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N
erve entrapment syndromes are common. cases. Current controversies on the two most
They are seen more frequently and better common upper extremity compression neuropa-
understood in the upper extremity, with the thies, carpal tunnel syndrome and cubital tunnel
prevalence of carpal tunnel syndrome estimated syndrome, are reviewed; however, it is important
to be as high as 3.72 percent in the United States.1 to recognize that the same principles of patho-
A wide variety of medical specialists evaluate and physiology, diagnosis, and management apply to
manage patients with compression neuropathies, the less common nerve compression syndromes,
including primary care providers, neurologists, including ulnar nerve compression at the Guyon
plastic surgeons, orthopedic surgeons, neurosur- canal, median nerve compression in the forearm,
geons, and general surgeons (See Video, Sup- and radial tunnel syndrome.
plemental Digital Content 1, which presents an
update on nerve entrapment to accompany this
PATHOPHYSIOLOGY OF CHRONIC
CME article, available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or NERVE COMPRESSION
at http://links.lww.com/PRS/B166.) Increased pressure on a nerve compresses
Individuals treating nerve compression must the neural microvasculature and alters the blood
be aware of the pathophysiology of chronic nerve flow dynamics. High pressures can lead to epineu-
compression and how it is different from other rial arterial ischemia. Lower pressures result in
neurologic problems. It is also critical to under-
stand the appropriate workup for a patient pre- Disclosure: Dr. Mackinnon is the co-inventor of the
senting with a nerve entrapment syndrome. This Synovis PGA Neurotube and has received research
article discusses these issues and provides an funding from AxoGen. None of the other authors has
evidence-based review of several controversial a financial interest in any of the products, devices, or
topics in nerve compression regarding the sur- drugs mentioned in this article.
gical management of primary cases and revision
From the Division of Plastic and Reconstructive Surgery, Related Video content is available for this
Washington University School of Medicine. article. The video can be found under the
Received for publication April 30, 2014; accepted June 26, “Related Videos” section of the full-text article,
2014. or, for Ovid users, using the URL citation pub-
Copyright © 2014 by the American Society of Plastic Surgeons lished in the article.
DOI: 10.1097/PRS.0000000000000828
www.PRSJournal.com 199e
Plastic and Reconstructive Surgery • January 2015
impaired venous outflow, which leads to venous leading to fibrosis that ultimately results in nerve
stasis. This can cause capillary leakage, intraneural compression and ischemia.7
and extraneural edema, and further intraneural There is substantial evidence to support an
pressure. Consequences of chronic compression association between certain work activities and
can then include inflammation, fibrosis, demyelin- carpal tunnel syndrome. In a cross-sectional study
ation, and ultimately axonal loss. The relationship of the relationship between repetitive work and
between compression pressure and axonal degen- the prevalence of upper limb musculoskeletal
eration appears to follow a dose-response pattern.2 disorders, Latko et al. observed this association,
There are two key differences in the patho- with an odds ratio of 3.11 for high versus low rep-
physiology of acute versus chronic nerve compres- etition.8 Occupational exposure to vibration has
sion injuries. The first is that the pathophysiology also demonstrated a strong association with car-
of chronic nerve compression injury is indepen- pal tunnel syndrome, with an odds ratio of 4.3.
