A fluid-immersed multi-body contact finite element formulation for median nerve stress in the carpal tunnel

Carpal tunnel syndrome (CTS) is among the most important of the family of musculoskeletal disorders caused by chronic peripheral nerve compression. Despite the large body of research in many disciplinary areas aimed at reducing CTS incidence and/or severity, means for objective characterization of the biomechanical insult directly responsible for the disorder have received little attention. In this research, anatomical image-based human carpal tunnel finite element (FE) models were constructed to enable study of median nerve mechanical insult. The formulation included large-deformation multi-body contact between the nerve, the nine digital flexor tendons, and the carpal tunnel boundary. These contact engagements were addressed simultaneously with nerve and tendon fluid-structural interaction (FSI) with the synovial fluid within the carpal tunnel. The effects of pertinent physical parameters on median nerve stress were explored. The results suggest that median nerve stresses due to direct structural contact are typically far higher than those from fluid pressure.     

Comparison of median and radial nerve sensory latencies in the electrophysiological diagnosis of carpal tunnel syndrome

An electrophysiological diagnosis of carpal tunnel syndrome (CTS) was made on the basis of the median sensory nerve action potential (SNAP) alone in 79 of 161 (49.1%) symptomatic hands without electrophysiological evidence of a generalised peripheral neuropathy. Comparison of distal sensory latencies (DSLs) for the median and radial nerves yielded abnormal results in 17 of the remaining hands with normal median nerve DSLs, increasing the electrodiagnostic yield to 59.6%. Carpal tunnel decompression has been performed in seven of these hands, with abnormal intraoperative findings reported in two, while all improved clinically following surgery, substantiating the diagnosis of CTS. Although the technique described here would not appear to increase the electrodiagnostic yield more than comparison of DSLs for the median and ulnar nerves, which has been reported previously, it remains an affective, quick and simple procedure for increasing the sensitivity of the nerve conduction studies.     

Assessment of Median Nerve Mobility by Ultrasound Dynamic Imaging for Diagnosing Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy and is characterized by median nerve entrapment at the wrist and the resulting median nerve dysfunction. CTS is diagnosed clinically as the gold standard and confirmed with nerve conduction studies (NCS). Complementing NCS, ultrasound imaging could provide additional anatomical information on pathological and motion changes of the median nerve. The purpose of this study was to estimate the transverse sliding patterns of the median nerve during finger movements by analyzing ultrasound dynamic images to distinguish between normal subjects and CTS patients. Transverse ultrasound images were acquired, and a speckle-tracking algorithm was used to determine the lateral displacements of the median nerve in radial-ulnar plane in B-mode images utilizing the multilevel block-sum pyramid algorithm and averaging. All of the averaged lateral displacements at separate acquisition times within a single flexion–extension cycle were accumulated to obtain the cumulative lateral displacements, which were curve-fitted with a second-order polynomial function. The fitted curve was regarded as the transverse sliding pattern of the median nerve. The R² value, curvature, and amplitude of the fitted curves were computed to evaluate the goodness, variation and maximum value of the fit, respectively. Box plots, the receiver operating characteristic (ROC) curve, and a fuzzy c-means clustering algorithm were utilized for statistical analysis. The transverse sliding of the median nerve during finger movements was greater and had a steeper fitted curve in the normal subjects than in the patients with mild or severe CTS. The temporal changes in transverse sliding of the median nerve within the carpal tunnel were found to be correlated with the presence of CTS and its severity. The representative transverse sliding patterns of the median nerve during finger movements were demonstrated to be useful for quantitatively estimating median nerve dysfunction in CTS patients.     

Estrogen and progesterone receptors in carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a compression median nerve neuropathy common in women at menopausal age. The aim of this work was to study immunohistochemically the expression of estrogen (ER) and progesterone (PR) receptors in CTS and control specimens. Biopsies of transverse carpal ligament (TCL) and flexor tendon synovitis were collected from 23 women and from 7 men undergoing surgery for median nerve decompression at the wrist for CTS. In TCL and synovial tissue, cells expressed ER and PR with statistically significant differences related to the age and sex of patients. Immunoreactivity was observed in fibroblasts of TCL, and in lining cells and fibroblasts of synovial tissue. In women, the number of ER-positive cells in the TCL and synovial tissue increased with the age, peaking at 55-70 years, and then decreasing. PR-immunoreactivity was observed only in fibroblasts of TCL and its expression decreased with age, while no immunolabeling was found in the synovial tissue. In TCL samples, the number of ER- and PR-positive cells in non-CTS patients was significantly lower than in CTS patients. These results demonstrate that ER and PR are present in TCL and flexor tendon synovitis, suggesting a role for sex steroid hormones in the pathogenesis of CTS disease.     

