Recurrent cubital tunnel syndrome. Etiology and treatment.

Controversy surrounds the treatment of recurrent cubital tunnel syndrome after previous surgery. Irrespective of the surgical technique, namely pure decompression in the ulnar groove and the cubital tunnel distal of the medial epicondyle, and the different methods of volar transposition (subcutaneous, intramuscular, and submuscular), the results of surgical therapy of cubital tunnel syndrome are often not favorable, especially in cases of long-standing symptoms and severe deficits. Twenty-two patients who had previously undergone surgical treatment for ulnar nerve entrapment at the elbow were evaluated because of persistent or recurrent pain, paresthesia, numbness, and motor weakness. Ten patients had undergone a nerve transposition, 5 patients underwent a simple decompression of the ulnar nerve, and 7 patients experienced two previous operations with different surgical techniques. Two patients underwent surgery at our hospital, whereas 20 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external neurolysis, subcutaneous anterior transposition, and subsequent transfer of the nerve back into the sulcus. The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial intermuscular septum. The average follow-up after the last procedure was 7 months (2 - 20 months). All 7 patients with subsequent transfer of the ulnar nerve back into the sulcus became pain-free, whereas only 11 of 15 patients who had external neurolysis or subcutaneous transposition became free of pain or experienced reduced pain. The recovery of motor function and return of sensibility were variable and unpredictable. In summary, reoperation after primary surgery of cubital tunnel syndrome gave satisfactory results in 18 of 22 cases. Subsequent transfer of the ulnar nerve back into the sulcus promises to be useful in cases in which subcutaneous transposition had not been successful.     

The failed ulnar nerve transposition. Etiology and treatment

Various procedures have been recommended for the treatment of cubital tunnel syndrome. Simple decompression in situ, medial epicondylectomy, subcutaneous transposition, intramuscular transposition, and submuscular transposition all have their advocates. The results of the surgical treatment for cubital tunnel syndrome are related to the severity of the compressive neuropathy at the time of diagnosis and to the adequate decompression of the nerve at all sites of potential compression at the time of surgical treatment. Fourteen patients who had previously undergone surgical treatment for cubital tunnel syndrome were evaluated because of persistent pain, paresthesia, numbness, and motor weakness. All patients had documented persistent compression of the ulnar nerve on clinical and electromyographic evaluation. The indication for repeat surgical exploration in all patients was unremitting pain despite nonoperative treatment. All patients had been treated by neurolysis and submuscular transposition of the ulnar nerve as described by Learmonth. The causes of continued pain after initial surgery included retention of the medial intermuscular septum, dense perineural fibrosis of the nerve after intramuscular and subcutaneous transposition, adhesions of the nerve to the medial epicondylectomy site, and recurrent subluxation of the nerve over the medial epicondyle after subcutaneous transposition. Revision surgery was found to be highly successful for relief of pain and paresthesias; however, the recovery of motor function and return of sensibility were variable and unpredictable.     

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 outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis

Background

Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period.

Methods

We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis .

Results

In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms.

Conclusions

In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.     

Anterior intramuscular transposition with ulnar nerve decompression at the elbow

The effectiveness of decompression and anterior intramuscular transposition of the ulnar nerve for treatment of severe cubital tunnel syndrome was evaluated. A consecutive series of 39 anterior intramuscular transpositions were reviewed. One surgeon performed the transpositions between 1993 and 1997 in 34 patients who presented with clinically severe cubital tunnel syndrome. Clinical outcome and satisfaction with surgery were assessed. The results showed early clinical improvement of 77% of patients (mean followup, 3.34 months). With repeated assessments later, the same group of patients had clinical improvement of 62% (mean followup, 30.9 months). Patients younger than 50 years, individuals who underwent external neurolysis, or patients who had a previously failed subcutaneous transposition had fewer satisfactory results.     

Reoperation in high ulnar neuropathy

Twenty-two reoperations were done on 16 arms in 14 patients who had previously been unsuccessfully treated by neurolysis for cubital tunnel syndrome. For the first reoperation subcutaneous transposition was chosen for 10 arms, and submuscular transposition for six. The symptoms were cured or improved in seven arms, eight were unchanged and one was made worse. In six arms in which first neurolysis and then subcutaneous transposition had been unsuccessful, submuscular transposition was carried out. Five patients were improved or cured, and the symptoms were unchanged in one. Reoperation after ulnar neurolysis therefore gave satisfactory results in about half the cases. Submuscular transposition carried out as a second reoperation may be useful in cases in which subcutaneous transposition had not been successful.     

