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Median Nerve Exploration

March 01, 2019

Contributors: Shreya Sanjay Veera, BS; Jacques Henri Hacquebord, MD; Jacques Henri Hacquebord, MD

Exploration of the median nerve in the proximal forearm is relatively uncommon but is indicated in patients with motor and/or sensory deficits secondary to focal injury of the proximal median nerve. This video discusses the treatment of a 50-year-old man with chronic severe pain and forearm atrophy 1 year after distal biceps tendon repair. Since the distal biceps repair, the patient had been managed nonsurgically and given an unclear explanation for his symptoms. After an appropriate evaluation, a diagnosis of severe median nerve compressive neuropathy localized to the proximal forearm was made. Electromyography and ultrasonography confirmed median nerve neuritis with proximal forearm median fascicular degeneration and pronounced atrophy of the median nerve innervated musculature. Median nerve exploration was indicated given the patient’s documented weakness, severe pain, atrophy, and hypersensitivity in the median nerve distribution. The lacertus fibrosis, pronator teres, and arch of the flexor digitorum superficialis were released in an orderly fashion to achieve complete median nerve decompression. The median nerve was discovered to be abnormal, with an hourglass deformity and diminished epineural vasculature discovered at the level of the lacertus fibrosus. The patient had near-complete and immediate pain relief; however, his motor and sensory function may never fully recover. Ultrasonography and electromyography are useful in determining the degree and location of nerve pathology. If indicated, surgical exploration and median nerve decompression should be performed in a systematic manner to fully decompress and thoroughly evaluate the nerve.