Neurophysiological study to assess the severity of each site through the motor neuron fiber in entrapment neuropathy

The purpose of this study is to evaluate prospectively the sensitivities of conventional and new electrophysiological techniques and to investigate their relationship with the body mass index (BMI) in a population of patients suspected of having carpal tunnel syndrome (CTS). In this study, 165 hands of 92 consecutive patients (81 female, 11 male) with clinical diagnosis of CTS were compared to reference population of 60 hands of 30 healthy subjects (26 female and 4 male). Extensive sensory and motor nerve conduction studies (NCSs) were performed in the diagnosis of subtle CTS patients. Also, the patients were divided into subgroups and sensitivities were determined according to BMI. The mean BMI was found to be significantly higher in the CTS than in the control group (p < 0.001). The sensitivity of the median sensory nerve latency (mSDL) and median motor distal latency (mMDL) were 75.8% and 68.5%, respectively. The most sensitive parameters of sensory and motor NCSs were the difference between median and ulnar sensory distal latencies to the fourth digit [(D4M-D4U), (77%)] and the median motor terminal latency index [(mTLI), (70.3%)], while the median-to-ulnar sensory action potential amplitude ratio (27%) and the median-thenar to ulnar-hypothenar motor action potential amplitude ratio (15%) were least sensitive tests. Sensory tests were more sensitive than motor NCSs. Combining mSDL with D4M-D4U, and mMDL with mTLI allowed for the detection of abnormalities in 150 (91%) and 132 (80%) hands, respectively. Measurements of all NCSs parameters were abnormal in obese than in non-obese patients when compared to the BMI. The newer nerve conduction techniques and combining different NCSs tests are more sensitive than single conventional NCS test for the diagnosis of suspected CTS. Meanwhile, CTS is associated with increasing BMI.     

Concomitant presentation of carpal tunnel syndrome and trigger finger

Background

Carpal tunnel syndrome (CTS) and trigger finger (TF) are common conditions that may occur in the same patient. The etiology of most cases is unknown. The purpose of this study was to evaluate the rate of concomitant occurrence of these two conditions at presentation and to compare the concomitant occurrence in normal and diabetic patients.

Methods

One-hundred and eight consecutive subjects presenting to our hand clinic with CTS and/or TF were evaluated. The existence of both of these conditions was documented through a standard history and physical examination. The definition of trigger finger was determined by tenderness over the A1 pulley, catching, clicking or locking. CTS was defined in the presence of at least two of the following: numbness and tingling in a median nerve distribution, motor and sensory nerve loss (median nerve), a positive Tinel's or Phalen's test and positive electrophysiologic studies.

Results

The average age of the participants was 62.2 ± 13.6 years. Sixty-seven patients presented with symptoms and signs of CTS (62%), 41 (38%) subjects with signs and symptoms of TF. Following further evaluation, 66 patients (61%) had evidence of concomitant CTS and TF. Fifty-seven patients (53% of all study patients) had diabetes. The rate of subjects with diabetes was similar among the groups (p = 0.8, Chi-square test).

Conclusion

CTS and TF commonly occur together at presentation though the symptoms of one condition will be more prominent. Our results support a common local mechanism that may be unrelated to the presence of diabetes. We recommend evaluation for both conditions at the time of presentation.     

A regression model for carpal tunnel syndrome

The purpose of this study was to determine whether a logistic regression model for the diagnosis of carpal tunnel syndrome (CTS) could be developed. Forty-eight variables were initially identified, for the 28 CTS and 34 non-CTS subjects, including 28 measures of nerve function, 6 anatomical measurements, 8 variables relating to disease symptoms, and 6 variables relating to physical attributes. An a priori clustering procedure was used to establish groups for the principal components analyses. The first principal component of each cluster was then used in a backward, stepwise logistic regression analysis. The best combination of candidate variables, as identified by the regression equation, was Raynaud's symptoms and median nerve motor function. The results of this study indicate that a model for CTS can be generated from a set of variables and that a linear combination of variables representing nerve function is closely associated with conduction decrements resulting from CTS.     

