Splinting and local steroid injection for the treatment of ulnar neuropathy at the elbow: clinical and electrophysiological evaluation

Ulnar neuropathy

Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.

Progression From Steroid Injection to Surgery in Carpal Tunnel Syndrome Patients With Concurrent Ulnar Nerve Compression: A Retrospective Analysis

BACKGROUND

Steroid injections are a common treatment option in the management of carpal tunnel syndrome (CTS). This study assesses various prognostic factors for progression to carpal tunnel release (CTR) after a first-time steroid injection for CTS with specific focus on concomitant ulnar nerve compression (UNC).

METHODS

This is a retrospective study of 426 hands with CTS treated with a first-time steroid injection in the Long Island region of New York. The main predictor variable was UNC measured in two analytical models of positive UNC and location of UNC (wrist or elbow). Multivariate logistic regression analyses adjusted for demographic, medical, and CTS-related variables for 2 study outcomes occurring within 1 year: (1) CTR; and (2) steroid reinjection.

RESULTS

Overall progression to CTR within 1 year of steroid injection was 23.0%. Ulnar nerve compression was present in 16.7% of patients and was significantly associated with increased odds for CTR but not with steroid reinjection. These results were further localized to be specific for UNC at the elbow. A moderate or severe result on electrodiagnostic studies was associated with increased odds for CTR. Increased age was associated with slightly increased odds of steroid reinjection while a history of distal radius fracture was associated with decreased odds of steroid reinjection.

CONCLUSIONS

Carpal tunnel syndrome patients with UNC may benefit from earlier definitive treatment with CTR rather than attempting steroid injections, as they are more likely to seek reintervention within 1 year of their initial injection.

Conservative Treatment of Ulnar Nerve Compression at the Elbow: A Systematic Review and Meta-Analysis

Background  The clinical results of conservative treatment options for ulnar compression at the elbow have not been clearly determined. The aim of this review was to evaluate available conservative treatment options and their effectiveness for ulnar nerve compression at the elbow. Methods  In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, a systematic review and meta-analysis of studies was performed. Literature search was performed using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Results  Of the 1,079 retrieved studies, 20 were eligible for analysis and included 687 cases of ulnar neuropathy at the elbow. Improvement of symptoms was reported in 54% of the cases receiving a steroid/lidocaine injection (95% confidence interval [CI], 41-67) and in 89% of the cases using a splint device (95% CI, 69-99). Conclusions  Conservative management seems to be effective. Both lidocaine/steroid injections and splint devices gave a statistically significant improvement of symptoms and are suitable options for patients who refuse an operative procedure or need a bridge to their surgery. Splinting is preferred over injections, as it shows a higher rate of improvement.

A Comprehensive Review of Cubital Tunnel Syndrome

Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.

Conservative therapy in ulnar neuropathy at the elbow (Review)

Ulnar neuropathy at the elbow (UNE) is the second most frequent entrapment syndrome in the upper limb after carpal tunnel syndrome. Clinical features are validated through electromyographic and sonographic examination. Although the two aforementioned entrapment syndromes share common pathophysiological traits, the conservative treatment approach for mild and moderate cases of UNE differs from that for median nerve entrapment. The present study identified 23 different types of scientific articles aimed to address this issue. The research stressed the importance of patient education and activity modification. Night splinting offers clinical and functional improvement. Although corticosteroid injections play a role in selected cases, their utility remains to be validated. Physiotherapy trials evaluated ultrasound, low-level laser therapy, diathermy, extracorporeal shock wave therapy and dry cupping. Neurodynamic mobilization may add value to therapeutic approaches and should be a part of it.

Cubital tunnel syndrome

Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function.The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis.Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate.Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis. Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129.

