title: Microvascular omental transfer for the treatment of severe recurrent median neuritis of the wrist: a long-term follow-up.
abstract: The results of reoperation for recurrent carpal tunnel syndrome have been quite disappointing. In addition to a secondary external or internal neurolysis, multiple tissues and procedures have been used to decrease scar adherence of the reoperated median nerve including muscle, fascial or fat flaps, and vein wrapping. However, each technique has certain limitations, especially in the carpal tunnel that has previously undergone multiple operations, with diffuse scar and adherence over an extended length of the median nerve. The purpose of this study was to evaluate the long-term functional and symptomatic outcome following microvascular omental transfer for severe recalcitrant median neuritis. Between 1989 and 1993, 10 extremities in seven patients underwent omental transfer for severe recurrent median neuritis at the wrist. Nine extremities in six women were available for personal evaluation at an average follow-up of 6.6 years (range, 4.5 to 8.75 years). All extremities had undergone a minimum of two previous surgical procedures, and since 1991, all patients also failed local pedicle tissue coverage. Each patient completed a physical examination, a questionnaire, and electrophysiologic studies. At surgery, all median nerves were encased in dense adherent scar, which often extended proximal to the wrist crease. There were seven neural abnormalities in six extremities, three patent median arteries, and one aberrant palmaris longus muscle. The Functional Status Index was 3.1 +/- 0.7 and the Symptom Severity Index was 3.1 +/- 0.9, with a range of 1 (best) to 5. Most symptoms were improved but not completely alleviated. Four of nine extremities exhibited improved two-point discrimination and five of seven improved sensitivity, according to the Semmes-Weinstein monofilament test. Grip strength increased an average of 73 percent in seven of nine extremities and pinch strength increased 101 percent in four of nine extremities. Five of six patients were satisfied with their results and reported improved quality of life. Preoperatively, five of seven patients were working on light duty; postoperatively, three of six patients attempted to return to work, but none were working at final follow-up. Electrophysiologic data did not correlate with the symptomatic or functional outcome. There were four complications; three were related to delayed wound healing, and one morbidly obese patient developed a ventral hernia. Wrapping the median nerve with vascularized omentum is a viable option for the treatment of severe recalcitrant carpal tunnel syndrome. Despite a high satisfaction rate and significant symptomatic improvement, many symptoms will persist, but to a lesser degree.
authors.affiliation: Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa 15213, USA. goitzrj@upmc.edu
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Goitz
authors.forename: James B
authors.initials: JB
authors.lastname: Steichen
mesh_terms: D000328:Adult; D002349:Carpal Tunnel Syndrome / Q000601:surgery*; D002921:Cicatrix / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D018737:Hand Strength; D006555:Hernia, Ventral / Q000209:etiology; D006801:Humans; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D009852:Omentum / Q000098:blood supply / Q000637:transplantation*; D017060:Patient Satisfaction; D010808:Physical Examination; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D012720:Severity of Illness Index; D016038:Skin Transplantation; D011795:Surveys and Questionnaires; D020858:Tissue and Organ Harvesting / Q000009:adverse effects; D016042:Transplantation, Heterotopic; D016896:Treatment Outcome