Risk factors for neck and upper extremity disorders among computers users and the effect of interventions: an overview of systematic reviews

Background

To summarize systematic reviews that 1) assessed the evidence for causal relationships between computer work and the occurrence of carpal tunnel syndrome (CTS) or upper extremity musculoskeletal disorders (UEMSDs), or 2) reported on intervention studies among computer users/or office workers.

Methodology/Principal Findings

PubMed, Embase, CINAHL and Web of Science were searched for reviews published between 1999 and 2010. Additional publications were provided by content area experts. The primary author extracted all data using a purpose-built form, while two of the authors evaluated the quality of the reviews using recommended standard criteria from AMSTAR; disagreements were resolved by discussion. The quality of evidence syntheses in the included reviews was assessed qualitatively for each outcome and for the interventions.Altogether, 1,349 review titles were identified, 47 reviews were retrieved for full text relevance assessment, and 17 reviews were finally included as being relevant and of sufficient quality. The degrees of focus and rigorousness of these 17 reviews were highly variable. Three reviews on risk factors for carpal tunnel syndrome were rated moderate to high quality, 8 reviews on risk factors for UEMSDs ranged from low to moderate/high quality, and 6 reviews on intervention studies were of moderate to high quality. The quality of the evidence for computer use as a risk factor for CTS was insufficient, while the evidence for computer use and UEMSDs was moderate regarding pain complaints and limited for specific musculoskeletal disorders. From the reviews on intervention studies no strong evidence based recommendations could be given.

Conclusions/Significance

Computer use is associated with pain complaints, but it is still not very clear if this association is causal. The evidence for specific disorders or diseases is limited. No effective interventions have yet been documented.     

Carpal Tunnel Syndrome Assessment with Ultrasonography: Value of Inlet-to-Outlet Median Nerve Area Ratio in Patients versus Healthy Volunteers

Objective

To evaluate the diagnostic value of the Inlet-to-outlet median nerve area ratio (IOR) in patients with clinically and electrophysiologically confirmed carpal tunnel syndrome (CTS).

Methods

Forty-six wrists in 46 consecutive patients with clinical and electrodiagnostic evidence of CTS and forty-four wrists in 44 healthy volunteers were examined with ultrasonography. The cross-sectional area (CSA) of the median nerve was measured at the carpal tunnel inlet (the level of scaphoid-pisiform) and outlet (the level of the hook of the hamate), and the IOR was calculated for each wrist. Ultrasonography and electrodiagnostic tests were performed under blinded conditions. Electrodiagnostic testing combined with clinical symptoms were considered to be the gold standard test. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic value between the inlet CSA and IOR.

Results

The study population included 16 men and 30 women (mean age, 45.3 years; range, 18–83 years). The control population included 18 men and 26 women (mean age, 50.4 years; range, 18–79 years). The mean inlet CSA was 8.7 mm² in healthy controls and 14.6mm² in CTS group (P<0.001). The mean IOR in healthy volunteers (1.0) was smaller than that in patients (1.6, P<0.001). Receiver operating characteristic analysis revealed a diagnostic advantage to using the IOR rather than the inlet CSA (P<0.01). An IOR cutoff value of ≥ 1.3 would yield 93% specificity and 91% sensitivity in the diagnosis of CTS.

Conclusion

The IOR of median nerve area promises to be an effective means in the diagnosis of CTS. A large-scale, randomized controlled trial is required to determine how and when this parameter will be used.     

The effect of provocative tests on electrodiagnosis criteria in clinical carpal tunnel syndrome

Introduction and objectiveNerve conduction study is the most sensitive test for diagnosis of carpal tunnel syndrome (CTS). This test is normal in some patients with mild CTS. Median nerve conduction study evaluation after a provocative test (e.g. wrist flexion) may be helpful for diagnosis of mild CTS. This study aimed to determine the effect of wrist flexion on median nerve conduction in patients suspected to CTS and in healthy subjects.Materials and methodsIn this case-control study, 20 patients (20 hands) with clinical signs of CTS and normal routine electrodiagnosis test results and 20 healthy subjects were investigated. Measured parameters included: median nerve distal sensory latency (DSL), nerve conduction velocity (NCV) across wrist, compound nerve action potential (CNAP), distal motor latency (DML) and compound muscle action potential amplitude (CAMPAMP). The above noted parameters were measured before and after 5 min of full wrist flexion. Data were analyzed using paired T-test.ResultsDistal sensory latency increment and NCV decrimental after 5 min of wrist flexion in the patients group were statistically significant (p < 0.01). The same parameters did not show significant incremental or detrimental changes in the control group.ConclusionMedian nerve DSL and NCV measurement after 5 min of wrist flexion may be helpful in determining more sensitive parameters in the electrodiagnosis of CTS.     

