Cubital tunnel syndrome: a retrospective review of 53 anterior subcutaneous transpositions

Intramuscular compared with subcutaneous transposition for surgery in cubital tunnel syndrome

Background There is no consensus on the most effective surgical technique in the treatment of cubital tunnel syndrome. Anterior subcutaneous transposition (AST) and anterior intramuscular transposition (AIT) are common surgical treatments in this regard. The aim of this study was to compare the clinical outcomes of these two surgeries for cubital tunnel syndrome. Methods In a retrospective study, we compared surgical outcomes (pain, sensation, motor recovery, atrophy, and total satisfaction) in 40 patients undergoing AIT and 43 undergoing AST of the ulnar nerve. Results The patients undergoing AIT showed a significant improvement in all the outcomes after the surgery (P = 0); however, those undergoing AST only experienced an improvement in pain and sensation after the surgery (P = 0). Comparing the two surgeries, we found that there was a high total satisfaction with AIT compared with AST (P = 0). When we independently compared each outcome in the two groups, we found that the muscle force recovery was significantly improved in the AIT group compared with the AST group (P = 0). Conclusions AIT is preferable to AST for the surgical treatment of cubital tunnel syndrome. In particular, AIT achieves a better motor recovery of the ulnar nerve compared with AST.

Thoracic outlet syndromes. The so-called "neurogenic types"

Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial pain syndromes of the upper limbs. The controversies revolve around both the diagnosis and treatment of the non-specific or subjective subtypes. Their diagnosis rests on a combination of history, suggestive symptoms and clinical examination. Proximal pain is primarily muscular in origin, while distal symptoms may be the result of intermittent nerve compression and/or myofascial pain syndrome. Stringent clinical criteria are required to confirm the diagnosis of subjective TOS. In reality, multiple factors can be entangled, with TOS being one element within a multifactorial pain disorder; any musculotendinous pathology of the upper limb and any peripheral nerve entrapment require screening for potential concomitant TOS. Surgery is indicated in most cases of true neurogenic TOS, whereas rehabilitation is the standard treatment for subjective TOS.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PURPOSE

Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years.

MATERIALS AND METHODS

Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale.

RESULTS

Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination.

CONCLUSION

An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years.

Anterior subcutaneous transposition of the ulnar nerve improves neurological function in patients with cubital tunnel syndrome

Although several surgical procedures exist for treating cubital tunnel syndrome, the best surgical option remains controversial. To evaluate the efficacy of anterior subcutaneous transposition of the ulnar nerve in patients with moderate to severe cubital tunnel syndrome and to analyze prognostic factors, we retrospectively reviewed 62 patients (65 elbows) diagnosed with cubital tunnel syndrome who underwent anterior subcutaneous transposition. Preoperatively, the initial severity of the disease was evaluated using the McGowan scale as modified by Goldberg: 18 patients (28%) had grade IIA neuropathy, 20 (31%) had grade IIB, and 27 (42%) had grade III. Postoperatively, according to the Wilson & Krout criteria, treatment outcomes were excellent in 38 patients (58%), good in 16 (25%), fair in 7 (11%), and poor in 4 (6%), with an excellent and good rate of 83%. A negative correlation was found between the preoperative McGowan grade and the postoperative Wilson & Krout score. The patients having fair and poor treatment outcomes had more advanced age, lower nerve conduction velocity, and lower action potential amplitude compared with those having excellent and good treatment outcomes. These results suggest that anterior subcutaneous transposition of the ulnar nerve is effective and safe for the treatment of moderate to severe cubital tunnel syndrome, and initial severity, advancing age, and electrophysiological parameters can affect treatment outcome.

SUBCUTANEOUS ANTERIOR TRANSPOSITION FOR TREATMENT OF CUBITAL TUNNEL SYNDROME: IS THIS METHOD SAFE AND EFFECTIVE?

