Management of Failed Carpal and Cubital Tunnel Release: An Evidence-Based Guide to Success

Abstract

Carpal tunnel and cubital tunnel syndromes are the most common compressive neuropathies of the upper extremity with surgical treatment having high success rates for both conditions. Although uncommon, persistent or recurrent carpal and cubital tunnel syndrome presents a challenge for patients and providers. Diagnosis of persistence versus recurrence of the pathology is key in establishing an appropriate treatment plan to provide the best possible patient outcomes. After an established diagnosis, a wide array of treatment options exist which varies based on previous procedures performed. This review discusses relevant anatomy, etiology, and clinical presentations of persistent and recurrent carpal and cubital tunnel syndromes. The range of treatment options is presented based on history and diagnostic findings. Treatment options span from revision of nerve decompression to the use of soft tissue rearrangement procedures. Some specific treatment options discussed include simple revision nerve decompression, external neurolysis, soft tissue rearrangement, such as the hypothenar fat flap or various transposition techniques, and the use of nerve wraps. Included is an evidence-based management guide for diagnosis and treatment of persistent versus recurrent carpal and cubital tunnel syndromes. Carpal tunnel and cubital tunnel syndromes are the most common compressive neuropathies of the upper extremity with surgical treatment having high success rates for both conditions. Although uncommon, persistent or recurrent carpal and cubital tunnel syndrome presents a challenge for patients and providers. Diagnosis of persistence versus recurrence of the pathology is key in establishing an appropriate treatment plan to provide the best possible patient outcomes. After an established diagnosis, a wide array of treatment options exist which varies based on previous procedures performed. This review discusses relevant anatomy, etiology, and clinical presentations of persistent and recurrent carpal and cubital tunnel syndromes. The range of treatment options is presented based on history and diagnostic findings. Treatment options span from revision of nerve decompression to the use of soft tissue rearrangement procedures. Some specific treatment options discussed include simple revision nerve decompression, external neurolysis, soft tissue rearrangement, such as the hypothenar fat flap or various transposition techniques, and the use of nerve wraps. Included is an evidence-based management guide for diagnosis and treatment of persistent versus recurrent carpal and cubital tunnel syndromes. Carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTS) are the first and second most common compressive neuropathies of the upper extremity. In the United States, the incidence of CTS has been estimated to be approximately 424 cases per 100,000 patients and between 1997 and 2010 was the second most common cause of days lost from the workplace.1American Academy of Orthopaedic Surgeonsmanagement of carpal tunnel syndrome evidence-based clinical practice guideline.https://www.aaos.org/globalassets/quality-and-practice-resources/carpal-tunnel/cts-cpg_4-25-19.pdfDate accessed: November 22, 2021Google Scholar There are approximately 75,000 new cases of CuTS reported annually2Aleem A.W. Krogue J.D. Calfee R.P. Outcomes of revision surgery for cubital tunnel syndrome.J Hand Surg. 2014; 39: 2141-2149Google Scholar with an incidence of approximately 20.9 cases per 100,000 patients.3Bartels R.H.M.A. Verbeek A.L.M. Risk factors for ulnar nerve compression at the elbow: a case control study.Acta Neurochir (Wien). 2007; 149: 669-674Google Scholar Carpal tunnel release (CTR) for addressing CTS is one of the most common procedures performed on the hand with a success rate between 80%–95%4Jansen M.C. Duraku L.S. Hundepool C.A. et al.Management of Recurrent carpal tunnel syndrome: systematic review and meta-analysis.J Hand Surg. 2022; 47: 338.e1-338.e19Google Scholar, 5Jørgsholm P. Flondell M. Björkman A. Thomsen N.O.B. Outcome of carpal tunnel release in patients with normal nerve conduction studies.J Orthop Sci. 2021; 26: 798-803Google Scholar, 6Louie D.L. Earp B.E. Collins J.E. et al.Outcomes of open carpal tunnel release at a minimum of ten years.J Bone Jt Surg Am. 2013; 95: 1067-1073Google Scholar and the success rate of decompression of the ulnar nerve at the elbow for CuTS is estimated to be between 65%–95%.2Aleem A.W. Krogue J.D. Calfee R.P. Outcomes of revision surgery for cubital tunnel syndrome.J Hand Surg. 2014; 39: 2141-2149Google Scholar,7Macadam S.A. Bezuhly M. Lefaivre K.A. Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature.J Hand Surg. 2009; 34: 1482-1491.e5Google Scholar Despite a relatively high success rate and generally overall improved outcomes in both conditions when treated surgically, recurrence rates following surgery for CTS are estimated to be approximately 7%–20% with between 3%–5% requiring revision surgery within a median time of 1.23 years.8Beck J.D. Brothers J.G. Maloney P.J. Deegan J.H. Tang X. Klena J.C. Predicting the outcome of revision carpal tunnel release.J Hand Surg. 2012; 37: 282-287Google Scholar, 9Cobb T.K. Amadio P.C. Reoperation for carpal tunnel syndrome.Hand Clin. 1996; 12: 313-323Google Scholar, 10Wadstroem J. Nigst H. Reoperation for carpal tunnel syndrome. A retrospective analysis of forty cases.Ann Chir Main Organe Off Soc Chir Main. 1986; 5: 54-58Google Scholar, 11Westenberg R.F. Oflazoglu K. de Planque C.A. Jupiter J.B. Eberlin K.R. Chen N.C. Revision carpal tunnel release: risk factors and rate of secondary surgery.Plast Reconstr Surg. 2020; 145: 1204-1214Google Scholar, 12Wessel L.E. Gu A. Asadourian P.A. Stepan J.G. Fufa D.T. Osei D.A. The epidemiology of carpal tunnel revision over a 1-year follow-up period.J Hand Surg. 2021; 46: 758-764Google Scholar Recurrence following cubital tunnel release (CuTR) is estimated at approximately 19%–25%,13Krogue J.D. Aleem A.W. Osei D.A. Goldfarb C.A. Calfee R.P. Predictors of surgical revision after in situ decompression of the ulnar nerve.J Shoulder Elbow Surg. 2015; 24: 634-639Google Scholar,14Lauder A. Chen C. Bolson R.M. Leversedge F.J. Management of recalcitrant cubital tunnel syndrome.J Am Acad Orthop Surg. 2021; 29: 635-647Google Scholar with a revision surgery rate between 3%–19% occurring at a median time of 10 months.13Krogue J.D. Aleem A.W. Osei D.A. Goldfarb C.A. Calfee R.P. Predictors of surgical revision after in situ decompression of the ulnar nerve.J Shoulder Elbow Surg. 2015; 24: 634-639Google Scholar,15Gaspar M.P. Kane P.M. Putthiwara D. Jacoby S.M. Osterman A.L. Predicting revision following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome.J Hand Surg. 2016; 41: 427-435Google Scholar Recurrence of both conditions following primary decompression has produced diagnostic and therapeutic challenges for patients and surgeons and has been shown to lead to poorer outcomes including but not limited to persistent pain, numbness/tingling, and loss of function with a lower chance of full symptom resolution.16Grandizio L.C. Maschke S. Evans P.J. The management of persistent and recurrent cubital tunnel syndrome.J Hand Surg. 2018; 43: 933-940Google Scholar The purpose of this article is to review pertinent anatomy, etiology, clinical presentations and treatments associated with persistent or recurrent CTS and CuTS. Furthermore, the article will discuss evidence supporting various treatment options for persistent and recurrent disease while providing an evidence-based guide to assist with clinical decision making when treating these challenging conditions. The median nerve (MN) originates from the C5 to T1 nerve roots and receives contributions from the medial and lateral cords of the brachial plexus. In the arm, the nerve courses lateral to the brachial artery in the upper arm and medial to the artery at the elbow. The MN enters the forearm between the pronator teres and biceps tendon before traveling between the and between the and The MN enters the hand the carpal tunnel with the and is at this the nerve is most to compressive as the carpal the of the carpal the for these to After the carpal the MN the recurrent to the as as the nerve pronator syndrome.J Hand Surg. 2020; R.M. neuropathies of the median nerve.J Am Soc Surg Scholar The ulnar nerve originates from the nerve roots and receives contributions from the medial of the brachial plexus. The nerve courses to the brachial artery in the of the upper the medial the nerve the medial at the of and to the medial the cubital of which a common the The nerve courses the of the the between the of the The nerve the forearm between the and the before at the and the of the hand as as the and ulnar of the of compression of the at the elbow include the medial of medial and the between the of the Management of secondary cubital tunnel Reconstr Surg. tunnel syndrome.J Hand Surg. Scholar The Academy of Orthopaedic clinical practice CTS as compression of the MN at the of the evidence of within the carpal tunnel and function of the nerve at Academy of Orthopaedic Surgeonsmanagement of carpal tunnel syndrome evidence-based clinical