M. Long-term remyelination fails to reconstitute normal thickness of central myelin sheaths. J Neurol Sci. 1984;64(2):193–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Gupta R, et al. Shear stress alters the expression of myelin-associated glycoprotein (MAG) and myelin basic protein (MBP) in Schwann cells. J Orthop Res. 2005;23(5):1232–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Tung TH, Mackinnon SE. Secondary carpal tunnel surgery. Plast Reconstr Surg. 2001;107(7):1830–43; quiz 1844, 1933.Google Scholar
  9. 9.
    Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2(7825):359–62.PubMedCrossRefGoogle Scholar
  10. 10.
    Flak M, et al. Double crush syndrome evaluation in the median nerve in clinical, radiological and electrophysiological examination. Stud Health Technol Inform. 2006;123:435–41.PubMedGoogle Scholar
  11. 11.
    Paget J. The first description of carpal tunnel syndrome. J Hand Surg Eur Vol. 2007;32(2):195–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Palmer DH, Hanrahan LP. Social and economic costs of carpal tunnel surgery. Instr Course Lect. 1995;44:167–72.PubMedGoogle Scholar
  13. 13.
    Gelberman RH, et al. The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am. 1981;63(3):380–3.PubMedGoogle Scholar
  14. 14.
    Brain W, Wright A, Wilkerson M. Spontaneous compression of both median nerves in carpal tunnel. Six cases treated surgically. Lancet. 1947;1:277–82.PubMedCrossRefGoogle Scholar
  15. 15.
    Agee JM, et al. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg Am. 1992;17(6):987–95.PubMedCrossRefGoogle Scholar
  16. 16.
    Chow JC. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy. 1989;5(1):19–24.PubMedCrossRefGoogle Scholar
  17. 17.
    Varitimidis SE, Herndon JH, Sotereanos DG. Failed endoscopic carpal tunnel release. Operative findings and results of open revision surgery. J Hand Surg Br. 1999;24(4):465–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Urbaniak JR, Desai SS. Complications of nonoperative and operative treatment of carpal tunnel syndrome. Hand Clin. 1996;12(2):325–35.PubMedGoogle Scholar
  19. 19.
    MacDonald RI, et al. Complications of surgical release for carpal tunnel syndrome. J Hand Surg Am. 1978;3(1):70–6.PubMedGoogle Scholar
  20. 20.
    O’Malley MJ, et al. Factors that determine reexploration treatment of carpal tunnel syndrome. J Hand Surg Am. 1992;17(4):638–41.PubMedCrossRefGoogle Scholar
  21. 21.
    Stutz N, et al. Revision surgery after carpal tunnel release—analysis of the pathology in 200 cases during a 2 year period. J Hand Surg Br. 2006;31(1):68–71.PubMedGoogle Scholar
  22. 22.
    Schreiber JE, et al. Common risk factors seen in secondary carpal tunnel surgery. Ann Plast Surg. 2005;55(3):262–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Stevens JC, et al. Conditions associated with carpal tunnel syndrome. Mayo Clin Proc. 1992;67(6):541–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Shurr DG, Blair WF, Bassett G. Electromyographic changes after carpal tunnel release. J Hand Surg Am. 1986;11(6):876–80.PubMedGoogle Scholar
  25. 25.
    Jarvik JG, Yuen E, Kliot M. Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation. Neuroimaging Clin N Am. 2004;14(1):93–102, viii.Google Scholar
  26. 26.
    Mesgarzadeh M, Triolo J, Schneck CD. Carpal tunnel syndrome. MR imaging diagnosis. Magn Reson Imaging Clin N Am. 1995;3(2):249–64.PubMedGoogle Scholar
  27. 27.
    Koenig RW, et al. High-resolution ultrasonography in evaluating peripheral nerve entrapment and trauma. Neurosurg Focus. 2009;26(2):E13.PubMedCrossRefGoogle Scholar
  28. 28.
    Spratt JD, et al. The role of diagnostic radiology in compressive and entrapment neuropathies. Eur Radiol. 2002;12(9):2352–64.PubMedGoogle Scholar
  29. 29.
    Brahme SK, et al. Dynamic MR imaging of carpal tunnel syndrome. Skeletal Radiol. 1997;26(8):482–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Silbermann-Hoffman O, et al. Contribution of magnetic resonance imaging for the diagnosis of median nerve lesion after endoscopic carpal tunnel release. Chir Main. 1998;17(4):291–9.PubMedGoogle Scholar
  31. 31.
    Wong SM, et al. Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis Rheum. 2002;46(7):1914–21.PubMedCrossRefGoogle Scholar
  32. 32.
    Hunter JM. Recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy. Hand Clin. 1991;7(3):491–504.PubMedGoogle Scholar
  33. 33.