Objective: To evaluate the results from subcutaneous anterior transposition of the cubital nerve for treating cubital tunnel syndrome (CTS) and the influence of prognostic factors such as preoperative McGowan stage, age and duration of symptoms. Methods: 36 patients with CTS who underwent subcutaneous anterior transposition of the cubital nerve between 2006 and 2009 were evaluated after an average follow-up of 28 months. Their mean age was 41.6 years. Nine patients were in McGowan stage I, 18 in stage II and nine in stage III. Results: There was a statistically significant improvement in sensory and motor deficits. 78% of the patients with severe neuropathy improved after surgery. According to the modified Bishop score, 21 patients (58.3%) had excellent results, seven (19.4%) good, six (16.7%) satisfactory and two (5.55%) poor. The satisfaction rate was 86% and 72% of the patients recovered their daily activities without limitations. Conclusion: The severity of neuropathy and preoperative duration of symptoms, but not age, had a negative influence on the outcome. The subcutaneous anterior transposition of the cubital nerve is safe and effective for treating CTS of different degrees of severity. Given the major prognostic factors identified, surgical treatment should be advised as soon as axonal loss has become clinically evident.

Ulnar nerve stability-based surgery for cubital tunnel syndrome via a small incision: a comparison with classic anterior nerve transposition

OBJECTIVE

The purpose of this study was to compare the clinical outcomes of ulnar nerve stability-based surgery via a small incision with those of classic anterior transposition of the ulnar nerve for cubital tunnel syndrome.

METHODS

From March 2008 to December 2013, 107 patients with cubital tunnel syndrome underwent simple decompression or anterior transposition via a small incision, according to an ulnar nerve stability-based decision based on an assessment of intraoperative ulnar nerve stability (group A, n = 51), or anterior transposition via a classic incision (group B, n = 56). Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop scale.

RESULTS

At the final follow-up, all outcome measures improved significantly in both groups and there were no significant differences between the two groups. However, there were fewer operation-related complications in group A (one revision surgery) than in group B (one superficial infection, two painful scars, and five cases of numbness at the medial elbow).

CONCLUSIONS

Outcomes after the ulnar nerve stability-based approach and anterior transposition were similar, although more patients experienced operation-related complications after anterior transposition via a classic incision. Making an ulnar nerve stability-based decision to perform either simple decompression or anterior transposition via a small incision seems to be a better strategy for patients with cubital tunnel syndrome.

Predictors of surgical revision after in situ decompression of the ulnar nerve

BACKGROUND

This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome.

METHODS

This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery.

RESULTS

Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19).

DISCUSSION

The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery.

Clinical classification and treatment of cubital tunnel syndrome

The aim of the present study was to investigate a new clinical classification of cubital tunnel syndrome that provides an improved basis for the clinical diagnosis and treatment of the disease. Retrospective analysis was performed on 341 patients with cubital tunnel syndrome. Based on the etiology, signs and symptoms, neurophysiological tests and computed tomography (CT) imaging, a new clinical classification was proposed. The patients enrolled in the study were treated according to the new classification. According to the new classification, cubital tunnel syndrome cases were divided into types I-IV. Treatment for patients with type I consisted of rest, immobilization or physiotherapy, while patients with type II received simple ulnar neurolysis. Type III patients underwent ulnar neurolysis with expansion of the ulnar nerve sulcus or ulnar nerve anterior transposition surgery. Type IV patients represented a subgroup of cubital tunnel syndrome cases caused by factors other than degenerative joint diseases, including cysts, tumors, traumatic fracture, deformity and elbow deformity. Patients of this type received appropriate surgical treatment according to the specific etiology. Based on previous classifications that relied on sensation and strength symptoms, a new clinical classification of elbow tunnel syndrome has been established in the present study that adopts a CT imaging evaluation index. The new classification is reasonable, simple and practical, and therapies based on this classification are more targeted than those based on previous classifications.

Is routine ulnar nerve transposition necessary in open release of stiff elbows? Our experience and a literature review

PURPOSE

Prophylactic release of the ulnar nerve to reduce the incidence of postoperative nerve symptoms in stiff elbows has been recommended. However, the necessity for routine anterior transposition remains unclear. In this study, we aim to gain an insight into the value of routine transposition in open release of stiff elbows.