Cubital tunnel perfusion in different postures-An anatomical investigation

Introduction/Aims

For cubital tunnel syndrome, the avoidance of predisposing arm positions and the use of elbow splints are common conservative treatment options. The rationale is to prevent excessive stretching and compression of the nerve in the cubital tunnel, as this mechanical stress impedes intraneural perfusion. Data regarding those upper extremity postures to avoid, or whether elbow flexion alone is detrimental, are inconsistent. This study aimed to assess perfusion and size changes of the cubital tunnel during different postures in an experimental cadaver setup.

Methods

Axillary arteries in 30 upper extremities of fresh cadavers were injected with ultrasound contrast agent. High‐resolution ultrasound of the cubital tunnel was performed during five different arm postures that gradually increased tension on the ulnar nerve and caused cubital tunnel narrowing. Contrast enhancement within the tunnel was measured to quantify perfusion. Cubital tunnel cross‐sectional area was measured to detect compression.

Results

Increasing tension significantly reduced perfusion. When isolated, neither shoulder elevation, elbow flexion, pronation, nor extension of wrist and fingers impaired perfusion. However, combining two or more of these postures led to significant decreases. Significant narrowing of the cubital tunnel was seen in full elbow flexion and shoulder elevation.

Discussion

Combinations of some upper extremity joint positions reduce nerve perfusion, but isolated elbow flexion does not have a significant impact. We hypothesize that elbow splints alone may not influence cubital tunnel perfusion but may only prevent direct compression of the ulnar nerve. Advising patients about upper extremity postures that should be avoided may be more effective.

Nerve entrapment around elbow

Entrapment neuropathy around elbow is a common cause of disability across all age groups. The major nerves that traverse the elbow are ulnar, median and radial nerves and their branches. Cubital tunnel syndrome leading to ulnar nerve compression can often present with significant pain, paresthesia or weakness. Median and Radial nerve compression around the elbow, albeit less frequent, can also lead to significant morbidity and must be kept in the differential diagnosis when dealing with patients complaining of persistent pain around the elbow and weakness of forearm/hand muscles. Electrodiagnostic studies can be a useful adjunct to clinical examination, to help localize the site and quantify the grade of compression. Management should involve a trial of conservative treatment and failing that, surgical treatment should be considered. We hereby provide an overview of nerve entrapments around the elbow including their applied anatomy, etiology, clinical assessment and overview of the current concepts in surgical treatment.

Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment

Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.

Ulnar neuropathy at the elbow

At the elbow, the ulnar nerve (UN) may be the site of a static compression (by the cubital tunnel retinaculum and Osborne's ligament between the two heads of the flexor carpi ulnaris), or a dynamic compression, especially when the nerve is unstable (subluxation/dislocation outside the ulnar groove). The clinical basis for the diagnosis of ulnar neuropathy involves looking for subjective and objective signs of sensory and/or motor deficit in the ulnar nerve's territory in the hand, a pseudo-Tinel's sign, and doing manipulations to provoke UN irritation. The diagnosis is confirmed by electromyography and ultrasonography. In the early stages, patient education and elimination of flexion postures or repeated elbow flexion motions can provide relief. If this fails or signs of sensory and/or motor deficit are present, surgical treatment is proposed. If the nerve is stable, in-situ nerve decompression is typically done as the first-line treatment. If the nerve is unstable, anterior nerve transposition - generally subcutaneous - or more rarely, a medial epicondylectomy can be done. If surgical treatment fails, the patient's history is reviewed, and diagnostic tests can be repeated. Except in cases of a fibrotic scar, the main causes of failure are neuroma of a branch of the medial cutaneous nerve of the forearm, instability of the nerve and persistence of a compression point. In the latter two cases, surgical revision is justified and anterior nerve transposition or epicondylectomy can be proposed.

Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow

Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE.

Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS (N = 9,522), UNE (N = 2,507), or both (N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions.

Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status.

Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile.

Level of Evidence Diagnostic; Retrospective Database Level III study.