Potential Contributions of Neck Muscle Dysfunctions to Initiation and Maintenance of Carpal Tunnel Syndrome

A biomechanical perspective of the carpal tunnel (CT) is reviewed that lends itself to an understanding of carpal tunnel syndrome (CTS) from a broader pathophysiological perspective than focusing narrowly or solely on nerve disturbance in the extremity. A wider integration of physiological systems in the etiology and maintenance of CTS is proposed that links muscular dysfunction in the neck and possibly elsewhere to dysfunction at the CT. A significant subset of individuals who develop CTS have a primary contribution from muscular dysfunctions rather distal to the CT itself. Neurophysiological dysregulation of normal inhibitory feedback at the level of the motoneuron pool specifically involving gamma motoneuron impulses may be a primary contributing mechanism. Empirical demonstration of amelioration of CTS symptoms by means of surface electromyography (sEMG) retraining of dysfunctional neck muscle patterns is reviewed as support for the hypothesized link. The specific retraining techniques are described. Future conceptual and research directions are noted.     

Epidemiology of musculoskeletal disorders among computer users: lesson learned from the role of posture and keyboard use.

Reports in the scientific literature and lay press have suggested that computer users are at increased risk of upper extremity musculoskeletal disorders (MSDs). Early studies often found elevated rates of MSD outcomes among keyboard users when compared to non-users. Attention soon focused on specific aspects of keyboard work that might be responsible for the observed rate increase. In this review, the epidemiological evidence examining associations between MSD outcomes and computer user posture and keyboard use intensity (hours of computer use per day or per week) are examined. Results of epidemiological studies of posture and MSD outcomes have not been entirely consistent. Reasons for the inconsistency in results include cross-sectional study design (with possible failure to assure that measured exposure preceded health effect), imprecision of posture measures used, and difficulties involved in analyzing multiple related variables. Despite the inconsistencies, it appears from the literature that posture is an independent risk factor of modest magnitude for MSDs among computer users. It appears that lowering the height of the keyboard to or below the height of the elbow and resting the arms on the desk surface or chair armrests is associated with reduced risk of neck and shoulder MSDs. Results of epidemiological studies examining computer use (hours keying per day or per week) are more consistent than those examining posture, although some inconsistency is observed. Reasons for the inconsistency include possible selective survival bias resulting from cross-sectional study design, differences in exposure categorization, and possible interaction with other exposure variables. Overall, the literature shows that daily or weekly hours of computer use is more consistently associated with hand and arm MSDs than with neck and shoulder MSDs.     

Conduction velocity distribution estimation using the collision technique—Theory and simulation study

Current nerve conduction studies (NCS) are influenced by the activity of the largest active fibers, making it difficult to assess the state of smaller nerve fibers. This study is aimed at alternative diagnostic techniques for assessing carpal tunnel syndrome (CTS). A conduction velocity distribution (CVD) estimator based on the collision technique that incorporates volume conductor modeling is proposed and discussed in this paper. Simulations were run to evaluate the accuracy of the CVD estimator and compare its performance with previous CVD estimators based on the collision technique. Results show the improved accuracy of the proposed approach, which is able to provide estimates with a percent mean square error (PMSE) lower than 1.1% for all CTS cases studied and lower than 2% in the presence of additive white Gaussian noise. Simulations also showed that conduction slowing in the carpal tunnel (CT) segment is detected by the proposed technique and displayed as an increase in the number of low velocity fibers. Results suggest that both CVD estimator and amplitude parameter proposed can help detect the severity of CTS in a patient more accurately than current NCS.     

Physiologic changes of compound muscle action potentials related to voluntary contraction and muscle length in carpal tunnel syndrome.

The affect of muscle length and voluntary contraction upon compound muscle action potentials (CMAPs) in subjects with carpal tunnel syndrome (CTS) has been evaluated. Twenty-five hands in a CTS patient group and 29 hands in a normal subject control group were studied. The CMAPs from the abductor pollicis brevis induced by median nerve stimulation at the wrist were obtained for five thumb positions: neutral, abduction for shortening with and without contraction, and adduction for lengthening with and without contraction. Upon muscle shortening with relaxation, CMAP duration decreased in both groups, whereas waveform amplitude increased in the control group and showed no significant change in the CTS group. Muscle shortening with contraction afforded decreased CMAP duration and increased CMAP amplitude in both groups. Upon muscle lengthening with relaxation, both groups showed a reduction in CMAP amplitude and an increase in CMAP duration. Upon lengthening with contraction, CMAP duration decreased in the control group; in contrast, the CTS group showed further amplitude reduction and the waveform duration returned to the neutral value. These results demonstrate that, in patients with CTS, physiologic CMAP summations by muscle shortening or contraction may be less effective, whereas decreases in amplitude and increases in duration may be accentuated by lengthening and contraction.     