METHODS

We retrospectively reviewed 94 patients suffering from elbow stiffness with no pre-operative ulnar nerve symptoms. Simple decompression (with in situ decompression or epicondylectomy) and subcutaneous anterior transposition were chronologically performed in 53 and 37 patients, respectively. Another four patients were treated by a single lateral approach with no intervention of the ulnar nerve. Pre- and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. The function of ulnar nerve was measured by Amadio rating scale.

RESULTS

The incidence of ulnar nerve dysfuction was 18.9% (ten of 53) and 8.1% (three of 37) in the simple decompression and transposition groups, respectively. The mean Amadio scores were 7.62 and 8.22, respectively. All these data showed a statistically significant difference (P < 0.05). In the lateral approach group, 50 % (two of four) of patients developed nerve symptoms with a mean Amadio score of 6.50.

CONCLUSIONS

The transposition group exhibited a superior nervous outcomes compared with the simple decompression group. No comparison was conducted between the transposition and lateral approach groups because of too few patients in the latter. According to related literature and our experience, we conclude that routine transposition is necessary to prevent postoperative nerve symptoms.

Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months

BACKGROUND

Cubital tunnel syndrome is the second most frequent entrapment syndrome. Physiopathology is mixed, and treatment options are multiple, none having yet proved superior efficacy.

OBJECTIVES

The present retrospective multicenter study compared results and rates of complications and recurrence between the 4 main cubital tunnel syndrome treatments, to identify trends and optimize outcome.

MATERIALAND METHODS

Patients presenting with primary clinical cubital tunnel syndrome diagnosed on electroneuromyography were included and operated on using 1 of the following 4 techniques: open or endoscopic in situ decompression, or subcutaneous or submuscular anterior transposition. Four specialized upper-limb surgery centers participated, each systematically performing 1 of the above procedures. Subjective and objective results and rates of complications and recurrence were compared at end of follow-up.

RESULTS

Five hundred and two patients were included and 375 followed up for a mean 92 months (range, 9-144 months); 103 were lost to follow-up and 24 died. Whichever the procedure, more than 90% of patients were cured or showed improvement. There was a single case of scar pain at end of follow-up, managed by endoscopic decompression; there were no other long-term complications. None of the 4 techniques aggravated symptoms. There were 6 recurrences by end of follow-up: 1 associated with open in situ decompression and 5 with submuscular transposition.

CONCLUSION

Surgery was effective in treating cubital tunnel syndrome. Submuscular anterior transposition was associated with recurrence. In contrast to literature reports, subcutaneous anterior transposition, which is a reliable and valid technique, was not associated with a higher complication rate than in situ decompression.

LEVEL OF EVIDENCE

Level IV. Multicenter retrospective.

[Cubital tunnel syndrome: a retrospective review of 55 subcutaneous transpositions with minimum 3-year follow-up]

The surgical management of the cubital tunnel syndrome has no strict rules to follow. Surgical treatments are various, but none of them has been shown to be superior to the others. This retrospective study presents the clinical results in 73 patients who underwent an anterior subcutaneous transposition of the ulnar nerve, between January 2000 and January 2010, with a minimum 3-year follow-up. Fifty-five patients were assessed with an average follow-up of 65.7 months. McGowan grading system as modified by Goldberg was used to analyse clinical results, preoperatively and at follow-up. The DASH score was used to assess physical function. The average preoperative evolution of symptoms was 16.7 months, and mean period to resolution was 4.7 months. The grade in McGowan grading system as modified by Goldberg significatively improved at follow-up (P=0.0002). Only five patients kept paresthesia. The mean postoperative DASH score was 7.27/100. The satisfaction rate was 96%, and all the patients except one returned back to their occupation. There was neither infection nor complex regional pain syndrome. The anterior subcutaneous transposition leads to very good clinical results, satisfaction and physical function. It is an effective surgical method, without complication in our study, which gives long-term results.