    Amadio PC. Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release. J Hand Surg Am. 2009;34(7):1320–2.PubMedCrossRefGoogle Scholar
  34. 34.
    Ellis RA, et al. Workers’ compensation, return to work, and patient satisfaction after carpal tunnel decompression. Am J Orthop. 2007;36(4):E63–6.PubMedGoogle Scholar
  35. 35.
    Chaise F, et al. Return-to-work interval and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients. J Hand Surg Br. 2004;29(6):568–70.PubMedCrossRefGoogle Scholar
  36. 36.
    Cobb TK, et al. Outcome of reoperation for carpal tunnel syndrome. J Hand Surg Am. 1996;21(3):347–56.PubMedCrossRefGoogle Scholar
  37. 37.
    Mackinnon SE, et al. Internal neurolysis fails to improve the results of primary carpal tunnel decompression. J Hand Surg Am. 1991;16(2):211–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Steyers CM. Recurrent carpal tunnel syndrome. Hand Clin. 2002;18(2):339–45.PubMedCrossRefGoogle Scholar
  39. 39.
    Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median nerve for severe carpal-tunnel syndrome. J Bone Joint Surg Am. 1985;67(2):253–6.PubMedGoogle Scholar
  40. 40.
    Pizzillo MF, Sotereanos DG, Tomaino MM. Recurrent carpal tunnel syndrome: treatment options. J South Orthop Assoc. 1999;8(1):28–36.PubMedGoogle Scholar
  41. 41.
    Varitimidis SE, et al. Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator. J Hand Surg Am. 2001;26(2):296–302.PubMedCrossRefGoogle Scholar
  42. 42.
    Wulle C. The synovial flap as treatment of the recurrent carpal ­tunnel syndrome. Hand Clin. 1996;12(2):379–88.PubMedGoogle Scholar
  43. 43.
    Strickland JW, et al. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg Am. 1996;21(5):840–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Stutz NM, et al. Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome. Neurosurgery. 2008;62(3 Suppl 1):194–9; discussion 199–200.Google Scholar
  45. 45.
    Fusetti C, et al. A reliable and simple solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap. Am J Orthop. 2009;38(4):181–6.PubMedGoogle Scholar
  46. 46.
    Mathoulin C, Bahm J, Roukoz S. Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Hand Surg. 2000;5(1):33–40.PubMedCrossRefGoogle Scholar
  47. 47.
    Spokevicius S, Kleinert HE. The abductor digiti minimi flap: its use in revision carpal tunnel surgery. Hand Clin. 1996;12(2):351–5.PubMedGoogle Scholar
  48. 48.
    Pomerance J, Fine I. Outcomes of carpal tunnel surgery with and without supervised postoperative therapy. J Hand Surg Am. 2007;32(8):1159–63; discussion 1164–5.Google Scholar
  49. 49.
    Chang B, Dellon AL. Surgical management of recurrent carpal tunnel syndrome. J Hand Surg Br. 1993;18(4):467–70.PubMedCrossRefGoogle Scholar
  50. 50.
    Hulsizer DL, et al. The results of revision carpal tunnel release ­following previous open versus endoscopic surgery. J Hand Surg Am. 1998;23(5):865–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Unglaub F, et al. Subjective and functional outcome after revision surgery in carpal tunnel syndrome. Arch Orthop Trauma Surg. 2008;128(9):931–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Hartz CR, et al. The pronator teres syndrome: compressive neuropathy of the median nerve. J Bone Joint Surg Am. 1981;63(6):885–90.PubMedGoogle Scholar
  53. 53.
    Bilecenoglu B, Uz A, Karalezli N. Possible anatomic structures causing entrapment neuropathies of the median nerve: an anatomic study. Acta Orthop Belg. 2005;71(2):169–76.PubMedGoogle Scholar
  54. 54.
    Kiloh LG, Nevin S. Isolated neuritis of the anterior interosseous nerve. Br Med J. 1952;1(4763):850–1.PubMedCrossRefGoogle Scholar
  55. 55.
    Kaplan EB, Spinner M. The anterior interosseous nerve syndrome. J Bone Joint Surg. 1969;51A:1677.Google Scholar
  56. 56.
    Dunn AJ, Salonen DC, Anastakis DJ. MR imaging findings of anterior interosseous nerve lesions. Skeletal Radiol. 2007;36(12):1155–62.PubMedCrossRefGoogle Scholar
  57. 57.
    Mackinnon SE. Compressive neuropathies. In: Green D, editor. Green’s operative hand surgery. 5th ed. New York: Churchill Livingstone; 2005.Google Scholar
  58. 58.
    McGowan A. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. 1950;32-B(3):293–301.PubMedGoogle Scholar
  59. 59.
