Proximal median nerve release at the pronator tunnel
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The commonest site of compression of the median nerve is the carpal tunnel. Rarely, a primary more proximal compression may be responsible for symptoms and a careful review of patients with failed symptom resolution after carpal tunnel decompression (CTD) may identify a source of proximal compression that requires release.
There are various common sites pression at this site may be due to the lacertus fibrosis, the proximal edge of the pronator muscle or the flexor digitorum superficialis (FDS) arch. The typical symptoms include proximal forearm pain, sensory disturbance in the radial volar digits and palm, Tinel’s sign at the point of compression and pain on resisted pronation or resisted FDS contraction to the middle finger.
Imaging of the nerve should be performed prior to surgery to exclude an intrinsic nerve tumour or extra-neural mass causing pressure in this tight space. Surgery aims to identify the median nerve at the proximal edge of the lacertus fibrosus and trace distally decompressing the nerve throughout its course while protecting proximal motor branches.
Dominic Power MA MB BChir(Cantab)FRCSEd FRCSLon FRCS(Tr & Orth)
Consultant Hand and Peripheral Nerve Surgeon
Honorary Senior Clinical Lecturer, University of Birmingham, UK
West Midlands Peripheral Nerve Injury Service
Birmingham Hand Centre, UK
Author:Dominic Power FRCS (Tr & Orth)
Institution: West Midlands Peripheral Nerve Injury Service, Birmingham Hand Centre, UK
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- Operation Quiz – 1 CPD point
- Surgical steps Quiz – 1/4 CPD point
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- Problem case Quiz – 1/2 CPD point
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