Ulnar neuropathy at the elbow: an evidence-based algorithm

Ulnar neuropathy at the elbow is the second most common compression neuropathy of the upper extremity and poses a challenge for treating physicians. Lack of a standardized grading system, outcome measures, or surgical indications can make treatment decisions difficult to justify. Conclusions drawn from the available literature include similar rates of good to excellent outcomes for in situ decompression; transposition in the subcutaneous, submuscular, or intramuscular planes; and endoscopic decompression. Outcomes for revision surgery are generally less favorable. Development of standardized outcomes measures will be important in improving the quality and comparability of the literature on this subject.

Outcomes following modified oblique medial epicondylectomy for treatment of cubital tunnel syndrome

PURPOSE

To quantify and define objective and patient-rated outcomes after our modification of medial epicondylectomy for the treatment of cubital tunnel syndrome. Although medial epicondylectomy has been previously studied, data are lacking regarding elbow-specific outcomes after our technique that aims to minimize complications historically associated with medical epicondylectomy.

METHODS

A total of 27 subjects with clinical and electrodiagnostic evidence of cubital tunnel syndrome underwent a modified oblique medial epicondylectomy that was designed to minimize bony resection and preserve the origin of the ulnar collateral ligament of the elbow. Average age was 57 years, mean duration of symptoms was 24 months, and mean postoperative follow-up was 29 months. Eight patients had McGowan stage I disease, 14 had stage II, and 5 had stage III. Preoperatively, we measured intrinsic hand strength, 2-point discrimination, and residual medial elbow pain, and assessed for continuing signs and symptoms of nerve compression. Postoperatively, we added to the clinical examination elbow stability testing, elbow range of motion, and assessment of medial antebrachial cutaneous nerve injury. We collected patient-reported outcomes, including Quick Disabilities of the Shoulder, Arm, and Hand; Levine-Katz Severity Score; and Patient-Rated Elbow Evaluation.

RESULTS

We noted improvement of at least 1 McGowan grade in 20 of 27 patients (74%). Three of the 7 patients who had no change in McGowan grade still reported excellent patient-rated outcomes. Good to excellent results were achieved in 25 of 27 patients (93%). One patient had long-term severe medial elbow pain. Three patients had postoperative medial elbow pain that resolved with a single corticosteroid injection. One patient had a 30° flexion contracture; preoperative motion was not available for comparison. No patients had signs of elbow instability or numbness in the medial antebrachial cutaneous nerve distribution.

CONCLUSIONS

Modified oblique medial epicondylectomy was effective in improving symptoms in cubital tunnel syndrome. This medial collateral ligament sparing technique minimized complications previously associated with the original technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Minimal epicondylectomy improves neurologic deficits in moderate to severe cubital tunnel syndrome

BACKGROUND

Previous studies of minimal medial epicondylectomy for cubital tunnel syndrome included patients with mild disease, making it difficult to determine how much this procedure improved sensory and motor impairments in patients with moderate to severe disease.

QUESTIONS/PURPOSES

We asked if minimal epicondylectomy improved sensory and motor impairments in patients with moderate to severe cubital tunnel syndrome.

METHODS

We retrospectively reviewed 25 patients treated with minimal medial epicondylectomy for advanced cubital tunnel syndrome involving motor weakness between January 2003 and February 2009. Preoperatively, five patients had Medical Research Council (MRC) Grade 4 motor strength without atrophy (McGowan Grade IIA), nine had MRC Grade 3 motor strength with detectable atrophy (McGowan Grade IIB), and 11 had MRC Grade 3 or less motor strength with severe atrophy (McGowan Grade III). Postoperatively we obtained DASH scores and evaluated improvement of sensory impairment and motor impairment: excellent with minimal sensory deficit and motor deficit, good with mild deficits, fair with improved but persistent deficit(s), and poor with no improvement. The minimum followup was 13 months (mean, 46 months; range, 13-86 months).

RESULTS

The mean DASH score was 14 points (range, 2-47 points). Of the 25 patients, sensory improvement and motor improvement were excellent in 16 patients, good in five, fair in two, and poor in two. Twenty-three of the 25 patients improved at least one McGowan grade. There were no complications, such as medial elbow instability.