dent of axonal damage.3 Instead, decreased nerve This odds ratio increases to 16.0 with more than
conduction observed in chronic nerve com- 20 years of occupational exposure to vibrating
pression is understood to be the result of demy- hand tools.9
elination followed by remyelination.4,5 Axonal
integrity is preserved until much later in the dis-
ease process, when motor atrophy is clinically HISTORY AND PHYSICAL
appreciable. Second, Schwann cell proliferation EXAMINATION
in chronic nerve compression injury is indepen- Nerve entrapment syndromes have tradi-
dent of macrophages, and induced by mechanical tionally been considered a clinical diagnosis. A
forces.3 In addition to this proliferative response, detailed history can reveal sensory disturbances,
extensive Schwann cell apoptosis occurs. A 2003 motor dysfunction, and pain. Important features
in vitro model by Gupta and Steward confirmed from the history include onset and duration of
induction of Schwann cell turnover with mini- symptoms, characteristics of sensory disturbance,
mal axonal injury, supporting the concept that anatomical distribution, alleviating and aggravat-
chronic compressive mechanical stimuli have a ing factors, and the presence of nocturnal symp-
direct mitogenic effect on Schwann cells.6 toms, associated motor dysfunction, weakness or
Several systemic conditions have been impli- clumsiness, and pain. The history is often very
cated in the development of nerve compression helpful, as nighttime wakening and relief of noc-
syndromes, including diabetes, thyroid disease, turnal paresthesia with “shaking the hand” is typi-
heavy alcohol use, generalized edema, and sys- cal of carpal tunnel syndrome. Pain with overhead
temic inflammatory disease. Repetitive activities activities, makeup application, hair grooming,
involving the wrist or fingers have received much and driving associated with paresthesias suggests
attention, with some hypothesizing that idio- more proximal issues of thoracic outlet syndrome
pathic carpal tunnel syndrome is the result of and muscle imbalance around the shoulder. On
shear injury to the subsynovial connective tissue, every visit, we have patients complete our pain
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Fig. 1. Pain evaluation used in the assessment of all patients with nerve injuries. Modified by
Mackinnon SE and Novak CB, 2001, from Hendler N, Viernstein M, Gucer P, Long D. A preoperative
screening test for chronic back pain patients. Psychosomatics 1979;20:801–808; Mackinnon SE,
Dellon AL. Surgery of the Peripheral Nerve. Thieme Medical Publishers, 1988; and Melzack R. The
McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975;1:277–299.
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Fig. (Continued)
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evaluation. The patient’s drawings frequently help diagnosis and electrodiagnostic findings will be
determine the diagnosis and associated proximal managed very differently, depending on associ-
shoulder issues. Patients with an identical referral ated issues (Fig. 1).
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Table 1. Common Provocative Tests for Various Nerve Entrapment Syndromes of the Upper Extremity*
Nerve Site of Entrapment Provocative Test
Median nerve Carpal tunnel Phalen test (wrist hyperflexion), reverse Phalen test (wrist hyperextension),
Durkan test (wrist hyperflexion with direct pressure over the carpal tunnel)
Median nerve Proximal volar Resisted elbow flexion, pronation, and finger flexion; direct pressure over
forearm the proximal, volar forearm near the pronator teres with the forearm in
supination
Ulnar nerve Guyon canal Wrist hyperextension, direct pressure over Guyon canal
Ulnar nerve Cubital tunnel Elbow flexion test, elbow flexion with direct pressure over the cubital tunnel
Radial sensory nerve Dorsal forearm Resisted forearm pronation with wrist in ulnar flexion with or without pres-
sure over the entrapment point
Posterior interosseous Arcade of Frohse Resisted forearm supination, resisted long finger and wrist extension, direct
nerve pressure over the dorsal forearm near the supinator muscle
Brachial plexus Supraclavicular Elevation of arms above the head, direct pressure over the brachial plexus in
the interval between the anterior and middle scalene muscles
*Common provocative tests for various nerve entrapment syndromes of the upper extremity. The Tinel sign and the scratch collapse test can
also be used in the assessment of each of these syndromes. (Adapted from Mackinnon S, Novak C. Compression neuropathies: Compression
of the ulnar nerve–cubital tunnel syndrome. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed.
Philadelphia: Elsevier; 2011. Reproduced with permission from Elsevier.)
The physical examination should involve a noninvasive. The technique is well described and
complete assessment of the involved extremity, can be used to identify single and multiple sites of
the contralateral limb, and the cervical and/or nerve compression or injury (Reference 10 Level
lumbar spine. We always examine the patient’s of Evidence: Diagnostic, IV).10,11 The sensitivity
scapular movement and evaluate for shoulder and specificity of the test compare favorably with
abnormality. The examiner should look for signs the other known provocative tests for carpal tun-
of chronic denervation of the skin; muscle atro- nel syndrome, cubital tunnel syndrome, and com-
phy; and abnormal postures of the hand, elbow, mon peroneal nerve compression at the fibular
and shoulders. Objective assessment includes neck.10,12 Since its first description in the literature,
light touch, two-point discrimination, baseline several refinements in the scratch collapse test have
pinch strength, grip strength, and British Medi- been identified. The most important refinement is
cal Research Council grading of involved muscles. the use of topical ethyl chloride (Gebauer’s Ethyl
Provocative tests are key to the examination and Chloride; Gebauer Company, Cleveland, Ohio) to
can broadly be categorized into the Tinel sign, detect multiple sites of concomitant compression.