肘管综合征135例尺神经皮下前移术疗效分析

目的 随访肘管综合征135例尺神经皮下前移术治疗效果.方法 分析2002年2月一2005年12月,135例肘管综合征尺神经皮下前移患者的病情特点及效果.其中男109例,女26例,男女比例为4.2:1.41岁以上占68.1%.以手指活动笨拙就诊15例(占11%);电生理检测均有尺神经肘部段卡压征象.42例合并肘部骨折史.占病因的31%.135例均采用尺神经外膜松解,皮下前移术.结果 术后92例获得2-5年随访.平均2.5年;43例失访.按中华医学会手外科学会上肢功能评定标准,本组优72例,良12例,差8例,优良率为91.3%.结论 尺神经皮下前移术简单、有效,术中应保护前臂内侧皮神经、尺神经血供及分支,并确保尺神经无张力.应重视因肘部骨折和以手部活动笨拙为主要症状的早期诊治.     

Cubital tunnel syndrome: evaluation of anterior subcutaneous transposition of the ulnar nerve]

57 cases of cubital tunnel syndrome were treated by anterior subcutaneous transposition of the ulnar nerve. Physical examination showed that ulnar nerve function--motor and sensory improved after surgery treatment. Subcutaneous transposition is a reliable and effective surgical option.     

Cubital tunnel syndrome. Treatment by decompression without transposition of ulnar nerve.

Cubital tunnel syndrome is the second most common entrapment neuropathy in the upper limb; however, surgical treatment of the ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous, submuscular or intramuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. This paper presents the experience of treating cubital tunnel syndrome with simple decompression in 40 patients. Three months after surgery 23/36 patients did not feel any pain in their operated hands. In 11/36 cases we observed an improvement of preoperative pain. Sensory disturbances disappeared completely in 24/40 cases. 11/40 patients reported an improvement of preoperative dysesthesia or hypesthesia. In 12/22 patients we observed complete recovery of preoperative pareses of adductor muscle of thumb or hypothenar muscles weakness. 7/22 cases demonstrated an improvement of these pareses. In total 28 patients (70 %) had an excellent outcome without residual symptoms. For 5 patients treatment results were classified as good with slight residual pain and sensory disturbance (12.5 %). In 4 cases (10 %) we only observed a fair outcome with persistent severe sensory and motor deficits but slow improvement over the last three months. Three patients did not demonstrate any improvement (7.5 %). The mean duration of postoperative disablement in our working patients (18/40) was 28 days. In summary, simple decompression of the ulnar nerve seems to be an adequate and successful minimally invasive technique for the treatment of cubital tunnel syndrome.     

Severe tardy ulnar nerve palsy caused by traumatic cubitus valgus deformity: functional outcome of subcutaneous anterior transposition

Ten male patients with McGowan's grade III ulnar neuropathy due to traumatic cubitus valgus deformity underwent anterior subcutaneous ulnar transposition. Evaluation was performed using subjective and objective measures, and a modified Bishop score. After operation, subjective sensory and motor disturbances were improved or resolved in most of the patients, while objective measures improved less well. Improvement in two-point discrimination (2PD) was consistently associated with symptom relief. All of the patients reported satisfaction with the operation. There were no complications or recurrences. The results of ulnar nerve transposition in our patients were comparable to the results of this operation in patients with severe idiopathic cubital tunnel syndrome. Although the outcome of surgery is not always satisfactory in severe ulnar neuropathy, symptom relief may justify performing the operation.     

Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation

Ten patients who had persistent or recurrent paresthesias, muscular weakness, or sensory loss following transposition of the ulnar nerve at the elbow were explored. Operative findings included compression of the nerve at the intermuscular septum or at the entrance to the cubital tunnel, dense scarring after intramuscular transposition, and constriction by fascial slings. The average interval from the previous operation to re-exploration was 13 months. All patients were improved following neurolysis and submuscular transposition. Recovery was incomplete in nine patients. The average follow-up was 14.5 months.     

