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healthy or only moderately injured, and to use local or
free flaps for clearly distressed nerves in the presence of a
strong inflammatory reaction. [44]

Vein conduits
Masaer et al. was the first to describe nerve‑wrapping
[45]
in an “opened” vein segment, which provided satisfactory
results both in terms of sensitivity improvement and
of reduction of recurrences. Elliot reported poor a
[9]
[46]
outcomes in neuromas‑in‑continuity of the palm and the
fingers, describing pain recurrence at the site of treatment
due especially to repeated trauma, because the thin
vein wall does not adequately protect the nerve against
external insults.
Some authors suggest covering sutures with a vein, as b
earlier for collagen‑gel, to prevent end‑neuroma formation Figure 3: (a) Adipofascial dorsoulnar Becker flap covering and wrapping
at direct suture sites. [47] a median nerve; (b) the bulk effect of the flap protects the nerve from
external trauma
Flaps
A variety of flaps, pedicled (local) or free, are used for to reconstruct the median nerve, and described early pain
coverage after neurolysis: synovial, fascial, adipofascial, resolution and full recovery of wrist and hand mobility
muscle and skin with subcutaneous tissue flaps. five months from the procedure. We recommend such
Compared to vein wraps, gels, and other anti‑adhesion complex procedures only in patients with severe nerve
devices, flaps have a dual function: to envelop the injury and failure of multiple surgical procedures, where
injured nerve in a highly vascularized tissue to maximize another local flap could result in local tissue damage.
nutrient supply, and to provide a bulk effect, for example, Pain neuromodulation
protection against external mechanical insults. This Multiple surgical failures may provide an indication for
approach is often used in patients in whom revision direct peripheral nerve stimulation, to relieve chronic
surgery has had poor outcomes or when the quality of pain through preferential activation of myelinated fibers,
local tissue does not allow a simpler procedure. inducing long‑term depression of synaptic efficacy. [55,56]
Typical local flaps raised in patients with recurrences or Spinal cord stimulation, which is applied more often to
sequelae of carpal tunnel syndrome (CTS) include the treat CRPS I, may also be beneficial. [57]
[48]
hypothenar fat pad flap first described by Cramer and
improved by Strickland, and the palmaris brevis flap SCAR NEURITIS AND OUTCOMES:
[49]
described by Rose et al. Their main advantage is that
they provide a buffer of highly vascularized adipofascial or LITERATURE REVIEW
muscle tissue above the treated nerve. The synovial flap
from the flexor tendons described by Wulle is still a very PubMed was reviewed for papers reporting treatment
good option for recalcitrant CTS. [50] approaches and patient outcomes of scar neuritis and
neuropathic pain, in particular studies of recurrent
Thicker flaps can be raised from the volar forearm: the median and ulnar nerve compression, postsurgical fibrosis
dorsal ulnar artery adipofascial flap described by Becker of lower and upper limb nerves, CRPS II, and application
and Gilbert can be used as an adipofascial flap to wrap of HA acid and gels that also described pre‑ and
[51]
the nerve [Figure 3a and b] or as a fasciocutaneous flap post‑operative pain assessment by the visual analogue
to provide greater protection, the adipofascial radial scale (VAS) or numerical rating scale. Case reports and
artery perforator flap and the adipofascial variant of the animal studies were excluded. Papers were sorted by the
[32]
posterior interosseous flap raised from the dorsal portion treatment approach to neurolysis.
of the forearm can be employed in the same way; and
[52]
the pronator quadratus muscle flap may be a useful Overall, 21 papers were retrieved; the majority described
[53]
solution when the injury is proximal to the wrist. the treatment of median and ulnar nerve entrapment
recurrence. The method most frequently associated with
Numerous free vascularized flaps, described for coverage neurolysis was flap coverage (15 articles); the remaining
of freed nerves, are however, rarely used. The free papers described the use of anti‑adhesion devices
omental flap, lateral arm flap, scapular flap, and groin (3 articles) to reduce pain and prevent recurrences, and
[54]
flap seem to be more effective than local flaps, yet the vein wraps (3 articles).
[44]
approach is recommended only for use in patients with
severe conditions who have already been treated and in All approaches provided good outcomes, although
those with hand and forearm lesions where a local flap most studies involved small samples, from 4 patients
would impair hand use. Yamamoto et al. have gone to 65 patients. All methods achieved a postoperative
[20]
further, and they raised an anterolateral vascularized thigh reduction of at least four VAS points. All but one study
flap that included the lateral cutaneous nerve of the thigh described complete or satisfactory pain reduction. These
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