various compression and positional maneuvers, After identification of the primary site of compres-
and the scratch collapse test (Table 1). Our physi- sion, topical ethyl chloride is applied to the skin to
cal examination worksheet is completed on all temporarily eliminate that site and unmask a poten-
patients. A visual of this sheet quickly lets the sur- tial secondary site of nerve entrapment. Each sub-
geon note the patient’s various physical findings sequent site can be eliminated in this manner to
(see Appendix, Supplemental Digital Content 2, identify a hierarchy of nerve compression sites. It
which provides the physical evaluation worksheet, is also positive when there is periscapular muscle
http://links.lww.com/PRS/B167). This evaluation of imbalance. The identification of this hierarchy is
all potential points of nerve compression, muscle not license to operate on each of these entrapment
imbalance, tendinitis, and cervical disk disease is points, but does provide the surgeon a complete
especially important in patients with diffuse symp- understanding of the patient’s clinical picture,
toms and normal electrodiagnostic studies. If most helping to guide the appropriate use of surgical and
of the patient’s symptoms relate to one entrap- nonsurgical treatment modalities. In general, we
ment point and electrodiagnostic tests are posi- will leave any surgical considerations until all con-
tive, evaluation and treatment are simple. It is the servative management has been exhausted (Fig. 2).
patient with normal studies and diffuse symptoms Electrodiagnostic studies are conventionally
that is the challenge. These patients can only be used to diagnose compression neuropathies but
managed successfully when all diagnoses are evalu- should be considered more of a confirmatory/
ated and treated conservatively, with surgery care- adjunctive modality, or a means of excluding
fully directed after physical therapy and correction other abnormality. In fact, some authors sup-
of postural poor “habits” have been addressed. port the surgical management of compression
The scratch collapse test is a recently described neuropathies without electrodiagnostic studies,
provocative test that is simple, painless, and with demonstration of good outcomes in patients
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Fig. 2. Scratch collapse test. The patient faces the examiner with the arms adducted, elbows
flexed, and hands outstretched with the wrists at neutral. (Left) Step A: The patient resists bilateral
shoulder adduction/internal rotation to the forearms applied by the examiner. (Center) Step B:
Next, the examiner “scratches” or swipes with fingertips over the course of the compressed nerve
(ulnar nerve at the elbow is illustrated). (Right) Step C: Step A is repeated immediately. Brief tem-
porary loss of the patient’s external resistance tone is considered a positive scratch collapse test.
(From Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evalua-
tion of carpal and cubital tunnel syndrome. J Hand Surg Am. 2008;33:1518–1524.)
foregoing this diagnostic tool.13 We obtain electro- Although peripheral nerve imaging can also
diagnostic studies when recommending surgical be used to confirm a clinical diagnosis of compres-
decompression to stage the degree of nerve injury. sion, we order this only when the presentation
This allows us to anticipate the rate of recovery is atypical or technical limitations to electrodi-
and educate patients on when they should expect agnostic studies exist. Imaging modalities are
recovery. In addition, we will obtain studies if noninvasive and readily available but costly and
there is suspicion of a diagnosis other than com- rarely necessary with chronic nerve compression
pression neuropathy, such as cervical disk disease. injuries. Magnetic resonance imaging is capable
If the patient’s presentation is of significant motor of demonstrating pathologic features of compres-
loss with relatively intact sensation, an electromyo- sion neuropathy in both the upper and lower
gram will always be obtained to rule out more con- extremities with great detail.15,16 High-resolution
cerning central diagnoses such as motoneuron ultrasonography is a more cost-effective imaging
disease and amyotrophic lateral sclerosis (Fig. 3). modality and is capable of demonstrating real-time
Nerve conduction studies provide useful static and dynamic anatomy of peripheral nerves
information regarding sensory and motor nerve and their surrounding soft tissues.17 The ultraso-
latency, amplitude, and conduction velocity, nographic hallmark of compression neuropathy
which are features important in nerve entrapment is hypoechoic swelling of the nerve just proximal
syndromes. Electromyography is typically used to the site of compression.18 Ultrasound can also
to identify significant features of noncompres- be used to identify other peripheral nerve abnor-
sion nerve injury, including insertional activity, malities including neuromas and space-occupying
fibrillation potentials, and motor unit potentials. lesions.19 For example, if a diagnosis of motor
However, electromyography can be useful in nerve compression at the Guyon canal is made in
compression neuropathies, where it can demon- isolation of any other compressive ulnar neuropa-
strate a particular distribution of abnormality and thy, magnetic resonance imaging or ultrasonogra-
in severe compression neuropathy with axonal phy should be ordered to evaluate for a lipoma or
injury. Examples include differentiating between ganglion. Currently, however, there is no standard
lesions of the proximal median nerve versus ante- protocol for ultrasound assessment of peripheral
rior interosseous nerve, proximal radial nerve ver- nerves regarding type of transducer, frequency, or
sus posterior interosseous nerve, and sciatic nerve technique, and ultrasonography remains opera-
versus S1 lesions.14 tor dependent.