Ultrasound-Guided Perineural Injection for Pronator Syndrome Caused by Median Nerve Entrapment

Patients and physicians have increasingly sought minimally invasive procedures such as ultrasound-guided injection for the treatment of peripheral nerve entrapment syndromes. In this series, we assessed subjective outcome data in 14 patients who underwent ultrasound-guided perineural hydrodissection and steroid injection for pronator syndrome secondary to median nerve entrapment in the pronator tunnel. Excellent symptomatic relief (≥75% improvement) was achieved in 70% of nerves with 3-month follow-up data, with no significant change in symptoms between 3 and 6 months. These outcomes suggest that this technique could play a role in the management of pronator syndrome due to median nerve entrapment.

Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial

OBJECTIVE

To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE).

DESIGN

Prospective, randomized, double-blind, controlled trial (6-month follow-up).

SETTING

Outpatients of local medical center settings.

PARTICIPANTS

Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis.

INTERVENTIONS

Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively.

MAIN OUTCOME MEASURES

The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection.

RESULTS

Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward.

CONCLUSIONS

We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.

Conservative treatment of cubital tunnel syndrome: A systematic review

Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available.

Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS.

There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.

A reliable technique for ultrasound-guided perineural injection in ulnar neuropathy at the elbow

INTRODUCTION

Ulnar neuropathy at the elbow (UNE) is a common peripheral compression neuropathy and, in most cases, occurs at 2 sites, the retroepicondylar groove or the cubital tunnel. With regard to a potential therapeutic approach with perineural corticosteroid injection, the aim of this study was to evaluate the distribution of injection fluid applied at a standard site.

METHODS

We performed ultrasound-guided (US-guided) perineural injections to the ulnar nerve halfway between the olecranon and the medial epicondyle in 21 upper limbs from 11 non-embalmed cadavers. In anatomic dissection we investigated the spread of injected ink.

RESULTS

Ink was successfully injected into the perineural sheath of the ulnar nerve in all 21 cases (cubital tunnel: 21 of 21; retroepicondylar groove: 19 of 21).

CONCLUSION

US-guided injection between the olecranon and the medial epicondyle is a feasible and safe method to reach the most common sites of ulnar nerve entrapment. Muscle Nerve 56: 237-241, 2017.

The effect of operative technique on ulnar nerve strain following surgery for cubital tunnel syndrome

BACKGROUND

The aim of this study is to compare the amount of strain on the ulnar nerve based on elbow position after in situ release, subcutaneous transposition, submuscular transposition, and medial epicondylectomy.

METHODS

Six matched cadaver upper extremity pairs underwent ulnar nerve decompression, transposition in a sequential fashion, while five elbows underwent medial epicondylectomy. A differential variable reluctance transducer (DVRT) was placed in the ulnar nerve. An in situ release, a subcutaneous transposition, and a submuscular transposition were performed sequentially with the strain being measured after each procedure in neutral, full elbow flexion, and extension positions. The strain was then averaged and compared for each procedure. Five cadavers underwent medial epicondylectomy and were similarly tested.

RESULTS

After the in situ release, there was no statistically significant change in strain in either flexion or extension. After a subcutaneous transposition, there was a statistically significant decrease in strain in full elbow flexion but not in extension. Similarly after a submuscular transposition, there was a statistically significant decrease in strain in full flexion but not in extension. There was not a statistically significant change in strain with medial epicondylectomy.

CONCLUSION

An in situ release of the ulnar nerve at the elbow may relieve pressure on the nerve but does not address the problem of strain which may be the underlying pathology in many cases of ulnar neuropathy at the elbow (UNE). Transposition of the ulnar nerve anterior to the medial epicondyle addresses the problem of strain on the ulnar nerve. In addition, it does not create an increased strain on the ulnar nerve with elbow extension.