CONCLUSIONS

Minimal medial epicondylectomy can improve sensory and motor impairments for patients with moderate to severe cubital tunnel syndrome.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

Predictors of surgical outcomes following anterior transposition of ulnar nerve for cubital tunnel syndrome: a systematic review

PURPOSE

Although cubital tunnel syndrome is the second most common nerve entrapment neuropathy, few studies explore potential predictor(s) of surgical outcomes. The purpose of this systematic review was to determine which factors affect the postoperative outcome for patients who undertake anterior transposition of the ulnar nerve.

METHODS

We included all studies reporting predictor(s) of clinical, electrophysiological study, or functional outcome after any anterior transposition of the ulnar nerve. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL from 1980 to April 2011 and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality, and data extraction independently of each other.

RESULTS

We assessed 26 studies including 2 randomized controlled trials, 10 cohort studies, and 14 case series. Overall, the methodological quality of the studies ranged from low to moderate. Six aspects of prognosis were sufficiently studied for a narrative evidence synthesis on age, duration of symptom, severity of operative status, preoperative electrodiagnostic testing results, type of surgery, and work compensation status. Evidence was conflicting across studies in terms of both the direction and intensity of the impact of these 6 potential predictors on surgical outcomes.

CONCLUSIONS

Because of conflicting results, we were unable to conclude which predictor(s) affect surgical outcomes after anterior transposition of the ulnar nerve. Surgeons who are aware of only a limited number of prognostic studies and their limited scope of evidence may not appreciate the extent of the inconsistency about whether factors commonly viewed as prognostic actually have a noteworthy impact on outcomes achieved. Such factors may be identified in the future with higher-quality studies, because limitations in the current research undoubtedly contribute to the controversies observed.

Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact

INTRODUCTION

Thoracic outlet syndrome is a controversial cause of neck and shoulder pain due to complex mechanisms involving muscular dysfunction and nerve compression. Although management of thoracic outlet syndrome must be based on a multidisciplinary approach, physicians and occupational therapist should be familiar with the principles of diagnosis and treatment.

METHOD, RESULTS AND CONCLUSION

The purpose of this article is to review the definitions, diagnosis and management of this syndrome. A particular emphasis was described on the links between the workplace and the individual in the pathogenesis, prevalence in the workforce and the course of this disease.

Fascial flap protecting the fibular nerve: a rare childhood case

Compression of the peripheral nerves (PNs) induces intraneural lesions, which, once surgical decompression has been achieved, requires that the peripheral scar tissue be as non-adherent as possible. This allows optimal nerve tissue regeneration and the flexibility necessary for longitudinal movements of the PNs. In cases showing a risk for adherence, tissue interposition (with fat, muscle, fascia, etc.) can be proposed. The authors describe the use of a fascial flap of the fibular muscles used to protect the fibular nerve (FN) and the fibula head. This flap procedure was performed in a case of PN compression due to exostosis of the fibular nerve in a child.

Comparative study of surgical treatment of ulnar nerve compression at the elbow

HYPOTHESIS

The optimal surgical treatment for cubital tunnel syndrome remains unclear. We aim to evaluate the long-term outcome of surgical treatment by comparing the results of the different methods proposed.

MATERIALS AND METHODS

We retrospectively reviewed 113 patients in whom 3 different surgical methods were used for cubital tunnel syndrome treatment. In situ decompression, partial epicondylectomy, and anterior subcutaneous transposition were performed from 1997 to 2007.

RESULTS

Results were graded as excellent in 51 patients (45%), good in 34 (30%), fair in 8 (7%), and poor in 20 (18%). When we compared the results among the different surgical procedures, good and excellent results were achieved in 26 of 31 patients (84%) treated with in situ decompression, 36 of 45 (80%) treated with release and partial medial epicondylectomy, and 23 of 37 (62%) treated with release and anterior subcutaneous transposition of the nerve.

CONCLUSIONS

Our results indicate that in situ decompression and partial epicondylectomy both represent efficient and safe methods for cubital tunnel syndrome management. In patients in whom anterior subcutaneous transposition was performed, although they had a significant improvement of their clinical signs and symptoms, they had an inferior outcome when compared with patients treated with the other 2 methods.