尺神经外膜松解前置筋膜皮下组织瓣悬吊治疗重度肘管综合征

目的评价尺神经外膜松解前置筋膜皮下组织瓣悬吊治疗重度肘管综合征的临床疗效。方法自2005年2月-2008年8月,对重度尺神经肘管综合征行外膜松解、前置、筋膜皮下组织瓣悬吊68例。结果59例随访3～48月,平均随访18月,按2000年手外科学会上肢部分功能评定试用标准评价,优良率80．9％。结论采用尺神经外膜松解前置筋膜皮下组织瓣悬吊治疗重度肘管综合征疗效满意。     

Intermediate and long-term outcomes following simple decompression of the ulnar nerve at the elbow

INTRODUCTION: There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow. METHOD: Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0-12.4 years postoperatively. Ulnar nerve conduction studies (slowest conducting 5 cm segment of ulnar nerve motor fibers measured at the elbow) were performed both pre- and postoperatively. The primary clinical outcome was percentage relief of symptoms, divided into "excellent" outcome group or less (> or = 90% improvement or < 90% improvement). RESULTS: Ulnar nerve conduction improved pre- to postoperatively, but clinical improvement was not related to changes in velocity. Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release. DISCUSSION: Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain.     

肘部单切口下二氧化碳灌注内窥镜辅助下尺神经松解及前置术

目的 介绍一种在单个小切口下利用二氧化碳(CO2)气泵于肘部尺神经行经处创造气腔,在内窥镜辅助下彻底松解尺神经并前置的方法.方法 2005年至2008年,对12例临床确诊为肘管综合征的患者在肘内侧做单个纵行小切口,利用气腹机在肘部皮下与前臂或臂部深筋膜之间产生的CO2气腔内,采用℃角内窥镜下行尺神经松解及屈肌筋膜下前置术.采用Dellon及改良Bishop评分系统进行手术前后评估.结果 术前根据Dellon评分,12例肘管综合征中轻度5例、中度5例、重度2例.肘部手术切口长(15±3)mm,CO2气腔均成功建立,尺神经松解长度为(18±2)cm,内窥镜下的神经松解及筋膜下前置手术均顺利,整个手术持续时间为(30±5)min.术后所有患者的尺神经症状均较术前有改善,无并发症发生.随访时间为12～18个月,按改良Bishop 评分:优10例(占83.3％),良2例(占16.7％).结论 肘部单个小切口下,CO2灌注产生的皮下气腔可以更好地暴露尺神经,结合内窥镜肘部尺神经松解及前置术减少了对神经分支及血供的损伤.该方法简单安全,创伤小,恢复快.     

Postoperative clinical results in cubital tunnel syndrome

This article reports on factors affecting the postoperative results in cubital tunnel syndrome. We evaluated 111 limbs of 107 patients who had been surgically treated for cubital tunnel syndrome. Average patient age was 43.9 years (range: 11-77 years). Postoperative follow-up ranged from 1 to 17 years (mean: 5.2 years). Causal diseases included cubitus valgus following fractures in childhood in 43 limbs, osteoarthritis in 45 limbs, and others in 23 limbs. Surgical treatment involved King's method for 66 limbs, anterior transposition for 41 limbs, and Osborne's method for 4 limbs. Preoperative severity and postoperative results were evaluated according to the critera for evaluation of ulnar nerve palsy of Yokohama City University. Preoperative severity was stage I in 19 limbs, stage II in 12 limbs, stage III in 41 limbs, and stage IV in 39 limbs. Postoperative results at final evaluation were excellent in 37 limbs, good in 39 limbs, fair in 26 limbs, and poor in 9 limbs. Age at surgery, duration of cubital tunnel syndrome, preoperative severity, and clinical symptom score and motor nerve conduction velocity in the early postoperative stage (one month after surgery) were found to be important prognostic factors of the syndrome.     