Iatrogenic lesions of peripheral nerves

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

New treatment alternatives in the ulnar neuropathy at the elbow: ultrasound and low-level laser therapy

Ulnar nerve entrapment at the elbow (UNE) is the second most common entrapment neuropathy of the arm. Conservative treatment is the treatment of choice in mild to moderate cases. Elbow splints and avoiding flexion of the involved elbow constitute majority of the conservative treatment; indeed, there is no other non-invasive treatment modality. The aim of this study was to investigate the efficacy of ultrasound (US) and low-level laser therapy (LLLT) in the treatment of UNE to provide an alternative conservative treatment method. A randomized single-blind study was carried out in 32 patients diagnosed with UNE. Short-segment conduction study (SSCS) was performed for the localization of the entrapment site. Patients were randomized into US treatment (frequency of 1 MHz, intensity of 1.5 W/cm(2), continuous mode) and LLLT (0.8 J/cm(2) with 905 nm wavelength), both applied five times a week for 2 weeks. Assessments were performed at baseline, at the end of the treatment, and at the first and third months by visual analog scale, hand grip strength, semmes weinstein monofilament test, latency change at SSCS, and patient satisfaction scale. Both treatment groups had significant improvements on clinical and electrophysiological parameters (p < 0.05) at first month with no statistically significant difference between them. Improvements in all parameters were sustained at the third month for the US group, while only changes in grip strength and latency were significant for the LLLT group at third month. The present study demonstrated that both US and LLLT provided improvements in clinical and electrophysiological parameters and have a satisfying short-term effectiveness in the treatment of UNE.

Image-guided elbow interventions: a literature review of interventional treatment options

Over the years, a wide range of image-guided interventional therapies have been used in treating different elbow pathologies, many of which are predominantly based on anecdotal and low-level study findings. This article critically assesses the existing literature and discusses the efficacy of the most commonly utilized interventional procedures for elbow pathology.

Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome and occurs most commonly at the elbow due to mechanical forces that produce traction or ischemia to the nerve. The primary symptom associated with UNE is diminished sensation or dysesthesias in the fourth or fifth digits, often coupled with pain in the proximal medial aspect of the elbow. Treatment may be conservative or surgical, but optimal management remains controversial. Surgery should include exploration of the ulnar nerve throughout its course around the elbow and release of all compressive structures.

Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain

STUDY DESIGN

Prospective cohort.

INTRODUCTION

There is limited evidence for conservative management of patients with non-radicular peripheral neuropathic pain (PNP).

PURPOSE

To investigate the effectiveness of a comprehensive treatment approach on pain and disability in patients with non-radicular PNP and to determine if improvements are maintained following the discontinuation of therapy.

METHODS

Patients received a multi-modal therapeutic intervention. Outcome measures were the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QDASH), Numeric Pain Rating Scale (NPRS), and grip strength. Follow-up data were collected 5 ± 2 months post-discharge.

RESULTS

There was a significant improvement in the QDASH and mean pain (p < .001). There was no significant change in grip strength (p > .13). Follow-up data suggest that pain and disability scores are maintained (p < .001).

CONCLUSION

A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP.

LEVEL OF EVIDENCE

IIIa.

Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study

OBJECTIVE

To investigate the feasibility of ultrasound (US)-guided steroid injection by in-plane approach for cubital tunnel syndrome (CuTS), based on symptomatic, morphologic and electrophysiological outcomes.

METHODS

A total of 10 patients, who were clinically diagnosed as CuTS and confirmed by an electrodiagnostic study, participated in this study. US-guided injection into the cubital tunnel was performed with 40 mg triamcinolone and 2 mL of 1% lidocaine. Outcomes of the injections were evaluated at pre-injection, 1st week and 4th week after injection. Visual analog scale, self-administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), and McGowan classification were used for clinical evaluation. Cross-sectional area of the ulnar nerve by US and the electrophysiological severity scale through a nerve conduction study were utilized in the evaluation of morphologic and electrophysiological changes. The cross-sectional area of the ulnar nerve was measured at 3 points of condylar, proximal, and distal level of the cubital tunnel.