Submuscular versus subcutaneous anterior ulnar nerve transposition: a rat histologic study

PURPOSE

The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model.

METHODS

Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation.

RESULTS

Nerve health was assessed using a 4-part classification in which 4 = normal nerve, 3 = abnormal axons in one-third cross-sectional area (CSA), 2 = abnormal axons in two-thirds CSA, and 1 = abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3 = scar completely encasing nerve, 2 = scar formation partially surrounding nerve, and 1 = no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue.

CONCLUSIONS

On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method.

Patient-rated outcome of ulnar nerve decompression: a comparison of endoscopic and open in situ decompression

PURPOSE

To report patient-rated outcomes after ulnar nerve decompression at the elbow and to compare the outcome after open in situ decompression with that after endoscopic in situ decompression.

METHODS

Patients having ulnar nerve decompression were evaluated using patient-rated outcome measures. Fifty-five patients were recruited; 3 were lost to follow-up, and 18 were excluded because they had anterior transposition. Of the thirty-four patients followed up for 12 months, 19 had endoscopic decompression and 15 had open in situ decompression. Patient demographics, presenting symptoms, range of elbow movement, grip and pinch strength, and sensation were recorded preoperatively and at 12 months by an independent observer. Postoperative patient satisfaction, pain, and ongoing paresthesia were recorded using visual analog scales. Subgroup analysis was performed to compare the outcome of open in situ decompression with that of endoscopic in situ decompression.

RESULTS

At 12 months after surgery, the proportion of patients satisfied with the outcome was 9 of 15 (60%) for open in situ surgery and 15 of 19 (79%) for endoscopic in situ surgery. The postoperative complication rate was significantly higher after open in situ decompression than that after endoscopic in situ decompression surgery (10%). Preoperative function scores were predictive of patient-rated satisfaction and were related to McGowan grade.

CONCLUSIONS

The patient-reported outcome of surgical treatment of cubital tunnel syndrome is good but is affected by preoperative symptom severity. Outcomes after open and endoscopic in situ decompression, including the proportion of patients reporting satisfaction and functional improvement, are equivalent, but more patients reported complications after open decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Cubital tunnel surgery in patients with cervical radiculopathy: double crush syndrome?

To determine differences in clinical outcomes in patients harboring both cubital tunnel syndrome (CuTS) and cervical radiculopathy and the influence of the so-called double crush syndrome. Both procedures were performed in 24 patients, mean age 55 years; first group of 14 patients underwent CuTS surgery as a first procedure. Second group of 10 patients underwent anterior cervical discectomy and fusion (ACDF) then ulnar nerve release (UNR). Two patients underwent bilateral nerve surgery and six multiple cervical discectomies. Surgeries consisted in 26 nerve releases with associated external neurolysis in five, and 34 ACDF procedures, with plating in six. Clinical complaints (mean time 12 months) were sensory in 20 arms, with associated motor weakness and hypothenar atrophy involvement in another six. Electromyography changes were mild (two arms), moderate (16 arms), and severe (eight arms). Mean time of follow-up was 3 years (range 18 months-14 years). Clinical improvement was evidenced in 14 patients. Sensory nerve symptoms improved in 13 limbs in both groups and motor improvement was evident in three patients with UNR as first surgery. A comparative cohort of 20 patients with UNR but without cervical radiculopathy was studied to disclose outcome differences. Of these, 13 patients had clinical improvement. No differences were found among groups. In patients with double crush syndrome, factors that seemed to influence a poor CuTS outcome were evolution of symptoms longer than a year, history of multiple neuropathies or radiculopathies, and ACDF performed before UNR.

Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome

PURPOSE

To determine retrospectively whether the technique of ulnar nerve transposition (subcutaneous versus submuscular) is associated with clinical sensory and motor recovery in cubital tunnel syndrome, and whether recovery is influenced by prognostic factors such as preoperative McGowan stage, age, and duration of symptoms.