肘管综合征的成因和神经学检查

肘管综合征是常见的周围神经嵌压症之一。我院1990年12月—1995年12月共收治该症22例,均经严格的神经学检查和病因学分析后确诊,治疗全部行尺神经前移术。术后随访20例,平均随访2年5月,12例恢复正常,6例明显好转,2例较差。作者认为,当手部感觉改变和运动障碍为单纯尺神经损伤引起,肌电图提示尺神经传导速度在肘管部减慢,肘管内或外可找到神经受损原因,肘管综合征即可确诊;当肌电提示尺神经传导在肘管部减慢,而肘管内或外找不到神经受损原因,应高度疑诊肘管综合征。     

带尺侧下副动脉尺神经松解前置术治疗肘管综合征

目的 总结带尺侧下副动脉尺神经松解前置术治疗肘管综合征的手术方法及临床效果.方法 2005年9月-2006年5月,采用保留尺侧下副动脉在尺神经上的吻合支,行带血供尺神经松解前置术治疗25例肘管综合征.男19例,女6例:年龄20～72岁,平均60岁.发病至手术时间2个月～3年,平均6.7个月.发病原因:骨性关节炎23例,肘管内囊肿及尺神经滑脱各1例.术前按Pasque肘管综合征评分系统评定:可19例,差6例.电生理检查:肘关节周围尺神经运动神经传导速度<42 m/s.结果 术后切口均1期愈合,无手术并发症及复发患者.25例术后均获随访,随访时间1年～2年半,平均13.9个月.按Pasque肘管综合征评分系统评定:优15例,良9例,可1例,优良率96%;与术前评定结果比较,差异有统计学意义(P＜0.05).电生理检查;肘关节周围尺神经运动神经传导速度>42m/s.结论 带尺侧下副动脉尺神经松解前置术是治疗肘管综合征的安全有效方法之一.     

Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome

The purpose of this prospective randomised study was to evaluate which operative technique for treatment of cubital tunnel syndrome is preferable: subcutaneous anterior transposition or nerve decompression without transposition. This study included 66 patients suffering from pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome. Thirty-two patients underwent nerve decompression without transposition and 34 underwent subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits as well as motor nerve conduction velocities, were performed 3 and 9 months postoperatively. There were no significant differences between the outcomes of the two groups at either postoperative follow-up examination. We recommend simple decompression of the nerve in cases without deformity of the elbow, as this is the less invasive operative procedure.     

Cubital tunnel syndrome associated with medial elbow Ganglia and osteoarthritis of the elbow

BACKGROUND: Medial elbow ganglia have been reported in association with cubital tunnel syndrome. This lesion is thought to occur rarely and has not been emphasized in the literature. The purposes of the present study are to report our experience with this lesion in order to elucidate its prevalence as well as its clinical and radiographic features, to describe our operative findings, and to present the results of surgical treatment. METHODS: Four hundred and eighty-seven elbows in 472 patients were treated for cubital tunnel syndrome between 1980 and 1999. We performed a retrospective study of the thirty-eight patients who had a medial ganglion. All of the ganglia were excised, and the ulnar nerve was translocated subcutaneously. Thirty-two patients were followed for a mean of thirty-seven months. RESULTS: Medial elbow ganglion was the third most common causative factor associated with cubital tunnel syndrome, with an overall prevalence of 8%. Resting pain in the medial aspect of the elbow was reported by twenty-five of the thirty-eight patients, and a sudden onset of numbness in the ring and little fingers or of medial elbow pain without prior symptoms was reported by twenty-nine patients. The symptoms lasted two months or less in thirty-one patients. All ganglia originated from the medial aspect of the ulnohumeral joint, and radiographs of that joint showed degenerative changes in thirty-seven patients. At the time of follow-up, all measurements of sensory and motor function of the ulnar nerve had improved and no recurrence of nerve palsy was found. CONCLUSIONS: Although uncommon, medial elbow ganglia have a strong association with osteoarthritis of the elbow and can cause a relatively acute onset of cubital tunnel syndrome. A patient with cubital tunnel syndrome associated with elbow osteoarthritis who complains of medial elbow pain or severe numbness within two months after the onset of the syndrome should be strongly suspected of having a ganglion. Most ganglia are occult, and ultrasonography and magnetic resonance imaging can assist in the preoperative diagnosis. Careful excision of the ganglion performed concurrently with subcutaneous anterior transposition of the ulnar nerve can produce satisfactory results.     

肘管综合征的手术治疗

目的：探讨尺神经松解前移手术治疗肘管综合征的临床效果。方法：工治疗肝管综合征26例，观察尺侧上副供血情况。结果：经随访，本组病例尺神经功能有较大改善。结论：尺神经松解前移术为治疗肘管综合征的较佳术式。