Case Report
The Journal of Hand Surgery (Asian-Pacific Volume) 2018;23(1):116-120 • DOI: 10.1142/S2424835518720025
Treatment of Hand Allodynia Resulting from Wrist Cutting with Radial and Ulnar Artery Perforator Adipofascial Flaps Hideto Irifune*,†, Nobuyuki Takahashi*, Suguru Hirayama*, Eichi Narimatsu*, Toshihiko Yamashita† Departments of *Emergency Medicine and †Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
In this article, we report two cases in which recurrent adhesive hand neuropathy with allodynia were successfully treated with radial and ulnar artery adipofascial perforator flap coverage. Treatment of recurrent neuropathy, such as recurrent carpal tunnel syndrome and re-adhesion after neurolysis using free and pedicle flaps to cover the nerves, has been reported to show good results. However, for severe painful nerve disorders, such as complex regional pain syndrome, the efficacy of this treatment was unclear. We present two cases diagnosed with recurrent adhesive hand neuropathy with allodynia, resulting from wrist cutting; these cases were treated with neurolysis and flap coverage with good results and no recurrence. This suggests that neurolysis and flap coverage are effective methods for treating complex regional pain syndrome. Keywords: Allodynia, Neurolysis, Adipofascial perforator flap, Ulnar artery, Radial artery
INTRODUCTION For the treatment of peripheral nerve disorders, such as entrapment neuropathy and/or adhesive neuropathy, neurolysis is an effective treatment, but may sometimes result in recurrence. Adhesion of the surrounding tissue to the peripheral nerve can result in recurrent adhesive neuropathy and even complex regional pain syndrome (CRPS). In these cases, neither conservative nor surgical treatment is very challenging to surgeons. For recurrent adhesive neuropathy, re-neurolysis and flap coverage surgery have been reported to have good results. However, the effectiveness of this method for treating CRPS is largely unknown. A previous report only included a small case series of causalgia.1) Therefore, we report two cases in which recurrent
Received: Jun. 30, 2016; Revised: Sep. 1, 2016; Accepted: Sep. 3, 2016 Correspondence to: Hideto Irifune Department of Emergency Medicine, Sapporo Medical University, S-1, W-16, Chuo-ku, Sapporo 060-8543, Japan Tel: +81-11-611-2111(ex 3711), Fax: +81-11-611-4963 E-mail:
[email protected]
adhesive hand neuropathy with allodynia resulting from wrist cutting were successfully treated with radial and ulnar artery adipofascial perforator flap coverage.
CASE REPORT Case 1 A 31-year-old man presented to our department with severe right hand pain in the median nerve region; this pain worsened with wrist extension. He had attempted suicide more than once by cutting his wrist, although the cuts were superficial. We diagnosed the patient with median nerve adhesive neuropathy and performed median nerve neurolysis. Postoperatively, his pain completely disappeared. However, about 6 months later, he experienced recurrence of right hand pain that gradually deteriorated, leading to allodynia. Conservative treatment was ineffective. We diagnosed the patient with re-adhesion neuropathy and planned an additional procedure. We performed surgical exploration 6 months after the initial neurolysis. During surgery, the median nerve and palmar branch widely adhered to surrounding scar tissue (Fig. 1A). With sufficient external neurolysis and
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resection of the scar tissue, we restored smooth gliding against the surrounding tissue for the median nerve and palmar branch (Fig. 1B). Then, we elevated a 15 × 4 cm pedicled radial artery perforator adipofascial flap (Fig. 1C). We circumferentially wrapped the median nerve and palmar branch with this flap to avoid recurrent adhesion and improve perineural blood flow (Fig. 1D). We were able to suture the skin without tension. The patient’s allodynia of the hand dramatically disappeared by the day after surgery. Two years after surgery, no recurrence was observed, and the patient could use his hand and wrist normally. Case 2 A 47-year-old man presented to our emergency center with bilateral wrist cuts from a suicide attempt. We performed primary skin suture by delicately cutting both
A
B
C
wrists. Six months after cutting his wrists, the patient had severe bilateral hand numbness that gradually worsened. This numbness also worsened when he extended his wrist. Conservative treatment was performed, but there was no effect, and the patient ultimately exhibited allodynia. We performed neurolysis once for the right median and ulnar nerves and twice for the left median nerve; however, allodynia recurred in both. Two years after the patient cut his wrists, we performed a third surgery on the left hand. During surgery, the median nerve widely adhered to the surrounding scar tissue (Fig. 2A). With sufficient external neurolysis and resection of scar tissue, we restored smooth gliding against the surrounding tissue for the median nerve and palmar branch (Fig. 2B). Then, we elevated a 17 × 4 cm pedicled radial artery perforator adipofascial flap (Fig. 2C). We circumferentially wrapped the median nerve
D
Fig. 1. Intraoperative findings in Case 1. (A) Adhesion of the median nerve. (B) The median nerve after external neurolysis. (C) The radial artery perforator adipofascial flaps were harvested. (D) The flap was turned to cover the median nerve and was well vascularized.
