Sutureless Reconstruction of Median Nerve Using TISSEEL Fibrin Glue
Brendan J MacKay, MD, Bradley Osemwengie, BA, Hunter Jones, BS, Cameron Cox, BA and Joash R Suryavanshi, BA, Texas Tech University Health Sciences Center, Lubbock, TX
Introduction
Treatment of neuromas in critical nerves can be challenging. Some cases require resection of the neuroma and reconstruction with allograft or autograft. Historically, sutures have been used for neurorrhaphy. While direct repair is less common today, it is still used in conjunction with other techniques such as nerve conduits and connectors. Yet, the use of sutures can have negative implications for nerve regeneration. In direct repair, one major concern is that sutures cause an inflammatory response resulting in scarring and postoperative loss of function.
We present a case in which sutureless nerve reconstruction was performed after resection of neuroma in continuity in the median nerve, leading to improved sensory and functional outcomes.
Materials & Methods
35 year old female presented with postsurgical pain in the right hand after carpal tunnel release performed by a previous surgeon. She had complete numbness and tingling of affected fingers, weakness, and lack of motor function.
Upon exploration, a neuroma was found in the distal forearm, just proximal to the carpal tunnel involving approximately 75% of the median nerve. The nerve fascicles were resected back for nerve grafting. The remaining 25% was intact, allowing for axial stability of the nerve. Nerve allograft measuring 4mm x 47mm was then placed inside a collagen nerve tube and held in place with Tisseel fibrin sealant spanning the nerve gap and then fashioned with no tension on the nerve.
Results
Our patient reported pain scores of 7/10 pre-operatively, 5/10 at 3-month follow-up, and complete resolution of pain at 6 months. Grip and pinch strength at 6-months post-op were 70 pounds and 12.5 pounds on the operative side respectively.
The patient had improving Tinel's sign at the proximal finger crease as well as improved sensitivity (2 point discrimination ≤ 8mm at all digits) with no pain at 1-year. At this follow-up, the patient had retained preoperative grip strength: Right = 70lbs, Left = 50lbs. The patient made a composite fist and recorded palmar abduction and thumb opposition of 5/5. The patient will continue to be monitored as she attends physical therapy to improve ROM.
Conclusions
In this case, the use of TISSEEL glue for nerve graft fixation improved outcomes, with decreased pain and increased hand strength and sensitivity. While further research is needed to understand long-term outcomes of sutureless nerve repair, this case shows that this may be an effective treatment for median nerve reconstruction of neuroma in continuity.
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