RESULTS

No side effects were reported during the study period. The visual analog scale and cross-sectional area showed a significant decrease at 1st week and 4th week, as compared to baseline (p<0.05). The electrophysiological severity scale was significantly decreased at the 4th week, as compared with baseline and 1st week (p<0.05). Among the quantitative components of the scale, there were statistically significant improvements with respect to the conduction velocity and block.

CONCLUSION

The new approach of US-guided injection may be a safe tool for the treatment of CuTS. Symptomatic and morphologic recoveries preceded the electrophysiological improvement.

Cubital tunnel release using local anesthesia

This article discusses an alternative approach to general anesthesia with the use of local anesthesia in minor operating procedure suites when performing in situ decompression of cubital tunnel syndrome for those patients who have mild to moderately severe symptoms and for those who fail to respond to conservative measures. Anterior transposition can easily be performed in the same setting if indicated all with local anesthesia.

Real-time visualization of ultrasonography guided cubital tunnel injection: a cadaveric study

OBJECTIVE

To describe an ultrasonography-guided technique for cubital tunnel injection.

METHOD

The ulnar nerves from 12 elbows of 6 adult cadavers were scanned, and the cross-sectional areas of the ulnar nerves, cubital tunnel inlets and outlets were measured by using ultrasonography. All elbows were dissected after an ultrasonography-guided dye injection at the inlet of the cubital tunnel. The dissectors evaluated the spread of dye and the coloration of the nerve and remeasured the cross-sectional areas of the cubital tunnel inlets and outlets.

RESULTS

After a real-time visualization of an ultrasonography-guided injection, the ulnar nerves were seperated from the medial groove for the ulnar nerve. All the ulnar nerves of the cadavers were successfully colored with the dye, from the inlet to oulet of the cubital tunnel. The post-injection cross-sectional areas were significantly larger than the pre-injection cross-sectional areas. No significant differences were detected in the post-injection cross-sectional areas of the cubital tunnel outlet and the ulnar nerve as compared with the pre-injection areas.

CONCLUSION

Clinicians should consider real-time visualization of ultrasonography for guided injection around the ulnar nerve at the inlet of the cubital tunnel.

Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study

INTRODUCTION AND PURPOSE

Unlike carpal tunnel syndrome, little is known about injection with corticosteroids in patients with an ulnar neuropathy at the elbow (UNE). The purpose of this feasibility study is to see whether injection with corticosteroids is safe in patients with UNE and whether there are grounds to launch a prospective placebo-controlled study on the effects of corticosteroids.

METHODS

Patients with clinical symptoms of UNE and a nerve conduction study compatible with UNE or thickened ulnar nerve at the elbow (> 10 mm(2)) by ultrasonography were included. All included patients received an ultrasound-guided injection of 1 ml containing 40 mg methylprednisoloneacetate and 10 mg lidocainhydrochloride (Depo-Medrol(®)). Complications of the injection were monitored. After 3 months, nerve conduction studies and ultrasonography were repeated and a clinical outcome determined.

RESULTS

Eight patients with nine UNE were included. None of the patients mentioned increase in the symptoms directly after the injection nor had an infection on the injection site or haematoma. After 3 months, there was improvement of the symptoms in five patients. One patient deteriorated and three had no change of the symptoms at all. Overall, there was no significant change of the thickness of the ulnar nerve with mean difference -0.056 mm(2) (95% CI -2.56 to 2.45 mm(2)).

CONCLUSION

We showed that injection with corticosteroids in patients with UNE is easy and safe, and based on this result, we found enough arguments to launch a prospective, placebo-controlled trial to explore the effectiveness of corticosteroids in patients with UNE.

Ulnar neuropathy at the elbow: a review and single case cadaveric study

Introduction

Ulnar neuropathy at the elbow (UNE) causes sensory and motor dysfunction of the ulnar nerve and can lead to permanent loss of hand function. Hand therapists frequently encounter this pathology and are required to be cognisant of symptoms, diagnosis, therapeutic and surgical management. A detailed understanding of the anatomical structures will give the therapist greater expertise in managing this pathology.

