Vein Wrapping for Recurrent Carpal Tunnel Syndrome

Fig. 21.1

The median nerve has been exposed at the wrist. Note the excessive cicatrix (black arrows) around the median nerve

The greater saphenous vein graft is harvested from the ipsilateral or contralateral lower extremity. The vein graft can be harvested with a vein stripper to minimize the length of the incision and the morbidity of the donor site (Fig. 21.2a, b). A longitudinal incision (approximately 2 cm long) is made 1 cm anterior to the medial malleolus, and the greater saphenous vein is identified. Care is taken to avoid injury to the associated saphenous nerve. The saphenous vein is ligated distally, and a small longitudinal phlebotomy is made. The vein stripper is introduced through the phlebotomy and is advanced proximally within the vein. The vein stripper guide can be palpated through the skin, as it is advanced to the predetermined length. At that point, a second incision is made over the stripper proximally, and the vein is ligated proximally. The vein stripper guide is advanced out of the vein through a second longitudinal phlebotomy. The vein graft is retrieved by slowly pulling out the stripper. The skin is closed and the leg tourniquet is deflated. Alternatively, the vein can be harvested through a continuous incision or interrupted incisions and dissection without the use of a vein stripper.

Fig. 21.2

(a) Harvesting of greater saphenous vein graft in the lower extremity using a vein stripper (K knee, MM medial malleolus). (b) Greater saphenous vein graft

The vein graft is incised and opened longitudinally (Fig. 21.3a). With the intima of the vein graft against the nerve , the vein graft is wrapped carefully around the scarred segment of the median nerve (Fig. 21.3b). One of the ends of the graft is tacked distal to the scarred segment of the nerve on an immobile tissue. The vein graft is circumferentially wrapped around the exposed median nerve from distal to proximal. Each loop of the vein is loosely tacked to adjacent loop using a 7–0 Prolene stitch (Fig. 21.4). Wrapping should not be too snug. The other end of the vein graft is tacked proximal to the scarred segment of the nerve on unscarred tissue. During the wrapping procedure, care is taken to avoid nerve traction or suture of the vein to the median nerve. It is important for the entire segment of the scarred median nerve to be completely covered with the vein graft to prevent recurrence of the scarring (Fig. 21.5). The tourniquet is deflated, meticulous hemostasis is obtained, and routine closure is performed.

Fig. 21.3

Schematic of vein wrapping technique. (a) The saphenous vein graft is split longitudinally and is open to create a rectangle. (b) The saphenous vein graft is then wrapped around the scarred segment of the nerve with its intima against the nerve

Fig. 21.4

The autologous vein graft is wrapped around the scarred segment of the median nerve in a distal to proximal direction with its intima against the nerve. Each ring of the wrapped vein is tacked to the adjacent rings with a 7–0 Prolene stitch

Fig. 21.5

The autologous vein graft is covering the entire scarred segment of the median nerve

Postoperatively, the wrist is immobilized in slight extension for 2 weeks, and active and passive range of motion exercises are followed. Additionally, scar massage, desensitization, and strengthening exercises can also be initiated, if required. Heavy lifting is to be avoided for 6 weeks after surgery.

Clinical Data

The use of the autologous vein wrapping as a supplementary technique to treat recurrent carpal tunnel syndrome secondary to cicatrix of the median nerve has been showed to be an effective treatment method in several clinical studies [16, 21–23]. Improvement of the pain and sensation were significantly noted in the majority of patients with recalcitrant carpal tunnel syndrome after autologous vein wrapping of the previously scarred median nerve. The grip strength and two-point discrimination were also improved postoperatively. Follow-up electrodiagnostic studies in several patients revealed improvement in motor and sensory nerve conduction velocities, although they did not return to normal values. The procedure was well tolerated in most individuals, and no complications due to the saphenous vein graft harvesting were noted except transient leg swelling at the donor site that resolved in approximately 6 months.

Since the original clinical series, consistently good results with the autologous vein wrapping technique have been noted in more than 100 patients with recurrent carpal tunnel syndrome and severe median nerve scarring in the senior author’s (D.G.S.) personal series.

Based on the senior author’s (D.G.S.) clinical experience, repeated median nerve decompression should always be performed in combination with an ancillary technique to enhance scar-free healing of the nerve. For patients with recalcitrant carpal tunnel syndrome, multiple operations and excessive scarring of the nerve, we perform revision decompression, repeated neurolysis of the median nerve (external as well as possible internal) with autologous vein wrapping of the median nerve and coverage with hypothenar fat pad flap .

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