Revision Neurolysis Research Articles

Recurrence of ulnar tunnel syndrome: Long-term clinical and functional results of surgical management using revision neurolysis and subcutaneous anterior transposition

ObjectiveRecurrence after primary ulnar tunnel syndrome surgery is observed in 1.4%–25% of patients. However, the outcome of revision surgery is uncertain and limited. This study aimed to assess the clinical and functional outcomes of neurolysis combined with anterior subcutaneous transposition in cases of recurrence. Patients and methodsThis retrospective single-center study included patients who were operated on for iterative ulnar tunnel syndrome at the elbow between January 1996 and December 2020, with a minimum follow-up of 24 months. Demographic data, pre- and post-operative clinical evaluations, surgical details, and satisfaction levels were collected. ResultsTwenty-eight patients were reviewed. Mean follow-up was 11.7 years (range, 2.1–26.4 years). The secondary procedure led to significant improvement in mean Quick-DASH score, from 25.3 (range, 11–50) to 20.0 (range, 11–49) (p = 0.023), with a satisfaction rate of 78.5%. Symptoms of pain (p = 0.033), amyotrophy (p = 0.013), hypoesthesia (p < 0.01), and paresthesia (p < 0.001) also showed significant improvement. There were 7 cases of failure (25.0%). ConclusionThe combination of neurolysis and anterior subcutaneous transposition was a reliable technique, improving clinical outcome in recurrent ulnar tunnel syndrome after previous surgery. Level of evidenceIV — retrospective study.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

Introduction: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. Methods: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. Results: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). Conclusion: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Outcomes of revision neurolysis of the ulnar nerve and ulnar groove plasty for persistent and recurrent cubital tunnel syndrome—A retrospective study of 21 cases

BackgroundPatients undergoing revision surgical treatment of the ulnar nerve at the elbow for cubital tunnel syndrome (CuTS) will have worse results compared to patients successfully treated with primary surgery. ObjectiveThe purpose of this study is to evaluated clinical outcomes of revision neurolysis and ulnar groove plasty for recurrent and persistent cubital tunnel syndrome after failed surgical treatment. MethodsThis retrospective investigation included patients presented with recurrent and persistent CuTS who were treated surgically with combination of revision neurolysis and ulnar groove plasty at a single institution from May 2006 to Oct 2016 with postoperative follow-up more than 24 months. Demographic data of all patients including age, sex, months to revision surgery, presenting symptoms after index surgery, previous surgical procedure and intraoperative findings were all recorded and pre-operative and post-operative data were compared. McGowen grading was used to evaluated functional impairment before and after revision surgery. ResultsThere were 28 patients were identified with recurrent and persistent CuTS after primary surgery and 21 patients (75%) were completed in this study with an average age was 56 years, mean duration of symptoms was 17.24 months, and mean postoperative follow-up was 35.38 months. 17 patients had McGowan stage III and 4 had stage II preoperatively. The most common cause of recurrent and persistent CuTS was perineural fibrosis with or without kink which accounts for 86.36% according to intraoperative findings. McGowan grading improved after revision neurolysis and ulnar groove plasty is 80.95%. Improvement of Visual Analogue Scale (VAS) and 2-point discrimination test were 81.25% and 85.71%, respectively. Patients satisfaction after revision neurolysis and ulnar groove plasty was 95.24%. ConclusionThe favorable results of this study demonstrated that revision neurolysis and ulnar groove plasty as the treatment of choice for recurrent or persistent cubital tunnel syndrome.

Management of the scarred nerve using porcine submucosa extracellular matrix nerve wraps

Objectives: Scar tissue formation around the peripheral nerves causes nerve compression and ischemia, but it also causes adherence of nerves to the surrounding tissues, decreasing the nerve's ability to glide, and therefore, causing neurostenalgia – nerve pain with motion due to tether. Our unit has been using a porcine submucosal extracellular matrix (AxoGuard® AxoGen Inc., Alachua, FL, USA) nerve wrap to prevent nerve scarring. The aim of this study is to present a case series of our use of the AxoGuard® and early follow-up data. Methods: This study describes the use of AxoGuard® nerve protectors, including the indications, anatomic locations, and complications. After obtaining ethics approval from the Institutional Audit Review Board, a retrospective review was performed of all cases where AxoGuard® nerve protectors were used from June 2015 to July 2018. Results: Over a 3-year period, AxoGuard® nerve wraps were used in 71 cases. The indication for surgery was a scarred nerve after trauma surgery in 32 cases, scarring after primary nerve surgery in 19 cases, primary trauma in 9 cases, nerve scarring after elective nonnerve surgery in 5 cases, and nerve tumors in 5 cases. There have been no complications directly related to the use of the AxoGuard® nerve protector and no cases of postoperative infection. Conclusions: The AxoGuard® nerve protector has many clinical indications, an excellent safety profile with no reported complications directly related to the nerve wrap, and is effective in mitigating the effects of neurostenalgia following revision neurolysis.

Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping

Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS. We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained. Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients. Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.

Preliminary Results of Recurrent Cubital Tunnel Syndrome Treated With Neurolysis and Porcine Extracellular Matrix Nerve Wrap

To evaluate the clinical results of revision neurolysis and wrapping with porcine extracellular matrix (AxoGuard Nerve Protector, AxoGen Inc., Alachua, FL) for cubital tunnel syndrome after one previous surgical decompression. Twelve patients with recurrent cubital tunnel syndrome were treated with decompression, porcine extracellular matrix nerve wrap, and minimal medial epicondylectomy (if not previously performed). The average follow-up period was 41 months (range, 24-61 mo). All patients had recurrent symptoms after having previously undergone one surgical decompression. The mean patient age was 45 years (range, 30-58 y). All patients were evaluated subjectively and objectively (pain, satisfaction, static 2-point discrimination, grip strength, and pinch strength). A significant improvement was demonstrated in postoperative pain levels (from 8.5 to 1.7), grip strength (from 41% to 86% of the unaffected side), and pinch strength (from 64% to 83% of the unaffected side). Static 2-point discrimination improved from an average 10.4 mm preoperatively to 7.6 mm postoperatively. Eleven of 12 patients demonstrated 2 mm or more improvement in 2-point discrimination postoperatively. There were no complications related to the use of the porcine extracellular matrix for nerve wrapping. This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. Therapeutic IV.

Surgical treatment of chronic lower extremity neuropathic pain.

The current authors retrospectively reviewed 147 lower extremity peripheral nerve procedures in 114 patients (average age, 42 years) with chronic lower extremity neuropathic pain to determine whether surgical treatment based on an empirically derived algorithm could reduce pain and improve function. This algorithm assigns crush, stretch, and chronic transection injuries to treatment with transection and containment. Peripheral nerve stimulation was used in conjunction with transection and containment for patients with more chronic presentations for whom previous transections had been unsuccessful. Patients with adhesive neuralgia underwent revision neurolysis with vein wrapping. Patients with repetitive nerve trauma (overuse) underwent primary or revision neurolysis. Duration of symptoms averaged 37 months, and mechanisms of nerve injury included chronic transection, crush, adhesive neuralgia, stretch, repetitive trauma, and idiopathic etiology. Time to followup averaged 38 months. Pain and dysfunction were ranked from 0 points (no pain or dysfunction) to 10 points (pain prompting request for amputation or functional deficit warranting wheelchair use); preoperative and followup work status were documented. Average pain and dysfunction scores improved: 8.8 to 5.6 points and 7.6 to 5.0 points, respectively. Of the 114 patients, 52 (46%) patients improved their work status, including 35 of 87 (40%) involved in workers' compensation. There were no statistically significant differences in outcome based on mechanism of nerve injury or type of procedure. The consistent average improvement suggests this algorithm assigns the appropriate procedure to a given mechanism of injury.

Peripheral nerve vein wrapping for intractable lower extremity pain.

The purpose of this study was to determine the effectiveness of lower extremity peripheral nerve vein wrapping procedures in the management of patients with intractable lower extremity pain. The hypothesis was that nerve insulation through vein wrapping is effective in treating symptoms related to adhesive neuralgia, but not those secondary to intraneural damage. We retrospectively reviewed 25 consecutive patients whose intractable chronic lower extremity peripheral neuralgia had been treated with revision neurolysis and vein wrapping. The 14 women and 11 men had an average age of 39 years (range, 21 to 53 years). Vein wrapping was performed using a saphenous vein autograft in 19 patients and a fetal umbilical vein in six patients. The average length of follow-up after vein wrapping was 24 months (range, 12 to 63 months). Assessment of pain and dysfunction was on a scale of 0 (no pain/dysfunction) to 10 (severe enough to prompt request for amputation and required use of a wheelchair). Pain scores improved from a preoperative average of 8.7 points (range, 6 to 10 points) to a postoperative average of 4.6 points (range, 0 to 10 points); dysfunction improved from a preoperative average of 7.3 points (range, 3 to 10 points) to a postoperative average of 4.4 points (range, 0 to 9 points). Although 17/25 patients were satisfied with the procedure, only 14/25 stated they would undergo the surgery again. All eight patients who exhibited no improvement had preoperative and intraoperative evidence of an idiopathic etiology and/or intraneural damage. Preoperatively, 18/25 patients could not work; postoperatively, that number improved to 8/25. Vein wrapping of lower extremity peripheral nerves is most effective in relieving symptoms related to adhesive neuralgia and less beneficial in the presence of intraneural damage. Although symptoms are rarely relieved completely, vein wrapping typically results in a substantial improvement in symptoms related to scar entrapment of peripheral nerves.