A
B
C
D
Fig. 2. Intraoperative findings of the left hand in Case 2. (A) Adhesion of the median nerve. (B) The median nerve after external neurolysis. (C) The radial artery perforator adipofascial flaps were harvested. (D) The flap was turned to cover the median nerve and was well vascularized.
118 Hideto Irifune, et al. Adipofascial Perforator Flap for Allodynia
A
B
C
D
Fig. 3. Intraoperative findings of the right hand in Case 2. (A) Adhesion of the median nerve. (B) Adhesion of the ulnar nerve. (C) The radial and ulnar artery perforator adipofascial flaps were harvested. (D) The flap was turned to cover the median and ulnar nerves and was well vascularized.
sure without any trouble. Allodynia in both of the patient’s hands dramatically disappeared by the day after each surgery. Two years after the final surgery on the left hand and one year after the final surgery on the right hand, no recurrence was observed, and the patient could use both hands and wrists normally. There was no bulging of the flap transition, and his hand had a soft texture (Fig. 4).
DISCUSSION
Fig. 4. Final follow-up findings in Case 2. No complications, such as skin disorders and bulging of both hands and distal forearms, were seen.
with this flap to avoid recurrent adhesion and improve perineural blood flow (Fig. 2D). We sutured the skin without any problem. In addition, we performed a second surgery on the patient’s right hand three years after he cut his wrists. During surgery, the median and ulnar nerves were found to widely adhere to the surrounding scar tissue (Fig. 3A, B). With sufficient external neurolysis and resection of scar tissue, we restored smooth gliding against the surrounding tissue for the median and ulnar nerves (Fig. 3C). Then, we elevated a 15 × 4 cm pedicled radial and ulnar artery perforator adipofascial flaps (Fig. 3C). We circumferentially wrapped the median and ulnar nerves with these flaps to avoid recurrent adhesion and improve perineural blood flow (Fig. 3D). We performed skin clo-
In our experience with these cases, each patient cut his wrists without injury to the median and ulnar nerves, resulting in development of adhesive neuropathy with allodynia. Although we performed neurolysis several times in these patients, both experienced recurrence. We considered that it was important to cover the neurolyzed nerves with well-vascularized soft tissue to prevent recurrence. We successfully treated these cases of recurrent adhesive neuropathy with allodynia using pedicled adipofascial flaps in the forearm. Although we could not perform perioperative electrodiagnostic studies, the sensory and motor impairment of the median and ulnar nerves were alleviated after transfer of the adipofascial flaps. An electrodiagnostic study for peripheral nerve neuropathy is highly specific and reasonably sensitive, and it is considered the diagnostic test of choice. In these cases, however, the patients’ pain levels were so severe that they refused to undergo an electrodiagnostic study and other physical examinations that may have worsened their pain.