practice guideline.https://www.aaos.org/globalassets/quality-and-practice-resources/carpal-tunnel/cts-cpg_4-25-19.pdfDate accessed: November 22, 2021Google Scholar This is the hand surgery and has been the for of the Despite this the of to CTS is not cases of CTS are idiopathic but risk factors for the of carpal tunnel include and Carpal tunnel 2014; Scholar supporting such as hand and as for CTS is with a et S. S. D. The and of evidence for of carpal tunnel syndrome.J Hand Surg. Scholar in of tunnel syndrome be to on the at the of the nerve elbow and of the and to the nerve and be R.M. The of nerve Hand Surg. 12: Scholar elbow the of the cubital tunnel to with and while for an of of of the tunnel syndrome Scholar nerve and lead to nerve to the of R.P. J. Goldfarb C.A. of the ulnar nerve at the elbow: of and the of with clinical Bone Surg Am. Scholar the normal of the nerve or lead to and to the a of and which to the of such as and to nerve conduction A. at the Surg 2021; Scholar are risk factors for primary or risk factors for recurrence of disease are limited and in et R.M. Risk factors for revision surgery following ulnar nerve release at the cubital a of Shoulder Elbow Surg. 26: Scholar and to be risk factors for recurrent while et R.M. risk factors for recurrence after cubital tunnel release.J Hand Surg. 2022; Scholar and not risk Despite the of be for to risk factors of primary disease as of these be factors to the of recurrent history and are of in the of a patient for possible recurrent CTS or CuTS. the of be in between a recurrence of following a or versus persistent a or following the In be from previous patient and be to a with with to the time of primary an an diagnosis, or pathology the nerve is A patient with recurrence of tissue or to secondary compression of the In the of new a patient an nerve or a new compression been as a of the of or be performed This is to provide an of the of disease and of surgical In patients a new as nerve compression of the nerve as in cases of and such as or and disease with to CTS and such as pain, and C. H. Am. 2013; Scholar, S. in 2012; Scholar, H. neuropathies of disease and 2014; 34: Scholar, and presentations in the Hand Surg. 2013; Scholar, of patients with syndrome.J Hand Surg. Scholar In and A. The in Scholar a a of a nerve nerve to a second to a the has been used to the of compressive or to nerve and in CTS and M.P. Kane P.M. the of syndrome.J Hand Surg. 2016; 41: A. S. A. syndrome of the upper 2021; Scholar patients with open or release was performed be in persistent versus recurrent In a et D.L. H. K.A. J. D. or recurrent carpal tunnel syndrome following carpal tunnel release.J Hand Surg. Scholar of patients with of while recurrence within a shown a incidence of revision following primary release as as a incidence of release with these patients recurrent L.E. Gu A. Asadourian P.A. Stepan J.G. Fufa D.T. Osei D.A. The epidemiology of carpal tunnel revision over a 1-year follow-up period.J Hand Surg. 2021; 46: 758-764Google versus open carpal tunnel release.J Hand Surg. 2009; 34: D.L. M.P. The results of revision carpal tunnel release following previous open versus Hand Surg. Scholar between the In a systematic review and of control et S. Gu X. versus carpal tunnel release: a systematic review and of 2020; Scholar the rates of recurrence to of open release with in nerve patients release improved key to and S. Gu X. versus carpal tunnel release: a systematic review and of 2020; Scholar, J.C. J.H. versus open carpal tunnel release: a Hand Surg. Scholar, K. outcomes of versus open carpal tunnel release.J Hand Surg. 2021; 46: Scholar such as the in the MN of the loss of is a in primary CTS and be used in of J.G. and of diagnostic for carpal tunnel syndrome.J Hand Surg. The in the diagnosis of carpal tunnel Scholar not on and use the is to patient these to for to and for CTS with the to for possible or as persistent be a of of surgical be performed with to or tissue such as and the carpal tunnel compression be to the as as with from and are measures be used to in the extremity. of in CTS is as patients with are to nerve and are to to P. M. D. D. at diagnosis of carpal and cubital tunnel syndrome.J Hand Surg. 2007; Scholar In cases of previous in situ is to the et patients and lower rates following in situ when to open and this in to a lower incidence of to the medial which is a risk for the for revision A. versus cubital tunnel in situ a systematic review of outcomes and 12: Scholar are in outcome or recurrence rates between and open S. S. in situ decompression of the ulnar nerve in cubital tunnel syndrome: a retrospective 