Revision Decompression and Collagen Nerve Wrap for Recurrent and Persistent Compression Neuropathies of the Upper Extremity Ali M. Soltani, MD, Bassan J. Allan, MD, Matthew J. Best, BS, Haaris S. Mir, MD, and Zubin J. Panthaki, MD, CM, FRCSC, FACS Background: Recurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen con- duits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy. Methods: Patients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were re- trieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome. Results: The mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 post- operatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recur- rent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group. Conclusions: Here we report on the novel technique of using a collagen ma- trix wrap in recurrent compression neuropathies with good success. The colla- gen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching. Key Words: recurrent carpal tunnel syndrome, recurrent cubital tunnel syndrome, persistent carpal tunnel syndrome, persistent cubital tunnel syndrome, median nerve compression, ulnar nerve compression, collagen, hand surgery, peripheral nerve surgery, systematic review (Ann Plast Surg 2014;72: 572Y578) R ecurrent compression neuropathies of the upper extremity, includ- ing carpal and cubital tunnel syndrome, although uncommon, can be problematic conditions after failed primary treatment. Carpal tun- nel decompression, done by either the open or endoscopic technique is the most common surgical procedure performed on the hand. 1 Al- though most patients are satisfied with their result and have complete resolution of their symptoms, there remains a certain percentage of individuals who have either recurrent or persistent symptoms. The incidence of persistent or recurrent symptoms has ranged from 1% to 31% in prior reports, but in general the rate of revision in large series is generally around 5%. 1Y7 For recurrent carpal tunnel syndrome, repeat open decompression with external 5,8Y10 or internal neurolysis, 2,7,11,12 epineurectomy, 1 endoscopic release, 13,14 various flap techniques, 3,15Y25 saphenous vein wrapping, 26Y28 and even prosthetic implants have been reported. 29 Many experts feel that vascularized tissue in the form of local or even free flaps are necessary to provide a healthy tissue bed for nerve healing. 22,30 Others feel that neurolysis or epineurectomy is essential to remove the perineural fibrosis that is invariably present in these cases. 1 Further, nerve gliding is also felt to be critical in es- tablishing a gliding plane for the nerve in its natural state, so attempts to recreate this situation are seen as beneficial. 9 Compression of the ulnar nerve in the elbow, or cubital tunnel syndrome, has more varied primary surgical treatments described with generally lower success rates than primary carpal tunnel syndrome. In situ decompression, transposition (submuscular, subcutaneous, and subfascial), and medial epicondylectomy have been performed with- out clear superiority of any one technique. The incidence of recur- rent or persistent cubital tunnel syndrome has been estimated to be around 25%. 31 Historically, experts have advocated revision decom- pression and submuscular transposition in the case of recurrent or persistent symptoms. 32Y39 Similarly, many other techniques for recur- rent cubital tunnel syndrome have been described such as ulnar nerve repositioning, 40,41 subcutaneous transposition, 37,41,42 saphenous vein wrap, 28,43,44 and even silastic sheeting. 45 Nerve conduits have been reported on for the use in digital nerve injury since 1990 with comparable long-term outcomes to auto- graft. 46 Various materials have been used such as autogenous vein, collagen, polyglycolic acid, and caprolactone in nerve injury models. 47 There have been no reports on the use of collagen or synthetic poly- mer wraps in compression neuropathies of the upper extremity. How- ever, there has been 1 case series of 5 patients with cubital tunnel syndrome treated with decompression and acellular cadaveric dermis wrap with good outcome. 31 Wrap techniques are theorized to provide a microenvironment within the compressed nerve to isolate nerve growth factors within the epineurium. The material also allows for in- creased nerve gliding, while also subsequently being absorbed slowly. Here we report on a novel technique of nerve decompression of the upper extremities with use of a type 1 collagen conduit wrap (Neura Wrap; Integra LifeSciences, Plainsboro, NJ). To provide a basis of comparison for current surgical tech- niques, we performed a systematic review of the literature on surgical treatment of secondary compression neuropathies of the upper ex- tremity. This will provide a historical comparison of technique and efficacy in a succinct manner. MATERIALS AND METHODS Clinical Outcomes We retrospectively examined the records of the hand surgery service at the Miami Veterans Administration Healthcare System after approval by the quality assurance committee. The records of all pa- tients with recurrent or persistent compression neuropathy who were surgically treated from a 5-year period from September 2007 to January 2013 were retrieved from the Computerized Patient Record PERIPHERAL NERVE SURGERY AND RESEARCH 572 www.annalsplasticsurgery.com Annals of Plastic Surgery & Volume 72, Number 5, May 2014 Received February 10, 2013, and accepted for publication, after revision, March 27, 2013. From the Division of Plastic, Aesthetic, and Reconstructive Surgery, Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL. Conflicts of interest and sources of funding: none declared. Reprints: Ali M. Soltani, MD, 1120 NW 14th St, CRB Ste 402, Miami, FL 33136. E-mail: asoltani@med.miami.edu. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7205-0572 DOI: 10.1097/SAP.0b013e3182956475 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.