Combined median and ulnar nerve decompressions surgical technique
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Compression of the ulnar nerve within Guyon’s canal is uncommon and is often seen in association with a local space occupying lesion such as an aneurysm or a piso-triquetral ganglion.
Median nerve compression within the carpal tunnel however, represents the commonest peripheral nerve entrapment treated by hand surgeons.
Decompression of each nerve individually is dealt with in the relevant sections on Orthoracle.com
In the rare situation that both median and ulnar nerves are compressed at the wrist, decompression and complete visualisation of both nerves may be achieved through a single ulnar sided approach which is described here.
All of the typical causes of median or ulnar nerve entrapment described elsewhere may contribute to a combined compression.
In the setting of a peripheral nerve clinic, combined compression of both median and ulnar nerves at the wrist is often seen in the context of a more proximal, cord or trunk level brachial plexus injury. Observing such patients recovery over several months may reveal a sudden slowing or even arrest of regeneration as the regenerating front approaches a fibro-osseous canal or tunnel. Although still poorly understood, some authors suggest that this phenomenon relates to an auto-compression of the nerve as it’s volume increases during axonal regeneration.
The key factors for a successful outcome in combined median and ulnar nerve decompression through a Guyons canal approach are firstly, adequate decompression and visualisation of the deep motor branch of the ulnar nerve by careful division of the hypothenar tendinous arch at the hook of hamate, and secondly, decompression of the median nerve by release of the transverse carpal ligament from its ulnar sided attachments.
Author: Tahseen Chaudhry, Consultant in hand and peripheral nerve surgery
Institution: University Hospitals Birmingham Birmingham, UK