Year Book: Carpal Tunnel Decompression: 16 Second Look Operations
Sennwald, G. Hagen, K. Klinik fur Hand- und Ambulante Chirurgie, St Gallen, Switzerland. Abstract/Commentary:|1992 Year Book of Hand Surgery. Article 8-13.|Original Article:|Schweiz Med Wochenschr. 1990. 120. pp 931-935.. Background.--The functional role of the flexor retinaculum has received little attention, even in the specialized literature. Previous reports demonstrate that the flexor retinaculum acts as a pulley that provides guidance to the digital flexors, anchors the thenar muscles, and protects the underlying median nerve from mechanical shock. They do not clearly indicate the extent to which functional insufficiency of the flexor retinaculum contributes to decompression failure. The case reports of 184 patients who underwent decompression of the median nerve for carpal tunnel syndrome during a 12-month period were reviewed. Findings.--Fifteen women (mean age, 47 years), who underwent operation on a total of 16 wrists, experienced persistent or recurrent pain after simple decompression of the median nerve. The flexor retinaculum had been cut longitudinally in 15 of the 16 procedures. All wrists had deep-seated pain underneath the incision scar. In addition, 10 women (62.5%) had hyperesthesia of the scar itself, and 11 (69%) had peripheral dysesthesias. At reoperation, all median nerves had perineural fibrosis, 6 nerves (37.5%) were subluxated, and 6 were subluxated outside of the carpal tunnel. The 12 subluxated median nerves (75%) had become more or less attached to the retinaculum scar. One median nerve was found immediately underlying the skin. Six patients had concomitant luxated tendons: the flexors of the fourth and fifth fingers ran directly over the hook of the hamate instead of being guided over the radial margin (Fig 8-8). During operation, it was possible to make the subluxated tendons jump over the hook of the hamate by abducting and adducting the hand. The median nerve was freed from its fibrous attachments without touching the perineurium. The flexor retinaculum was then reconstructed. Outcome.--Deep pain under the scars was relieved in 13 patients (81.3%). Although 14 patients (87%) were improved after revision surgery, only 9 (56.3%) were truly satisfied with the results. Four patients (25%) still had persistent hyperesthesia of the scar and 3 (18.8%) had persistent peripheral dysesthesias. Conclusion.--Because release of the flexor retinaculum contributed significantly to the postoperative symptoms and instability in these patients, if at all possible, the intracarpal volume should be increased without disturbing the flexor retinaculum.
Original Text by Clifford R. Wheeless, III, MD.
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