2013; Scholar, outcome of ulnar nerve a of and open in situ Hand Surg. 2009; 34: Scholar, K. recurrence after cubital tunnel release.J Hand Surg 2020; Scholar, Chen tunnel release with results of a new Hand Surg. 24: Scholar, T.K. J.H. cubital tunnel recurrence 5: Scholar, of the ulnar retrospective of the first Shoulder Elbow Surg. 26: Scholar with of for CuTS with the to for of or evidence of surgical be with to or tissue Some patients with within the of of a for possible medial nerve be performed for and possible over the of the nerve as this is a following L.C. Maschke S. Evans P.J. The management of persistent and recurrent cubital tunnel syndrome.J Hand Surg. 2018; 43: 933-940Google of the medial nerve.J Hand Surg. A. Recurrent or persistent cubital tunnel syndrome.J Hand Surg. 2012; 37: Scholar and be used to in the extremity. In the case of recurrent of elbow and be of the in the hand be to between CuTS and compression at the as in the of the hand will be in ulnar tunnel syndrome. and with CuTS are of the of nerve and nerve and a to P. M. D. D. at diagnosis of carpal and cubital tunnel syndrome.J Hand Surg. 2007; Scholar a or are to The medial and be to assess for the of the within the cubital A of history and be in and of Carpal (CTS) and (CuTS) or in median or in ulnar of in a new primary CTS and CuTS a clinical The use of the or be in establishing the appropriate diagnosis the use of J.G. and of diagnostic for carpal tunnel syndrome.J Hand Surg. The in the diagnosis of carpal tunnel Scholar The and use of in primary CTS and CuTS is and a clinical diagnosis, to of hand surgeons to with the diagnosis, and providing in the of persistent of diagnostic for carpal tunnel syndrome: a of the for of the Hand Surg. 2022; 47: Scholar patients with CTS or CuTS after a performed decompression, the to This is most when patients results from performed before for and for in nerve or are when are for but provide a of nerve function and of for to provide evidence of possible or neuropathies in as discussed There is in the use of such as and to provide nerve and soft C.A. of the and of and Hand Surg. Scholar The use of these such as nerve of at compression and nerve a diagnosis of CTS or of 2016; Scholar, A. and 2018; Scholar, C. A. M. Carpal tunnel syndrome: of and 37: Scholar, the of ulnar nerve for cubital tunnel syndrome: a review and Scholar, H. et of and in ulnar at the 2012; Scholar be in the diagnosis of of such as or C.A. of the and of and Hand Surg. Scholar is for possible or to recurrent CTS or the not and on clinical and as In the of primary a diagnostic and therapeutic but not provide and therapeutic of carpal tunnel Hand Surg. Scholar, Earp B.E. for recurrent after a for carpal tunnel 2015; Scholar, Predicting the outcome of carpal tunnel release.J Hand Surg. Scholar in the of recurrent disease are In one et J.D. Brothers J.G. Maloney P.J. Deegan J.H. Tang X. Klena J.C. 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J.B. et of a nerve as an to primary Hand Surg. 2021; 46: Scholar Although the and outcomes of the use of nerve is shown in the treatment of recurrent CTS with in pain, and in the of revision Revision decompression and nerve for recurrent and persistent compression neuropathies of the upper Surg. 2014; Scholar, C. et nerve clinical outcome of 10 Orthop 2016; Scholar, P.J. nerve for median nerve 2015; Scholar, results of recurrent cubital tunnel syndrome treated with and nerve Hand Surg. 2015; Scholar tissue rearrangement such as hypothenar fat are treatments following revision The use of a hypothenar fat flap for improved of the MN while providing a between the nerve and the from and This is soft tissue rearrangement with in of The hypothenar fat flap for management of recalcitrant carpal tunnel syndrome.J Hand Surg. 1996; hypothenar fat flap for revision surgery in carpal tunnel syndrome: of Surg Scholar A of surgical options for recurrent CTS results for treatment but a outcomes on the Carpal symptom with the use of the hypothenar fat M.C. Duraku L.S. Hundepool C.A. et al.Management of Recurrent carpal tunnel syndrome: systematic review and meta-analysis.J Hand Surg. 2022; 47: 338.e1-338.e19Google Scholar The a transposition of a fat from the hypothenar The tissue is between the MN and the of the carpal The has been over the et The hypothenar fat flap for management of recalcitrant carpal tunnel syndrome.J Hand Surg. 1996; Scholar et C. J. S. hypothenar fat flap for median nerve in recalcitrant carpal tunnel syndrome.Hand Surg. 5: Scholar et The hypothenar fat transposition a surgical Hand Surg. 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