Redo neurolysis with adding autologous lipoaspirates around the median nerve for second recurrent carpal tunnel syndrome: a therapeutic case series
Ileen Domela Nieuwenhuis, MD1, Olivier FE Gostelie, MD2, Geraldine L Nanninga, MD3, Sjoerd B Paulusma, MD3, Joris A Van Dongen, MD PhD1, Michiel A Tellier, MD4, Brigitte EPA Van Der Heijden, MD PhD5,6, J. Henk Coert, MD PhD1 and Jean Bart Jaquet, MD PhD7, 1University Medical Center Utrecht, Utrecht, Utrecht, Netherlands, 2Catharina Ziekenhuis, Eindhoven, Netherlands, 3Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, Netherlands, 4Isala Ziekenhuis, Zwolle, Overijssel, Netherlands, 5Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Brabant, Netherlands, 6Radboud University Medical Center, Nijmegen, Gelderland, Netherlands, 7Maasstad Ziekenhuis, Rotterdam, Netherlands
Introduction: The incidence of persistent or recurrent CTS after a first carpal tunnel release (CTR) varies from 1-31% in literature. Recurrent CTS is mostly caused by new adhesions or incomplete nerve release. Extensive neurolysis is advised for a first recurrence. For second recurrences, addition of vascularised fat- fascia or muscle- tissue after an extensive neurolysis has been published. Lipografts contain many adipose derived stromal cells (ASC’s). ASC’s are multipotent mesenchymal stromal cells that secrete a plethora of cytokines, growth factors, exosomes and matrix metalloproteinases that may stimulate angiogenesis, reduce inflammation and remodel extracellular matrix. Remodelling of extracellular matrix might prevent fibrotic adhesions of the median nerve to the transverse carpal ligament. The authors hypothesised that lipografting following extensive neurolysis reduces CTS recurrences.
Materials & Methods: In this therapeutic case series, patients with 2nd to 5th recurrent CTS (n=26) are included. They are treated with extensive external neurolysis followed by perineural lipografting. Lipoaspirate was filtrated through a sterile gaze removing tumescent fluid, erythrocytes, debris and oil and injected around the median nerve. An additional 7-9cc lipografting was injected through a small residual part of the incision before closing the skin entirely. Primary outcome is the Boston Carpal Tunnel Questionnaire (BCTQ). Secondary outcome is electrodiagnostic nerve conduction velocity obtained with electromyography (EMG). Data are obtained pre-and postoperatively with a mean follow-up of 30 months [range 3-60]. This study was conducted in accordance with the declaration of Helsinki and approved by our Medical Ethical Review Committee (2016-70).
Results: The average BCTQ score decreased from 3.5 ±0.9 preoperative to 2.2 ±1.2 postoperative (p<0.0001). Also, the BCTQ total SSS score and BCTQ total FSS Score decreased, respectively 39.6 ±9.0 to 23.9 ±13.0 (p<0.0001); 26.9 ±9.5 to 16.9 ±10.0 (p<0.001). Likewise, an improvement was seen in the median nerve conduction velocity (p<0.05), with an average preoperative EMG score of 0.88 ±0.41 and 0.69 ±0.40 postoperative. 46% of patients tested negative for CTS on EMG postoperatively. Except for some anticipated postoperative pain and swelling around the operation site, no complications were observed.
Conclusions: Extensive neurolysis of the median nerve in combination with perineural lipografting in repetitive recurrent CTS may give a significant long-lasting improvement of symptoms with a low complication- and morbidity rate.
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