Persistence of symptoms after surgical release of compressive neuropathies and subsequent management.

Abstract

Persistent symptoms following surgical release for entrapment neuropathy are a source of great frustration for both the surgeon and patient. Fundamentals of management require review of the patient's history and examination in an attempt to confirm the initial diagnosis and to rule out elements of the differential diagnosis. Persistent symptomatology may be a reflection of an incorrect diagnosis or double crush syndrome. If the initial diagnosis can be reconfirmed, then it is reasonable to reinstitute conservative management and to objectively re-evaluate the entrapment neuropathy by electrodiagnostic testing. This electrodiagnostic testing must be comprehensive in order to evaluate all potential entrapment neuropathies within the differential diagnosis. Individuals who demonstrate a transient response to conservative management or evidence of further deterioration on electrodiagnostic testing may be considered candidates for revision surgery. These individuals may be found to have had an incomplete release, error of technique, or iatrogenic compression. Persistence of symptoms on the basis of end-stage disease must be recognized to avoid further surgery that is unlikely to be of benefit to the patient. If surgical intervention is chosen, the procedure must address issues of residual compression, preservation of nerve vascularity, prevention of neurodesis, and protective padding in the presence of nerve hypersensitivity.