Lacertus Syndrome is an uncommon, painful, progressive condition that is caused by compression of the median nerve at the elbow/forearm area.
Symptoms
Common symptoms of lacertus syndrome include numbness and tingling sensation in the outer 3 fingers except little finger; pain and burning sensation in forearm, hand and wrist that may radiate up to the shoulder and weakness in forearm/ hand with diminished grip strength.
Causes
The lacertus fibrosus is a tendinous band at the insertion of the biceps muscle in the elbow. This can cause the nerve to be compressed when it runs under this band. However certain factors increase the risk of developing lacertus syndrome and they include repetitive use of the forearm and elbow muscles especially seen in this age of digital gadgets such as computers, laptops, tablets and mobile phones. It is also caused by congenital abnormalities, repetitive motion of forearm, fractures and sprains, hormonal imbalance, and other medical conditions such as hypothyroidism, rheumatoid arthritis, diabetes, obesity, gout, overactive pituitary gland, or the presence of a cyst, tumour or abnormal muscle in the tunnel. Rarely acute trauma or old trauma such as a malunited fracture of the forearm bones can cause secondary lacertus syndrome.
Investigations
While the diagnosis of lacertus syndrome is mainly clinical, an ultrasound can identify median nerve atrophy/ soft tissue compression of the nerve by entities such as a ganglion, aberrant muscle or other SOL’s. It is commonly mistaken for carpal tunnel syndrome or tendinitis of the inner elbow and can often coexist with carpal tunnel syndrome. It is also an important cause of failed surgery for carpal tunnel syndrome. Thorough clinical manual muscle testing and special clinical tests are a much better diagnostic tool than investigations such as an MRI or a nerve conduction study. It is critical to screen with Xrays and an MRI of the neck to diagnose a double crush syndrome where the nerve can be both compressed in the forearm and in the neck. Typically the pain is distal to the elbow tendon origin.
Conservative Treatment Options
Lacertus syndrome may be treated using conservative approaches or surgery. The conservative treatments include:
- Treating underlying medical conditions
- Immobilisation of the elbow with a splint or an elbow brace for 4-6 weeks (Sometimes a tennis elbow brace can worsen the symptoms of a lacertus syndrome)
- Rest the hand
- Avoid activities that tend to worsen the symptoms
- Medications such as non-steroidal anti-inflammatory drugs and an ultrasound guided steroid injections
- Nerve gliding exercises, strengthening and stretching exercises once symptoms diminish
Surgery
If conservative treatment options fail to resolve the condition, Dr Bala may recommend a surgical procedure.
Lacertus Release Surgery
Lacertus syndrome can be treated with radial tunnel release Surgery. During the surgery, the tendinous insertion of the biceps muscle of the elbow will be dissected to release the pressure on the median nerve and release the tunnel. Rarely other structures compressing the nerve in the tunnel are also sometimes removed to decompress the tunnel. Dr Bala will decide which options are best for you based on your general and medical conditions.
Dr Bala believes that adequate decompression is difficult to achieve through keyhole or ultrasound guided minimally invasive surgery for this condition while addressing other conditions present in the elbow. Although he is trained to perform this keyhole, he also believes that the nerve is best visualized and freed in an open procedure. He prefers general anaesthesia over local anaesthesia for faster recovery and to better visualise important structures to protect. He may choose to do it under local anaesthesia or under WALANT (wide awake local anaesthesia no tourniquet) if medically indicated.
Post-Operative Care
Dr Bala may suggest you practice certain post-operative procedures for better recovery and to avoid further complications.
- Elevate the hand above heart level to reduce swelling.
- Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
- Physiotherapy may be ordered to restore wrist strength.
- Eating a healthy diet and not smoking will promote healing
Risks and Complications
Most patients suffer no complications following lacertus release surgery. However, in rare cases a patient may suffer from pain, infections, scarring, and nerve damage causing weakness, paralysis, or loss of sensation and stiffness in the forearm and elbow area.
Dr Bala uses special magnification loupes to visualize and protect these structures to minimize complications. In the event you may have a tattoo on the forearm Dr Bala is well versed in suturing tattoos back accurately with absorbable sutures.