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Treatment of recurrent peripheral nerve adhesion is challenging. Several flap covering methods to prevent re-adhesion after peripheral neurolysis have been reported. Regarding covering the nerves with flaps after neurolysis, it is said that utilizing well-vascularized tissue prevents external pressure and re-adhesion of the surrounding tissue, improves nerve nutrition, and maintains nerve gliding.2,3) As a result, the neurolysis effect is maintained. Several studies have reported good results of flap coverage after neurolysis in the forearm. Strickland et al. achieved good results in preventing carpal tunnel syndrome by wrapping with a hypothenar fat pad flap.4) However, there is a disadvantage with this method; since it utilizes a flap with less volume, only the carpal tunnel region may be covered. Tham et al. utilized a reverse radial artery fascial flap for recurrent carpal tunnel syndrome. This method provides a large coverage area, but sacrifices the radial artery.5) Adani et al. treated a painful median nerve neuroma with radial and ulnar artery perforator adipofascial flaps.6) This method utilizes a larger flap without sacrificing the radial or ulnar arteries. Sekiguchi et al. reported the use of brachial artery perforator-based propeller flap coverage after ulnar nerve neurolysis.7) Yamamoto et al. reported that recurrent carpal tunnel syndrome causing neuroma was treated with nerve graft and a free anterolateral thigh flap.8) Moreover, Yamamoto reported the use of a free temporoparietal fascial flap for recurrent superficial radial nerve adhesion.9) Thus, coating with a flap for adhesion neuropathy, including the method used in our cases, is considered a very effective method. On the other hand, few studies have reported on the flap coverage method for treatment of CRPS. Jupiter et al. reported that treatment of causalgia using neurolysis with local flap coverage of the peripheral nerves obtained good results.1) Dahlin et al. reported that median nerve neurolysis with coverage of free and pedicled flaps for the treatment of recurrent severe carpal tunnel syndrome obtained good results in 10/14 cases.2) In both our cases, hand allodynia, caused by nerve adhesion resulting from cuts to the wrist, dramatically disappeared after flap coverage. Thus, flap coverage after peripheral nerve neurolysis might be effective for treating cases of CRPS. Distally-based perforator adipofascial flaps of the radial and ulnar arteries are widely used as a method for covering hands that have soft tissue defects.10,11) In particular, this method is performed without sacrificing the major artery and can cover a wide area. Moreover, local adipofascial flaps can be done in the same operative field and involve a shorter operative time, with no
microsurgical anastomosis and low risks related to donor site morbidities.6) In conclusion, surgical treatment of intractable neurological disorders is challenging. In our experience, radial and ulnar artery perforator adipofascial flaps were effective for median and ulnar nerve coverage after neurolysis for adhesive neuropathy with allodynia. This method to treat CRPS is likely to be useful as therapy for intractable neurological disorders in the wrist.
CONFLICTS OF INTEREST The authors declare that there is no conflict of interest regarding the publication of this paper.
REFERENCES 1. Jupiter JB, Seiler JG 3rd, Zienowicz R. Sympathetic maintained pain (causalgia) associated with a demonstrable peripheral-nerve lesion. Operative treatment. J Bone Joint Surg Am. 1994;76(9):1376-84. 2. Dahlin LB, Lekholm C, Kardum P, Holmberg J. Coverage of the median nerve with free and pedicled flaps for the treatment of recurrent severe carpal tunnel syndrome. Scand J Plast Reconstr Surg Hand Surg. 2002;36(3):172-6. 3. Dahlin LB, Salo M, Thomsen N, Stutz N. Carpal tunnel syndrome and treatment of recurrent symptoms. Scand J Plast Reconstr Surg Hand Surg. 2010;44(3):4-11. 4. Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg Am. 1996;21(5):840-8. 5. Tham SK, Ireland DC, Riccio M, Morrison WA. Reverse radial artery fascial flap: a treatment for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am. 1996;21(5):849-54. 6. Adani R, Tos P, Tarallo L, Corain M. Treatment of painful median nerve neuromas with radial and ulnar artery perforator adipofascial flaps. J Hand Surg Am. 2014;39(4):721-7. 7. Sekiguchi H, Motomiya M, Sakurai K, Matsumoto D, Funakoshi T, Iwasaki N. Brachial artery perforator-based propeller flap coverage for prevention of readhesion after ulnar nerve neurolysis. Microsurgery. 2015;35(2):158-62. 8. Yamamoto T, Narushima M, Yoshimatsu H, Yamamoto N, Mihara M, Koshima I. Free anterolateral thigh flap with vascularized lateral femoral cutaneous nerve for the treatment of neuroma-in-continuity and recurrent carpal tunnel syndrome after carpal tunnel release. Microsurgery. 2014;34(2):145-8. 9. Yamamoto R, Motomiya M, Sakurai K, Sekiguchi H, Funakoshi T, Iwasaki N. Application of free temporoparietal
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fascial flap for recurrent neural adhesion of superficial radial nerve-A case report. Microsurgery. 2015;35(6):489-93. 10. Lai CS, Lin SD, Yang CC, Chou CK. The adipofascial turnover flap for complicated dorsal skin defects of the hand
and finger. Br J Plast Surg. 1991;44(3):165-9. 11. El-Khatib H, Zeidan M. Island adipofascial flap based on distal perforators of the radial artery: an anatomic and clinical investigation. Plast Reconstr Surg. 1997;100(7):1762-6.