Methods

A single case cadaveric study was undertaken to investigate known sites of ulnar nerve compression and observe the mechanisms by which compression occurs. A literature review reports on knowledge relating to the pathology, diagnosis, therapeutic and surgical management of UNE.

Results

Anatomic structures compressing the ulnar nerve are the Arcade of Struthers, the medial intermuscular septum, the cubital tunnel and the deep flexor aponeurosis. UNE is attributable to mechanical compression from fibrous and bony structures at these sites and to traction on the ulnar nerve from elbow flexion. Provocative tests are a useful tool in the diagnosis of UNE but should be used cautiously due to limitations in statistical accuracy. Conservative treatment approaches of splintage, ergonomic adaptations, education and neural mobilizations lack high-quality evidence but may have benefit primarily for early or mild to moderate disease. There is some evidence in support of conservative management in longer standing disease.

Discussion

Therapists play an important role in the diagnosis and management of UNE and should have a sound understanding of the relevant anatomy, pathology, diagnosis and treatment. Conservative treatment may be efficacious for UNE but lacks evidence from randomized, controlled trials. Further research is needed to verify current precepts and traditional approaches.

Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow

There exists no "gold standard" in the treatment of ulnar neuropathy at the elbow (UNE). We treated 7 patients with mild UNE using a local steroid injection with ultrasonographic monitoring. At clinical follow-up after 6 weeks, 4 patients had improved, 2 were stable, and 1 reported an increase in symptoms. Ultrasound-guided steroid injection in mild UNE is safe and could be effective. Further investigation is needed to prove its efficacy.

[Is intraoperative luxation of the ulnar nerve a criterion for transposition?]

BACKGROUND

The relevance of subcutaneous transposition of the ulnar nerve in the therapy of cubital tunnel syndrome is still under debate. The aim of this study was to compare the results after decompression to additional transposition in cases of intraoperative luxation.

METHODS

A total of 54 cases after surgery of cubital tunnel syndrome between 2000 and 2006 were analyzed. Nerve transposition was performed in cases of intraoperatively apparent nerve luxation.

RESULTS

Of the patients 12 were treated by decompression alone and 42 by additional subcutaneous transposition. There was no significant difference concerning symptom amelioration, usage properties of the hand, sensation impairment and duration of disability. Force measurements of grip strength and pinch strength revealed no significant differences between either hand in both groups. The 2-point discrimination ability of the 8th to 10th finger nerves was not significantly different between the groups either.

CONCLUSION

Nerve transposition revealed no benefits in the treatment of cubital tunnel syndrome when performed in cases of intraoperative nerve luxation.

Conservative treatment of the cubital tunnel syndrome

Conservative treatment of the cubital tunnel syndrome was evaluated in a randomised study of 70 patients with mild or moderate symptoms (Dellon, 1989). All patients were informed about the cause of symptoms and allocated to three groups: night splinting, nerve gliding and control. Evaluation consisted of Canadian Occupational Performance Measure, visual analogue pain scales, strength measurements and neurophysiological examination, before treatment and after six months. Fifty-seven patients were followed for six months. Fifty-one (89.5%) were improved at the follow-up. There were no significant differences between the groups in any of the recorded variables. Night splints and nerve gliding exercises did not add favourably. Routine neurophysiological examination seems unnecessary since 76% of the patients with typical symptoms had normal findings and 75% with pathological findings improved. Patients with mild or moderate symptoms have a good prognosis if they are informed of the causes of the condition and how to avoid provocation.

Entrapment and compressive neuropathies

Entrapment and compressive neuropathies of the upper and lower extremities are frequently encountered disorders in the office. Certain clinical clues in the history and examination, along with electrodiagnostic testing and imaging studies, often suggest the correct diagnosis. Some of the more common neuropathies are discussed, along with suggestions regarding testing and treatment.