Upper extremity biomechanics in computer tasks differ by gender

ObjectivesThis laboratory study examined gender differences in upper extremity postures, applied forces, and muscle activity when a computer workstation was adjusted to individual anthropometry according to current guidelines.MethodsFifteen men and 15 women completed five standardized computer tasks: touch-typing, completing a form, editing text, sorting and resizing graphical objects and navigating intranet pages. Subjects worked at a height-adjustable workstation with the keyboard on top of the work surface and the mouse to the right. Subjects repeated the text editing task with the mouse in two other locations: a “high” mouse position, which simulated using a keyboard drawer with the mouse on the primary work surface, and “center” mouse position with the mouse between the keyboard and the body, centered with the body’s center line. Surface electromyography measured muscle activity; electrogoniometric and magnetic motion analysis system measured wrist, forearm and upper arm postures; load-cells measured typing forces; and a force-sensing mouse measured applied forces.ResultsRelative forces applied to the keyboard, normalized muscle activity of two forearm muscles, range of motion for the wrist and shoulder joints and external rotation of the shoulder were higher for women (p < 0.05). When subjects were dichotomized instead by anthropometry (either large/small shoulder width or arm length), the differences in forces, muscle activity of the shoulder and wrist posture and shoulder posture became more pronounced with smaller subjects having higher values. Postural differences between the genders increased in the high mouse position and decreased in the center mouse location.ConclusionsWhen a workstation is adjusted per current guidelines differences in upper extremity force, muscle activity and postural factors still exist between genders. However, these were often stronger when subjects were grouped by anthropometry suggesting that perhaps the computer input devices themselves should be scaled to be more in proportion with the anthropometry and strength of the user.     

Effects of carpal tunnel syndrome on adaptation of multi-digit forces to object weight for whole-hand manipulation

The delicate tuning of digit forces to object properties can be disrupted by a number of neurological and musculoskeletal diseases. One such condition is Carpal Tunnel Syndrome (CTS), a compression neuropathy of the median nerve that causes sensory and motor deficits in a subset of digits in the hand. Whereas the effects of CTS on median nerve physiology are well understood, the extent to which it affects whole-hand manipulation remains to be addressed. CTS affects only the lateral three and a half digits, which raises the question of how the central nervous system integrates sensory feedback from affected and unaffected digits to plan and execute whole-hand object manipulation. We addressed this question by asking CTS patients and healthy controls to grasp, lift, and hold a grip device (445, 545, or 745 g) for several consecutive trials. We found that CTS patients were able to successfully adapt grip force to object weight. However, multi-digit force coordination in patients was characterized by lower discrimination of force modulation to lighter object weights, higher across-trial digit force variability, the consistent use of excessively large digit forces across consecutive trials, and a lower ability to minimize net moments on the object. Importantly, the mechanical requirement of attaining equilibrium of forces and torques caused CTS patients to exert excessive forces at both CTS-affected digits and digits with intact sensorimotor capabilities. These findings suggest that CTS-induced deficits in tactile sensitivity interfere with the formation of accurate sensorimotor memories of previous manipulations. Consequently, CTS patients use compensatory strategies to maximize grasp stability at the expense of exerting consistently larger multi-digit forces than controls. These behavioral deficits might be particularly detrimental for tasks that require fine regulation of fingertip forces for manipulating light or fragile objects.     

Aneurysm of the median artery causing recurrent carpal tunnel syndrome and anatomic review

A patient is presented who had recurrent carpal tunnel syndrome symptoms in his left hand 1 year after having undergone release of the transverse carpal ligament. On exploration, this was found to be due to an aneurysm of a median artery and possibly scarring due to this compression around the branches of the bifurcated median nerve. This represents the first case in the literature to comment on (1) the absence of bilaterality of the anatomic finding and (2) carpal tunnel syndrome relative to median artery aneurysm. With this in mind, a plea is made for careful exploration of the carpal tunnel, maintaining an incision as far to the ulnar side of the median nerve as technically possible with thorough visualization of the contents of the tunnel and any anatomic variance involved. The incidence of the combination of aberrant median artery with high bifurcation of the median nerve is unknown, as is the incidence of aneurysm of the median artery.     