METHODS

Twenty-five patients (average age, 53 years; follow-up, 7 years) with cubital tunnel syndrome had submuscular transposition, and 24 patients (average age, 46 years; follow-up, 3 years) were treated by subcutaneous transposition. There were 11 McGowan stage II and 14 stage III patients in the submuscular group and 14 stage II and 10 stage III patients in the subcutaneous group. Preoperatively, all patients presented with diminished 2-point discrimination. Postoperative sensory and motor recovery was evaluated clinically.

RESULTS

There was no significant difference between subjective results in the submuscular and subcutaneous groups: 20 of 25 patients in the submuscular group versus 17 of 24 patients in the subcutaneous group were clearly improved, and 3 of 25 patients in the submuscular group versus 6 of 24 patients in the subcutaneous group partially improved. The logistic multivariate regression analysis indicated that sensory and motor function were both significantly improved following both surgical techniques. Sensory function recovered (2-point discrimination <6 mm) in 17 of 25 patients in the submuscular group and in 17 of 24 patients in the subcutaneous group, and motor function recovered (intrinsic strength grade 5) in 19 of 25 patients in the submuscular group and in 19 of 24 patients in the subcutaneous group. Symptoms lasting more than 6 months were associated with a poor prognosis.

CONCLUSIONS

Sensory and motor recovery for patients with McGowan stages II and III of cubital tunnel syndrome were similar following submuscular and subcutaneous transposition techniques, and patients with symptoms lasting longer than 6 months had a worse prognosis regardless of surgical technique.

Selection of operative procedures for cubital tunnel syndrome

The purpose of this study was to investigate the primary operative procedures that are performed by hand surgeons for cubital tunnel syndrome and their reported satisfaction with these procedures. The survey consisted of 22 questions regarding primary operative treatment of cubital tunnel syndrome and demographics and was sent by email to the 459 active members of the American Association for Hand Surgery. One hundred sixty-four surgeons completed the survey (36% response rate). The total sample included 154 hand surgeons (143 males, 11 females) who operated on cubital tunnel syndrome and the majority of surgeons were in private practice (n = 100) followed by academic practice (n = 50). The most prevalent factors that influence the decision to operate include evidence of muscle atrophy (84%), abnormal nerve conduction studies (51%), and failed non-operative treatment (49%). Most surgeons (n = 133) reported using more than one operative procedure for their patients with cubital tunnel syndrome. Factors that influenced the operative procedure selected included the degree of nerve compression (60%), medical comorbidities (30%), patient's occupation (28%), and obesity (22%). Following carpal tunnel surgery, 88% of the surgeons were "very satisfied" with their patient outcome and following surgery for cubital tunnel syndrome, only 44% were "very satisfied" with their patient outcome. Most surgeons use more than one operative procedure in their treatment of patients with cubital tunnel syndrome and the selection of the operative procedure is influenced by patient factors and surgeon preference.

Simple decompression of the ulnar nerve for cubital tunnel syndrome

OBJECTIVE

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.

METHODS

According to Dellon's criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).

RESULTS

Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8+/-15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8+/-6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8+/-12.1 m/s to 47.8+/-12.1 m/s (p<0.05). After an average follow-up of 4.8+/-5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.

CONCLUSION

Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.

Operative findings in reoperation of patients with cubital tunnel syndrome

The purpose of this study was to report the operative findings in patients who underwent a secondary operation for cubital tunnel syndrome. A chart review was performed of 100 patients who had undergone a secondary operation for cubital tunnel syndrome by one surgeon. The mean age was 48 years (standard deviation 13.5 years). The most common complaint after primary surgery was increased symptoms in the ulnar nerve distribution (n = 55) and pain in the medial antebrachial cutaneous nerve distribution (n = 55). The most common operative findings included a medial antebrachial cutaneous nerve neuroma (n = 73) and a distal kink of the ulnar nerve (n = 57). This kink was noted as the nerve moved from its transposed position anterior to the medical epicondyle to its native position within the flexor carpi ulnaris. This study suggests that during primary surgery for cubital tunnel syndrome care should be given to avoid injury to the medial antebrachial cutaneous nerve, distal kinking of the ulnar nerve with transposition and pressure on the transposed nerve by the fascial flaps or tendinous bands.

