Surgical treatment of median nerve compression syndromes

1. Endoscopic carpal tunnel release has a higher risk of transient nerve injury than open release.

True

In the Sayegh–Strauch meta-analysis of 21 randomised controlled trials (1,859 hands), endoscopic release carried a higher risk of nerve injury (RR 2.84; 95% CI 1.08–7.46; p = 0.03), most of which were transient neurapraxias, with similar overall efficacy to open release.

• Sayegh ET, Strauch RJ. Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clin Orthop Relat Res. 2015;473(3):1120-1132. PMID 25135849

2. Persistent median artery thrombosis may contribute to CTS and should always be ligated during surgery.

False

Persistent median artery thrombosis can cause CTS, but thrombosis does not automatically justify ligation. Before sacrificing the artery, its contribution to hand perfusion and the collateral circulation must be assessed. Decompression with preservation has been reported even in a symptomatic thrombosed artery when its blood supply was important.

• Hines EM, Roberts CJ, Frahm-Jensen G. Acute carpal tunnel syndrome from thrombosed persistent median artery in a patient with congenitally absent radial artery. Vascular. 2024;32(4):896-899. PMID 36920039

3. Pronator syndrome is most commonly treated by endoscopic decompression.

False

Surgical management of pronator syndrome is performed through an open anterior approach with release of the lacertus fibrosus, the two heads of pronator teres, and the proximal arch of flexor digitorum superficialis as required; in Olehnik's series, complete or partial relief was achieved in 30 of 39 limbs through this open approach, and Hagert's wide-awake technique releases the lacertus through a small open incision.

• Olehnik WK, Manske PR, Szerzinski J. Median nerve compression in the proximal forearm. J Hand Surg Am. 1994;19(1):121-126. PMID 8169356
• Hagert E. Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study. Hand (N Y). 2013;8(1):41-46. PMID 24426891

4. Revision surgery for recurrent carpal tunnel syndrome may involve hypothenar fat pad flap coverage.

True

Strickland, Idler, Lourie and Plancher reviewed 62 hands in 58 patients undergoing revision carpal tunnel decompression with hypothenar fat pad flap coverage; the well-vascularised adipose tissue interposed between the median nerve and the transverse carpal ligament prevents readherence and is a recognised technique for recalcitrant CTS.

• Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg Am. 1996;21(5):840-848. PMID 8891983
• Plancher KD, Idler RS, Lourie GM, Strickland JW. Recalcitrant carpal tunnel. The hypothenar fat pad flap. Hand Clin. 1996;12(2):337-349. PMID 8724585

5. The ligament of Struthers is the principal site of compression in pronator syndrome.

False

The ligament of Struthers is a fibrous band running from the supracondylar process to the medial epicondyle and, when symptomatic, produces supracondylar process syndrome — not pronator syndrome. Pronator syndrome involves median nerve compression by the lacertus fibrosus, the two heads of pronator teres, and the proximal arch of flexor digitorum superficialis, as defined in Johnson, Spinner and Shrewsbury's three-level model.

• Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syndrome in the proximal forearm. J Hand Surg Am. 1979;4(1):48-51. PMID 759503
• Opanova MI, Atkinson RE. Supracondylar process syndrome: case report and literature review. J Hand Surg Am. 2014;39(6):1130-1135. PMID 24862112