    Ahcan U, Zorman P. Endoscopic decompression of the ulnar nerve at the elbow. J Hand Surg Am. 2007;32(8):1171–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Hoffmann R, Meek MF. Endoscopic decompression of the ulnar nerve at the elbow. J Hand Surg Am. 2008;33(4):615; author reply 615–6.Google Scholar
  61. 61.
    Kasdan ML. Endoscopic cubital tunnel release. J Hand Surg Am. 1999;24(3):647.PubMedCrossRefGoogle Scholar
  62. 62.
    Merolla G, et al. Endoscopic approach to cubital tunnel syndrome. J Neurosurg Sci. 2008;52(3):93–8.PubMedGoogle Scholar
  63. 63.
    Yoshida A, Okutsu I, Hamanaka I. Endoscopic anatomical nerve observation and minimally invasive management of cubital tunnel syndrome. J Hand Surg Eur Vol. 2009;34(1):115–20.PubMedCrossRefGoogle Scholar
  64. 64.
    Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clin. 1996;12(2):421–33.PubMedGoogle Scholar
  65. 65.
    Curtis B. Traumatic ulnar neuritis: transposition of the nerve. J Nerv Ment Dis. 1898;25:480–4.Google Scholar
  66. 66.
    Learmonth J. A technique for transplanting the ulnar nerve. Surg Gynecol Obstet. 1942;75:792–3.Google Scholar
  67. 67.
    Adson A. The surgical treatment of progressive ulnar paralysis. Minn Med. 1918;1:455–60.Google Scholar
  68. 68.
    King T, Morgan F. Late results of removing the medial humeral epicondyle for traumatic ulnar neuritis. J Bone Joint Surg Br. 1959;41:51–5.PubMedGoogle Scholar
  69. 69.
    Mowlavi A, et al. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg. 2000;106(2):327–34.PubMedCrossRefGoogle Scholar
  70. 70.
    Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am. 1989;14(4):688–700.PubMedCrossRefGoogle Scholar
  71. 71.
    AAOS. Thoracic Outlet Syndrome. American Academy of Orthopaedic Surgeons Website. Accessed 25 Aug 2009.
  72. 72.
    Wein TH, Albers JW. Electrodiagnostic approach to the patient with suspected peripheral polyneuropathy. Neurol Clin. 2002;20(2):503–26, vii.Google Scholar
  73. 73.
    Andreisek G, et al. Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features. Radiographics. 2006;26(5):1267–87.PubMedCrossRefGoogle Scholar
  74. 74.
    Martinoli C, et al. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics. 2000;20(Spec No):S199–213; discussion S213–7.Google Scholar
  75. 75.
    Lowe III JB, Mackinnon SE. Management of secondary cubital tunnel syndrome. Plast Reconstr Surg. 2004;113(1):E1–16.CrossRefGoogle Scholar
  76. 76.
    Dellon AL. Techniques for successful management of ulnar nerve entrapment at the elbow. Neurosurg Clin N Am. 1991;2(1):57–73.PubMedGoogle Scholar
  77. 77.
    Broudy AS, Leffert RD, Smith RJ. Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation. J Hand Surg Am. 1978;3(1):85–9.PubMedGoogle Scholar
  78. 78.
    Rogers MR, Bergfield TG, Aulicino PL. The failed ulnar nerve transposition. Etiology and treatment. Clin Orthop Relat Res. 1991;269:193–200.PubMedGoogle Scholar
  79. 79.
    Vogel RB, Nossaman BC, Rayan GM. Revision anterior submuscular transposition of the ulnar nerve for failed subcutaneous transposition. Br J Plast Surg. 2004;57(4):311–6.PubMedCrossRefGoogle Scholar
  80. 80.
    Pearce C, Feinberg J, Wolfe SW. Ulnar neuropathy at the wrist. HSS J. 2009;5(2):180–3.PubMedCrossRefGoogle Scholar
  81. 81.
    Lister GD, Belsole RB, Kleinert HE. The radial tunnel syndrome. J Hand Surg Am. 1979;4(1):52–9.PubMedGoogle Scholar
  82. 82.
    Portilla MAE, et al. The posterior interosseous nerve and the radial tunnel syndrome: an anatomical study. Int Orthop. 1998;22(2):102–6.CrossRefGoogle Scholar
  83. 83.
    Manske PR. Compression of the radial nerve by the triceps muscle: a case report. J Bone Joint Surg Am. 1977;59(6):835–6.PubMedGoogle Scholar
  84. 84.
    Payatakes A, Sotereanos DG. Radial Nerve Injuries. In: Slutsky D, editor. Upper extremity nerve repair—tips and techniques: a master skills publication. Rosemont: American Society for Surgery of the Hand; 2008. p. 399–412.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryUniversity of California, IrvineOrangeUSA
  2. 2.Department of Orthopedic SurgeryUniversity of California, IrvineOrangeUSA

Personalised recommendations