Natural history and conservative management of cubital tunnel syndrome

Successful treatment of cubital tunnel syndrome requires obtaining a history of the physical and environmental factors involved for each patient, conducting a thorough physical examination, and staging and implementing an individually tailored treatment plan. Rest and avoiding pressure on the nerve by activity modification might be sufficient. If symptoms persist, splint immobilization of the elbow is warranted. Keep in mind that the natural history of untreated cubital tunnel syndrome includes spontaneous improvement in approximately half of patients.

Comparison of range-of-motion constraints provided by splints used in the treatment of cubital tunnel syndrome--a pilot study

Nocturnal splinting of the elbow is commonly used to treat cubital tunnel syndrome (CBTS). Rationales are based on several studies, which suggest that proper nocturnal positioning of the elbow during sleep contributes to decreased cubital tunnel symptoms. Currently there is limited scientific evidence supporting the rationale for specific splinting protocols. Splints may be custom or prefabricated. The purpose of this article is to assess the range-of-motion constraints of five nighttime elbow orthoses commonly used in the treatment of CBTS. This preliminary study was conducted using a cadaveric model, using three arms to represent three human arm sizes, and compared five different splints, and no splint. Range-of-motion testing was performed using gravity alone and then testing was repeated using gravity plus a 1-pound weight in a standardized fashion. Results showed that all splints restricted elbow flexion significantly more than the unsplinted extremity. Of the five splints, the AliMed splint allowed the most elbow flexion both in the gravity assisted, and gravity plus a 1-pound weight assisted conditions. The only splint that restricted elbow extension was the Hely & Weber splint. The Pil-O-Splint Elbow Support with stay, Hely & Weber and the Folded Towel all restricted elbow flexion to less than 90 degrees under all study conditions. The information provided may be helpful in making clinical decisions regarding splinting for CBTS.

Treatment of cubital tunnel syndrome: perspectives for the therapist

The treatment of cubital tunnel syndrome provides therapists the opportunity to use a wide variety of their skills. Whether managed surgically or nonoperatively, differential diagnosis, manual therapy, application of therapeutic modalities, splinting, pain management, and facilitating return to work are often all included in a comprehensive treatment plan for return to functional strength and mobility of the affected arm. When surgery is indicated due to a failure of nonoperative methods or the degree of nerve compression, the decision-making process for the specific procedure to perform is multifactorial. Anatomic factors, patient needs, and surgeon preference all play a role in determining which procedure is performed. As with many other conditions, an alliance of patient, therapist, and surgeon will provide the most effective therapeutic team, and the best chance for a good clinical outcome.

A Review of Compressive Ulnar Neuropathy at the Elbow

OBJECTIVE

To review the anatomy, etiology, and symptoms associated with compressive ulnar neuropathy at the elbow and to discuss the diagnosis and treatment of this condition.

DATA SOURCE

The following were searched for information relevant to cubital tunnel syndrome: MEDLINE, WorldCat, and Index to Chiropractic Literature.

RESULTS

Cubital tunnel syndrome is the second most common nerve compression syndrome of the upper extremity. Clinical features of this syndrome are described along with electrodiagnostic techniques that can be used to provide evidence concerning the probable location, character, and severity of the lesion affecting the ulnar nerve. Conservative treatment of cubital tunnel syndrome is recommended for patients with intermittent symptoms and without changes in cutaneous sensation or muscle atrophy.

CONCLUSION

A definitive diagnosis can best be made using clinical tests along with nerve conduction studies and electromyography, conservative treatment can be effective in treating this neuropathy in mild cases; in moderate or severe cases, surgery may be necessary.

Elbow orthoses: a review of literature

The objective of this study is to review the available literature on elbow orthoses in patients with various diagnoses to assess the scientific base of the prescription of elbow orthoses. A search of literature in Medline, Embase, Cochrane and Recal was performed using the keyword "elbow" combined with "orthosis related keywords". Abstracts were read to select the papers dealing primarily with monoarticular elbow orthoses. References of the selected papers were also examined. A total of 57 papers were read of which 18 met the selection criteria. Both the quality and quantity of the studies appeared to be low, so in this study no definitive conctusions can be drawn about the efficacy of monoarticular elbow orthoses. Current prescriptions of elbow orthoses cannot be evidence based, because no scientific evidence on elbow orthoses is available.