Performance on a manual tracking task differentiates individuals at risk of developing carpal tunnel syndrome from those not at risk

Introduction

The purpose of this study was to determine whether sensorimotor abnormalities are detectable in asymptomatic individuals deemed at risk of developing carpal tunnel syndrome (CTS)

Methods

Seventeen individuals deemed at risk of developing CTS and 16 asymptomatic individuals deemed to be at minimal risk of developing CTS participated. Nerve conduction velocity, two-point discrimination ability, pressure acuity, Purdue Pegboard Test performance and tracking error and tracking variance on a manual tracking task performed at two different speeds were measured in all participants and compared between the groups.

Results

None of the measures of nerve conduction, sensory perception, or Purdue Pegboard task performance were different between the groups. The error in the manual tracking tasks was significantly different between the groups, where the at-risk group demonstrated more error than the control group.

Conclusion

These results suggest that manual tracking tasks may be useful in the identification of those individuals at risk of developing CTS before they develop any measurable sensorimotor impairment.     

Test of a new technique for the diagnosis of carpal tunnel syndrome.

Several new techniques for carpal tunnel syndrome diagnosis have been developed in the last few years. This work tests a technique that compares the distal motor latency of the median nerve to the second lumbrical muscle (2L) with the distal motor latency of the ulnar nerve to the interossei muscle (INT). Results from 40 normal hands give the superior limit of the normal difference (2L-INT) as 0. 26 ms (&xmacr;+3 SD). In 55 hands with different levels of carpal tunnel syndrome, this new technique was more sensitive and accurate than the conventional test which uses the distal motor latency of the median nerve to the abductor pollicis brevis muscle (APB), especially in the less severe cases. With the absence of the compound muscle action potentials of the APB muscle caused by severe thenar atrophy, it is much easier to obtain the potential from the 2L muscle. We concluded that this is a sensitive, simple, rapid, and non-invasive new technique, and therefore, it should be incorporated as part of the routine ENMG procedures for carpal tunnel syndrome diagnosis.     

Microvascular omental transfer for the treatment of severe recurrent median neuritis of the wrist: a long-term follow-up

The results of reoperation for recurrent carpal tunnel syndrome have been quite disappointing. In addition to a secondary external or internal neurolysis, multiple tissues and procedures have been used to decrease scar adherence of the reoperated median nerve including muscle, fascial or fat flaps, and vein wrapping. However, each technique has certain limitations, especially in the carpal tunnel that has previously undergone multiple operations, with diffuse scar and adherence over an extended length of the median nerve. The purpose of this study was to evaluate the long-term functional and symptomatic outcome following microvascular omental transfer for severe recalcitrant median neuritis. Between 1989 and 1993, 10 extremities in seven patients underwent omental transfer for severe recurrent median neuritis at the wrist. Nine extremities in six women were available for personal evaluation at an average follow-up of 6.6 years (range, 4.5 to 8.75 years). All extremities had undergone a minimum of two previous surgical procedures, and since 1991, all patients also failed local pedicle tissue coverage. Each patient completed a physical examination, a questionnaire, and electrophysiologic studies. At surgery, all median nerves were encased in dense adherent scar, which often extended proximal to the wrist crease. There were seven neural abnormalities in six extremities, three patent median arteries, and one aberrant palmaris longus muscle. The Functional Status Index was 3.1 +/- 0.7 and the Symptom Severity Index was 3.1 +/- 0.9, with a range of 1 (best) to 5. Most symptoms were improved but not completely alleviated. Four of nine extremities exhibited improved two-point discrimination and five of seven improved sensitivity, according to the Semmes-Weinstein monofilament test. Grip strength increased an average of 73 percent in seven of nine extremities and pinch strength increased 101 percent in four of nine extremities. Five of six patients were satisfied with their results and reported improved quality of life. Preoperatively, five of seven patients were working on light duty; postoperatively, three of six patients attempted to return to work, but none were working at final follow-up. Electrophysiologic data did not correlate with the symptomatic or functional outcome. There were four complications; three were related to delayed wound healing, and one morbidly obese patient developed a ventral hernia. Wrapping the median nerve with vascularized omentum is a viable option for the treatment of severe recalcitrant carpal tunnel syndrome. Despite a high satisfaction rate and significant symptomatic improvement, many symptoms will persist, but to a lesser degree.