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Fig. 3. Expected rate of recovery following nerve decompression depending on degree of nerve injury. (Above)
With dynamic ischemic injury, full functional nerve recovery is expected immediately. (Second row) With a demy-
elination injury, full or nearly full functional nerve recovery is expected in 3 to 4 months. (Third row) With an axonal
injury, functional nerve recovery is expected at the rate of nerve regeneration, requiring approximately 1 mm/
day. (Below) With a mixed nerve injury, functional nerve recovery follows a superimposed pattern of recovery seen
in above, second row, and third row.
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Fig. 4. Multiple sites of potential compression along the course of the ulnar nerve, including the arcade of Struthers, medial intermuscular septum, medial epicondyle, Osborne
ligament (tendinous leading edge of the flexor carpi ulnaris), antebrachial fascia, Guyon canal, and leading edge of the hypothenar musculature (deep motor branch of the ulnar
nerve).
Plastic and Reconstructive Surgery • January 2015
Volume 135, Number 1 • Nerve Entrapment Update
both thoracic outlet syndrome and cubital tunnel effects and complications in patients undergoing
syndrome, performing the distal cubital tunnel a carpal tunnel release. Primary results did not
operation before the thoracic outlet syndrome demonstrate superior relief of short- or long-term
decompression may provide sufficient relief of symptoms from endoscopic release. Only three
clinical symptoms without exposing the patient to studies reported an earlier return to work or activ-
the increased risk of the thoracic outlet syndrome ities of daily living for endoscopic release, with a
surgery. It will also allow more adequate time to weighted mean difference of 6 days. Six studies
conservatively manage the thoracic outlet syn- showed a higher relative risk of requiring revision
drome condition with physical therapy and other surgery in the endoscopic group. The authors
nonsurgical means. ultimately conclude that there is no strong evi-
dence supporting the need for replacement of the
standard open technique by existing alternative
CARPAL TUNNEL RELEASE UNDER techniques. Furthermore, the decision to apply
LOCAL ANESTHESIA endoscopic techniques seems to be guided by sur-
Surgical carpal tunnel decompression can be geon and patient preference.31
performed in one of several settings, including A 2004 meta-analysis of 13 randomized con-
the office, ambulatory clinic, and main operating trolled trials comparing endoscopic and open car-
room. In response to their health care system, a pal tunnel release surgery reported that patients
2007 Canadian study reported that the majority of who underwent endoscopic release had improved
carpal tunnel release operations are performed in pinch and grip strength at 12 weeks postopera-
the ambulatory setting with field sterility and local tively, but were three times more likely to incur a
anesthesia and without the need for an anesthesia reversible nerve injury (i.e., neurapraxia). Again,
provider. In addition, they demonstrated that car- the data regarding symptom relief were inconclu-
pal tunnel release surgery performed in the main sive (Level of Evidence: Therapeutic, II).32
operating room is four times as expensive and less Regardless of technique selected, anatomical
than half as efficient as the same operation per- variations in median nerve anatomy have been
formed in the ambulatory setting.29 documented in both clinical and cadaveric stud-
A similar cost-analysis study was conducted in ies.33,34 Iatrogenic median nerve injury can occur
the United States in 2011. The cost analyses for with both endoscopic and open techniques, and
both endoscopic and open carpal tunnel releases surgeons must be aware of these potential ana-
performed at a tertiary care academic center calcu- tomical variations to perform this operation
lated net revenues, profit margins, and efficiency. safely. An iatrogenic injury to the median nerve is
Like its Canadian counterpart, this study reported typically life altering to the patient and their fam-
that either endoscopic or open carpal tunnel ily. Thus, our position on carpal tunnel release
decompression performed in the main operating surgery has always been firmly in the camp of
room is more expensive and less efficient.30 open decompression (our preferred technique
With the rising costs of health care, there will for open carpal tunnel release can be viewed at
be greater focus in all surgical sectors to reduce https://vimeo.com/64551425 for the standard
costs and increase efficiency. Carpal tunnel release version and https://vimeo.com/64551423 for the
surgery in the ambulatory setting will undoubt- extended version).