Entrapment and compressive neuropathies

Entrapment and compressive neuropathies of the upper and lower extremities are frequently encountered disorders in the office. Certain clinical clues in the history and examination, along with electrodiagnostic testing and imaging studies, often suggest the correct diagnosis. Some of the more common neuropathies are discussed, along with suggestions regarding testing and treatment.

Factors that influence the duration of splint wear in peripheral nerve lesions

OBJECTIVE

To assess the weekly frequency and overall duration of wear for splints used to treat peripheral nerve lesions and factors that possibly influence splint wear.

DESIGN

A total of 78 patients (23 women, 55 men) who had been treated with a hand splint for peripheral nerve palsy were interviewed by telephone, based on a preformulated questionnaire. The duration of wear, reasons for terminating use, the effect of the splint, the patients' assessment of splint treatment, the patients' instruction, and the patients' level of education were recorded. Survival analysis for the entire period of wear and logistic regressions to determine factors that influence splint wear were performed. Comparison of effect scores between lesions in the dominant those in the nondominant hand were carried out with a test.

RESULTS

The median duration of wear was 6 mo for daytime and 4 mo for nighttime splints. Daytime splints were worn by 85% and nighttime splints by 84% of patients for 5-7 days per week. The reported effect of the splint was the only significant factor that influenced the frequency of wear. The splint was reported to be significantly more effective in the dominant hand than in the nondominant hand. Numerically, radial nerve lesions and cock-up wrist splints were most common.

CONCLUSION

Regular splint wear was registered in the majority of patients and was positively influenced by a good effect of the splint, which was reported to be better in the dominant hand.

Ulnar neuropathy at the elbow

Among the entrapment neuropathies, ulnar neuropathy at the elbow is second only to carpal tunnel syndrome in frequency; however, diagnosis and management are considerably more difficult in ulnar lesions than in carpal tunnel syndrome. Electrodiagnosis is the most important means of identifying and localizing ulnar neuropathies at the elbow, but even sophisticated techniques may sometimes fail to confirm diagnosis and localization preoperatively. Mild lesions are best managed conservatively. More severe lesions require surgical intervention. Simple decompression is now preferred over transposition in the majority of cases, but careful correlation of electrodiagnostic abnormalities and findings at surgery are necessary to ensure optimal outcome.

Cubital tunnel release with medial epicondylectomy factors influencing the outcome

From 347 cases of documented cubital tunnel syndrome, 160 required cubital tunnel release and medial epicondylectomy over a 10-year period and were considered for this retrospective study. These patients were monitored for 3 years after surgery. According to the modified scale of McGowan, 86% of patients were considered stage II. Eighty-one percent of the patients were symptom free, and 96% of the patients improved by 1 Wilson and Krout grade following surgery. We considered return of symptoms 3 months or longer after surgery as recurrence; there were 21 recurrences. There was no correlation between recurrence and limb dominance, patient age at the time of surgery, or length of preoperative conservative treatment. Of the patients with recurrences, 44% were in their fourth decade of life. The rate of recurrence in females (18%) was almost twice that in males (10%). The rate of recurrence was increased twofold when the patient did not return to work within 3 months. When concomitant ipsilateral carpal tunnel was present (44%), the recurrence rate was 17% compared with 9% in those without carpal tunnel syndrome. The recurrence rate was 20% when ipsilateral thoracic outlet syndrome was present compared with 9% in patients without other ipsilateral maladies. Therefore, higher recurrence rates should be anticipated in female patients, in patients with concomitant ipsilateral thoracic outlet syndrome and/or carpal tunnel syndrome, in patients in their third or fourth decade of life, or in patients not returning to work within 3 months after surgery.