Sokratis E. Varitimidis, Dean G. Sotereanos Introduction
Entrapment neuropathies are common entities in surgery of the upper extremity. The gold standard for operative treatment in this condition is surgical decompression of the entrapped nerve. Releasing the transverse ligament at the volar surface of the wrist for carpal tunnel syndrome and decompressing the ulnar nerve at the elbow for cubital tunnel are generally procedures with very satisfactory outcome. Despite the high success rates reported in the literature, recurrence of the compression is not uncommon.
If primary decompression was adequate, the reasons for failure include cicatrix formation and adhesion of the nerve with the surrounding tissue.
Management of recurrent entrapment neuropathies is difficult and controversial. Repeated nerve decompression, alone or accompanied by external or internal neurolysis, does not always relieve symptoms. Reports in the literature describe supplementary procedures in the revision setting such as the covering of nerve with muscle flap, fat flap, fascia flap, or even vascularized omentum.
The outcome of these procedures is generally unpredictable, and some techniques are associated with concomitant morbidity.
Masear et al1 reported the technique of using venous wrapping of nerves to prevent scarring for severe and recurrent nerve compression. In their clinical study, both autograft and allograft of vein were used to wrap the median nerve after decompression. Their results showed marked improvement in pain. A remarkable absence of scarring around the vein graft was noticed during surgical exploration for secondary reconstruction in three patients. In 1991, Gould2 also described this technique for the treatment of the painful injured nerve in continuity. Koman et al3 evaluated the symptomatic and functional assessment of allograft umbilical vein wrapping for dystrophic median nerve dysfunction. Their encouraging results showed that wrapping the nerve with a vein graft following decompression can improve recovery of nerve function and be beneficial to patients with severe recurrent nerve compression.
Since 1993, we studied the effect of vein graft wrapping around peripheral nerves. Our project included both experimental and clinical studies.4
The experimental study was planned in two steps. The first part was to wrap a vein graft on normal sciatic nerves using a rat model. In this part we assessed the
Reconstructive Microsurgery, edited by Konstantinos N. Malizos. ©2003 Landes Bioscience.
effect of vein wrapping on normal nerves using electrophysiologic and histologic evaluation. In the second part of the experimental study we wrapped a vein graft around sciatic nerves in which previously we created compression and scarring. The sciatic nerve was later evaluated functionally and by electrophysiologic and histo-logic examinations. The results were very encouraging. Function of the sciatic nerve and electrophysiologic studies were improved and histologic examination showed that no scar tissue developed between the epineurium of the wrapped sciatic nerve and the intimal surface of the vein.5
Encouraged by the results of this study, we applied the vein wrapping technique to patients with recurrent compressive neuropathy of the median and ulnar nerves.
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