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.

Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome

The purpose of this study was to review the results of 2 surgical methods for treating cubital tunnel syndrome. From 1994 to 2001, minimal medial epicondylectomy was performed on 22 elbows, and anterior subcutaneous transposition of the ulnar nerve was done on 34 elbows. In the group treated by medial epicondylectomy, 9 of the results (41%) were excellent, 10 (45%) were good, 2 (9%) were fair, and 1 result (5%) was poor. In the group treated by anterior subcutaneous transposition of ulnar nerve, 14 of the results (41%) were excellent, 13 (38%) were good, 6 (18%) were fair, and 1 result (3%) was poor. No significant difference was found between the 2 groups (P < .05). Both methods can be used for the treatment of cubital tunnel syndrome with a high rate of satisfaction.

Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome

PURPOSE

Functional outcomes of cubital tunnel surgery may decline as the severity of preoperative ulnar neuropathy increases. When functional recovery will be adequate, or whether tendon transfers should be required, may be unclear. We investigated the extent of functional recovery, the duration of the recovery process, and the necessity of restoring intrinsic muscle function in patients with severe cubital tunnel syndrome after surgery.

METHODS

We retrospectively studied outcomes after cubital tunnel release in 15 patients with marked intrinsic muscle atrophy, claw-hand deformity, immeasurable (electrically silent) sensory and motor nerve conduction velocities, and Semmes-Weinstein test (SWT) results ranging from purple (3.84-4.31) to red (4.56-6.65). We evaluated subjective (numbness and activities of daily living [ADL] disturbances), objective (manual muscle testing [MMT] of index-finger abduction, and SWT), and neurophysiologic (nerve conduction velocity) outcomes. Overall functional outcome was evaluated by Akahori's criteria.

RESULTS

At a median follow-up evaluation of 4.5 years all outcomes had improved. Numbness was gone in 5 patients and greatly reduced in 9 patients; 6 patients reported slight difficulties in ADLs; and 9 patients had no difficulties. Motor nerve conduction velocity was measurable (mean, 35.3 m/s) in all 15 patients and sensory nerve conduction velocity was measurable (mean, 43.4 m/s) in 12. Recoveries in nerve conduction velocities persisted beyond 2 years. The SWT results were blue (3.22-3.61) in 6 patients, purple (3.84-4.31) in 8 patients, and red (4.56-6.65) in 1 patient. MMT of index finger abduction was grade 4 or 5 in 11 of 15 patients. Half the patients over 70 years old, however, were grade 3 or less. Akahori's criteria were excellent in 3 patients, good in 6 patients, and fair in 6 patients.

CONCLUSIONS

Patients with severe intrinsic muscle atrophy and absent motor and sensory nerve conduction velocities can expect satisfactory long-term functional results after surgery. Function continues to improve beyond 2 years. Restoring index finger abduction is not always necessary for ADLs, although recovery requires several years and is poorer in the elderly.

Ulnar nerve strains at the elbow: the effect of in situ decompression and medial epicondylectomy

Strains were measured in the ulnar nerve at the elbow in 10 unembalmed, intact cadavers by using a microstrain gauge. In each cadaver, strains in the ulnar nerve behind the medial epicondyle, occurring between 60 degrees and 140 degrees flexion, were calculated for the following 3 conditions: (1) initial strain before in situ decompression, (2) strain after in situ decompression, and (3) strain after in situ decompression plus medial epicondylectomy. The average strain for each group was compared by using the paired Students t-test with multiple comparisons. The average initial percent strain was not significantly reduced by in situ decompression alone (5.3% to 4.3%). However, the average percent strain after medial epicondylectomy and in situ decompression was -0.54%, which was a significant reduction from the initial percent strain and after decompression alone. In situ decompression of the ulnar nerve at the elbow alone does not relieve the tensile strains at the elbow, which may contribute to cubital tunnel syndrome. Medial epicondylectomy after in situ decompression eliminates ulnar nerve strains with elbow flexion.