edly be looked at more closely in the future to Endoscope-assisted decompression has not
help achieve this goal. been restricted to carpal tunnel surgery alone.
Several studies have now been published regard-
ing the use of endoscopy in the surgical manage-
ENDOSCOPIC VERSUS OPEN CARPAL ment of cubital tunnel syndrome.35–40
TUNNEL RELEASE Tsai et al. first described the technique in
The most common peripheral nerve surgery, 1995, and there have been many variations on the
carpal tunnel decompression, continues to be technique since that time.41 The majority of stud-
controversial regarding the optimal technique for ies to date report good outcomes regarding sen-
surgical release of the transverse carpal ligament. sory improvement, grip strength measurements,
In 2009, the Cochrane Collaboration published a and increased conduction velocity in postopera-
review of 33 studies regarding the efficacy of vari- tive nerve conduction studies.42–44
ous surgical techniques in relieving symptoms and The concern raised from surgeons who per-
promoting return to work or activities of daily liv- form open ulnar nerve surgery at the elbow is the
ing. They also compared the occurrence of side risk of hematoma, injury to the medial antebrachial
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Plastic and Reconstructive Surgery • January 2015
cutaneous nerve, injury to the ulnar nerve or flexor The concern regarding disruption of neural
carpi ulnaris branches, and incomplete release of blood supply with nerve mobilization, however,
all potential points of compression. To date, there has been refuted. As early as 1975, Lundborg con-
is still a need for more well-designed, head-to-head cluded that nerves could be elevated over a long
trials to definitively compare the efficacy of endo- length and maintain circulation.49 More recently,
scopic versus open cubital tunnel surgery. animal studies have also demonstrated that the
mobilization of a nerve with only its proximal and
distal intrinsic blood flow intact actually results in
BEST OPERATION FOR PRIMARY increased blood flow to the nerve.50
CUBITAL TUNNEL SYNDROME Proponents of the ulnar nerve transposition,
Several different surgical techniques for treat- however, believe that in situ decompression is
ment of ulnar nerve compression at the elbow have not enough to adequately address the significant
been described and recommended, with continued role that tension and traction play in the cause
controversy regarding the optimal surgical manage- of cubital tunnel syndrome when the elbow is in
ment of this condition. Surgical treatment options a flexed position.51,52 It has also been reported
are discussed with emphasis related to what occurs that an anterior transposition may be a more
at the medial epicondyle. The procedures include reliable means of decompressing all potential
medial epicondylectomy, submuscular transposi- sites of ulnar nerve entrapment.53 In managing
tion, intramuscular transposition, subcutaneous subluxation of the ulnar nerve at the elbow asso-
transposition, open in situ decompression, and ciated with ulnar neuropathy, several authors
endoscopic in situ decompression. At the center of recommend a transposition procedure to miti-
the controversy is whether a transposition procedure gate nerve irritation caused by translation of the
is necessary over a simple in situ decompression. nerve across the medial epicondyle.44,54,55 The
Despite several recent efforts to determine review by Goldfarb et al. on in situ decompres-
one “best” operation for primary cubital tunnel sion demonstrated a 7 percent recurrence rate
syndrome, the startling truth is that as a profes- with a mean follow-up of 4 years; all of those
sion we have not yet come to a consensus. We sug- patients underwent a secondary anterior trans-
gest that the emphasis placed on what is occurring position operation.56 Perhaps with longer follow-
at the medial epicondyle distracts the surgeon up, that 7 percent may increase.
