Median and Ulnar Nerve Compressions: Simplifying Diagnostics and Surgery at the Elbow and Hand | Journal CME Article-Journal CME Article: Median and Ulnar Nerve Compressions: Simplifying Diagnostics and Surgery at the Elbow and Hand Video 5

Video Transcription

Bicarb, and the injection is partially placed proximal and then distal to the biceps aboneurosis.  It is injected in a subcutaneous layer, and our goal is to keep the media nerve preserved so that it can be tested intraoperatively.  A small needle, in this case a 27 gauge, is used to minimize pain, and we slowly inject, blowing slow before we go, always palpating ahead of the needle where the local anesthesia  goes. Sedation is rarely needed, except for perhaps a very anxious patient. The plant incision is quite small, transverse, in the flexion crease of the elbow.  After waiting roughly 25 to 30 minutes for the full epinephrine effect, a skin incision is made.  We dissect down through subcutaneous tissue, making sure to protect any MABC nerve branches, and we use bipolar cautery as necessary.  The first landmark to find is the fascia over top the pronator teres muscle. It is bluntly dissected, both superficial and deep, and this is the clear, shiny layer you can see here.  Using blunt scissors, this layer is cut so that the fascia of the biceps aboneurosis can be visualized underneath, gently cutting and spreading.  Here in this photo, the white, thick layer of the biceps aboneurosis can be visualized, and is carefully dissected both superficially and deep before cutting, as the media nerve  is often right under this layer. In other cases, there is often a layer of muscle superficial to the media nerve, which can be released as well.  In this video, we are cutting the aponeurosis along its course, and our goal is to cut the aponeurosis in its entirety as to release the media nerve, which is entrapped underneath.  Afterwards, we palpate the area both proximally and distally along the course of the media nerve to ensure that we have adequate release, and occasionally we require further release  of the aponeurosis or of the FDS sling. The nice thing about doing this procedure wide awake with a cooperative patient is that  after we have performed our release, we can test the patient intraoperatively by asking him to again flex the index finger FDP against our resistance, and in this case the patient  has immediate return of his strength. We also test the FPL tendon against resistance.

Video Summary

The video describes a surgical procedure performed to release the median nerve, often entrapped under the biceps aponeurosis in the elbow. The process involves local anesthesia without sedation, using a small needle to minimize pain. After anesthesia, a small transverse incision is made in the elbow's flexion crease. The surgeon carefully dissects to expose the median nerve, using blunt scissors and bipolar cautery as needed, while preserving nerve branches. Post-release, the patient's finger strength is tested intraoperatively to ensure successful nerve release. This technique allows immediate assessment of nerve function with the patient awake.

Keywords

median nerve release

biceps aponeurosis

local anesthesia

nerve function assessment

surgical technique