from what the pearls are in managing compres- To date, most comparative studies have demon-
sion along the entire course of the ulnar nerve.45 strated equivalent outcomes. A 2008 meta-analysis
Surgeons reporting excellent results with their of all randomized controlled trials and comparative
“technique” are likely choosing the appropriate observational studies comparing simple decom-
patient and attending to the technical principles pression with anterior transposition (subcutane-
of not injuring the medial antebrachial cutaneous ous or submuscular) did not report a statistically
nerve or causing any new compression points any- significant difference; instead, a trend in favor of
where along the length of the nerve. improved clinical outcome with transposition of
We suggest that there is no single best proce- the ulnar nerve over in situ decompression was
dure, and that is why a consensus regarding the reported. A subanalysis comparing subcutaneous
best operation will not be found. However, there and submuscular transposition did not demonstrate
is a caveat with this statement. The follow-up for a statistically significant difference in outcomes.57
recurrence rates is probably much longer than the An evidence-based review of ulnar neuropathy
traditional patient follow-up allows. The compres- at the elbow by Chung concluded that there is no
sion procedures may, with a longer follow-up, show single best surgical procedure for management of
recurrence because of the “untreated” persistent cubital tunnel syndrome.58 The author reported
tension on the nerve associated with elbow flexion. that the literature has yet to identify an inferiority
Proponents of the in situ decompression of in situ decompression compared with transpo-
believe that technique to have several advantages sition surgery, and has even changed his practice
over transposition procedures. In situ decom- in favor of simple decompression. However, we
pression is a technically simpler operation that have had excellent success with our transmuscu-
addresses the primary pathophysiologic factor of lar transposition and plan to continue this prac-
compression. It poses a smaller risk of disrupting tice (our preferred technique can be viewed at
extraneural blood supply, has a lower risk of post- https://vimeo.com/40013470 for the standard
operative complications, and allows for a faster version and https://vimeo.com/40022250 for the
recovery and rehabilitation.46–48 extended version).
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Regardless of the specific technique selected When new symptoms occur following surgical
for the surgical management of cubital tunnel treatment of compression neuropathy, such as new
syndrome, it is critical that certain principles are pain, new numbness, and/or new weakness, the
adhered to. It is important to avoid injury to all surgeon should have a high index of suspicion for
branches of the medial antebrachial cutaneous iatrogenic injury and neuroma formation in super-
nerve to prevent neuroma formation. All potential ficial sensory nerves (e.g., medial antebrachial cuta-
sites of ulnar nerve compression around the elbow neous nerve with cubital tunnel surgery, palmar
should be explored and released. If a transposition cutaneous branch of the median nerve in carpal
procedure is selected, ensure that new kink points tunnel surgery), injury to the primary nerve being
are not created at the proximal and distal transpo- decompressed (e.g., superficial fascicles of the
sition points. Equally important to direct manage- median nerve or common digital nerve to the third
ment of ulnar nerve compression at the elbow is webspace in carpal tunnel surgery), or development
appropriate treatment of secondary sites of com- of complex regional pain syndrome. Each of these
pression. This may include a distal Guyon canal conditions will involve new or worsening symptoms
release, flexor digitorum profundus tenodesis, unique from the primary entrapment syndrome.
supercharging end-to-side anterior interosseous–to– In addition, an array of nonneurologic condi-
ulnar nerve transfer, and/or physical therapy for tions should be considered, including rotator cuff
thoracic outlet syndrome and scapular dyskinesis.59 syndrome, medial or lateral epicondylitis of the
elbow, bursitis, and various tendinopathies. Fre-
The anterior transmuscular transposition technique
quently, pain in the hand from one problem will
and important ancillary procedures are described in
be associated with a posture of “protection” that
detail at www.nervesurgery.wustl.edu.
can result in secondary cubital tunnel or thoracic
outlet syndrome with shoulder postures, leading
REVISION SURGERY to scapular abduction and weakness.
Recurrent or persistent peripheral nerve com- In general, the surgical management of per-
pression can be a difficult diagnosis to confirm sistent or recurrent peripheral nerve compression
and an even more challenging condition to man- requires a more aggressive surgical approach to
age. A detailed history and physical examination address the underlying cause.62,63 More extensive
are critical to making the diagnosis, as electrodi- dissection is important to move from normal nerve
agnostic studies can remain abnormal for some to injured nerve to ensure safe dissection through
time following surgical decompression, even with scar tissue that may be causing recurrent compres-
clinical resolution of symptoms.60 By contrast, sion or traction neuropathy.64,65 Complete visualiza-
electrodiagnostic studies can be normal if the tion and release of all potential sites of residual or
new compression is critical. Neuromas of superfi-
main problem is, for example, scar and “kinking”
cial sensory nerves also require adequate exposure
of an otherwise normal nerve in an ulnar nerve
to appropriately manage. After identification of
transposition, or pain from a neuroma of a super-
the neuromatous nerve, a proximal second-degree
ficial sensory nerve. This is because small C and A crush injury is induced as far proximal as possible
delta nerve fibers that transmit pain to the brain on the cutaneous nerve. This second-degree injury
are not detectable by electrodiagnostic studies. sets the nerve regeneration as far away from the
A simple classification has been described for neurectomy site as possible to give the brain time to
secondary nerve compression, dividing presenta- “reset.” This is followed by nerve transection, elec-
tions as persistent, recurrent, or new symptom trocautery capping of the nerve end, and proximal
conditions. The patient’s history will determine transposition in a deep muscle plane.
the classification. In revision carpal tunnel surgery, incomplete
In persistent entrapment syndromes, the release of either the distal transverse carpal liga-
patient will not report any improvement in symp- ment or proximal antebrachial fascia is the most
toms following their primary operation. This common intraoperative finding (Level of Evi-
condition occurs because of incomplete surgical dence: Therapeutic, IV).66 Scarring of the median
release of the compression or an incorrect initial nerve to overlying structures and iatrogenic injury
diagnosis. In recurrent entrapment syndromes, to the median nerve or its branches are also com-
the patient will have had a period of symptomatic mon findings in revision carpal tunnel surgery,
relief postoperatively before a return of symptoms. with the latter being more common in patients
This condition occurs because of scarring, trac- presenting with new symptoms. Our approach
tion neuropathy, or new points of compression.61 to revision carpal tunnel release can be viewed at
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Fig. 5. Supercharged end-to-side anterior interosseous nerve–to–deep motor fascicle of ulnar nerve transfer. (Above) Relevant
nerve anatomy important to this transfer. (Below) Anterior interosseous nerve (green) transected just proximal to its point of inner-
vation to the pronator quadratus muscle, transferred end-to-side into the motor component of the ulnar nerve (red). Functioning
motor nerve fibers will now regenerate down the path of the motor component of the ulnar nerve (following the yellow arrow).
Table 2. Indications for Supercharged End-to-Side supercharged end-to-side transfer of flexor digito-
Nerve Transfer for Ulnar Intrinsic Atrophy rum superficialis to posterior interosseous nerve,
and triceps branches of the radial nerve or medial
Axonotmetic injuries (Sunderland II and III)
Severe cubital tunnel syndrome pectoral nerve to the axillary nerve for compres-
Failed cubital tunnel surgery sion in the quadrangular space. Although end-
C8–T1 nerve root injury to-end nerve transfer is indicated in fourth- to
Brachial plexus medial cord traction injury
Brachial plexus neuritis (Parsonage-Turner syndrome) fifth-degree injuries, the supercharged end-to-
Primary motor neuropathy (e.g., Charcot-Marie-Tooth) side transfer may find its place in the far more
Neurotmetic injuries (Sunderland IV and V)
Proximal to elbow with Martin-Gruber anastomosis common Sunderland second- and third-degree
Injury between elbow and 10 cm proximal to the wrist neuropathies, with the accepted donors for an
end-to-end transfer being used for the super-
charged end-to-side coaptation.76
nerve transfer was designed for in-continuity inju-
ries of the ulnar nerve, we believe that the super-
charged end-to-side procedure might have broad SUMMARY
clinical applicability for severe compression neu- Nerve entrapment syndromes are common
ropathy of other motor nerves. Application of in the general population and are managed by a
this technique can be used to augment partial wide variety of medical and surgical specialists. A
recovery and/or preserve motor endplates until thorough understanding of the pathophysiology of
the native axons within that nerve regenerate to nerve compression and appropriate clinical workup
the motor endplate. The supercharged end-to- are critical in the overall management of these
side nerve transfer technique could conceptually conditions. There remain several topics of contro-
apply in all scenarios of compression neuropathy versy regarding the surgical management of nerve
in which native axonal regeneration may eventu- entrapment syndromes, including multiple points
ally occur. Proposed options may also include a of nerve compression, carpal tunnel release under
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Plastic and Reconstructive Surgery • January 2015
local anesthesia, open versus endoscopic decom- where, and how to see the peripheral nerves on the muscu-
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