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.     

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report

IntroductionIntraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves. While the most common location of intraneural ganglion cysts is the ulnar nerve and its branches, intraneural ganglion cyst involving the superficial branch of the ulnar nerve has not yet been reported.Presentation of caseA-25-year-old woman presented with pain and a palpable mass in the hypothenar region of the volar side of her right hand. Her neuromuscular examination was normal. The pain was unresponsive to nonsurgical treatments. After confirming with imaging modalities, the initial diagnosis was considered as an intraneural ganglion cyst arising from superficial ulnar nerve. Excision of the ganglion and exploration of the articular branch (if seen in operation) decision was undertaken by the senior author. Whether MRI or intraoperative exploration, not identified an articular branch.DiscussionIntraneural ganglion cysts of peripheral nerves may be seen in miscellaneous locations in the body. However, to our knowledge, an intraneural ganglion cyst involving the superficial branch of the ulnar nerve is unique. While a variety of theories have been proposed to enlighten the etiopathogenesis of intraneural ganglia, the latest and most affirmed is the unifying articular (synovial) theory.ConclusionIntraneural ganglion cysts may be seen on the hypothenar side of the palm. The etiology and treatment of choice are closely associated with each other in this rare disorder. It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.     

带伴行动脉尺神经前置治疗肘管综合征

目的 探讨带伴行动脉尺神经松解前置术治疗肘管综合征的临床效果.方法 对28例肘管综合征患者,施行带伴行动脉尺神经前置术.术中观察肘管段尺神经的血供方式,术后观察其疗效.结果 术后随访时间平均为8.9个月,按肘管综合征评分系统评定:优17例,良10例,可1例,差0例;优良率为96%.术后无并发症及复发病例.结论 带伴行动脉尺神经松解前置术是治疗肘管综合征的一种安全有效的方法.     

The cubital tunnel syndrome caused by the two synovial cysts

The cubital tunnel syndrome caused by several synovial cysts has been rarely reported. In our case, a 63-year-old man had sensorial and motor complaints at the ring and little fingers of the right hand. The claw deformity and the atrophy of the hypothenar and interosseous muscles in the right hand were discovered on physical examination. Froment's sign was positive. Electromyography showed prolonged distal latencies and slowed conduction for ulnar nerve. A small spherical cyst within the cubital tunnel and another spindle-shaped cyst at the distal to the cubital tunnel were found to compress and wrap the ulnar and its branches intra-operatively. Finally, the cysts were removed and the ulnar nerve was decompressed and performed its anterior transposition. Synovial cysts were confirmed by histopathological examination.     

Endoscope-assisted microsurgical resection of an intraneural ganglion cyst of the hypoglossal nerve

An unusual case of an intraneural ganglion cyst of the hypoglossal nerve is presented. Only one case of this rare clinical entity has been reported previously. A 51-year-old woman presented with a 6-month history of left-sided hypoglossal nerve palsy. Magnetic resonance imaging revealed a cystic lesion related to the hypoglossal canal. There was no enhancement of the lesion after administration of Gd. A high-resolution computerized tomography scan of the skull base demonstrated an enlargement of the hypoglossal canal. To access the lesion, a far-lateral endoscope-assisted microsurgical approach was used. An intraneural ganglion lesion invading the hypoglossal nerve was found and resected. A histopathological examination confirmed that the lesion was an intraneural ganglion cyst. The occurrence of an intraneural ganglion cyst at the hypoglossal nerve is very rare. This case exemplifies an atypical location of a synovial cyst with cranial nerve involvement.     

Intraoperative measurement of pressure adjacent to the ulnar nerve in patients with cubital tunnel syndrome

PURPOSE: Little is known about whether the pressure adjacent to the ulnar nerve actually is increased in patients with cubital tunnel syndrome or if it is a causative factor. We measured the pressure adjacent to the ulnar nerve in patients with cubital tunnel syndrome during surgery and verified whether or not there was an association with patient age, duration of the disease, motor nerve conduction velocity, and severity of the ulnar nerve neuropathy. METHODS: Eight elbows in 8 patients with an average age of 62 years were treated surgically and the extraneural pressures within the cubital tunnel were measured during surgery by using a fiberoptic microtransducer. Pressure was measured 3 times with the elbow fully extended and then 3 times with the elbow flexed 130 degrees. The transducers were placed at 1, 2, and 3 cm distal to the proximal edge of the Osborne ligament. The severity of the neuropathy was evaluated according to Akahori's classification. The ulnar nerve palsy was graded as stage III in 5 patients and as stage IV in 3 patients. RESULTS: The average pressures within the cubital tunnel at 1, 2, and 3 cm distal to the proximal edge of the cubital tunnel retinaculum with the elbow flexed were 105, 29, and 18 mm Hg, respectively. The pressures at 1 and 2 cm distal to the proximal edge of the cubital tunnel retinaculum were significantly higher in elbow flexion than in elbow extension. There was also a positive correlation between the pressure and patient age but this was not significant The pressures correlated significantly with the stage of ulnar nerve neuropathy, motor nerve conduction velocity, and disease duration. CONCLUSIONS: The extraneural pressure within the cubital tunnel actually was increased in the patients and compression of the ulnar nerve might be a causative factor of cubital tunnel syndrome.     

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。     

Endoscopic approach to cubital tunnel syndrome

The cubital tunnel syndrome is one of the most common entrapment neuropathy of the upper limb. The ulnar nerve can be compressed in the oteofibrous tunnel by the bone structures, the Osborne's ligament, the fascia of the ulnar flexor muscle of the carpus or of the aponeurosis of the deep flexor of the fingers. Pressure values in the cubital tunnel >50 mm Hg induce blocking of intraneural circulation with electrodiagnostic modifications, clinical signs and histological changes including demyelinazion of the nerve proximal to the cubital tunnel. Surgery becomes essential in case of failure of conservative and physical therapy. Various surgical techniques have been described in the literature for the treatment of the ulnar neuropathy at the elbow. In this paper the authors report a new endoscopic technique for the treatment of ulnar nerve entrapment at the elbow which requires respect of specific electrodiagnostic and clinical criteria of inclusion. The restored joint active motion following elbow arthroscopy in osteoarthritis can induce or get worse a ulnar nerve neuropathy; endoscopy neurolysis is essential to remove perineural adherences and reduces the nerve stress. Immediate well-being of the patient, lesser invasiveness and minimum vascular complications are clear advantages of the endoscopic approach, while the treatment of the pathologies proximal and distal to the Struther's arcade is a limit of the technique.     

Macrodactyly in ulnar nerve distribution associated with cubital tunnel syndrome

Isolated macrodactyly in the ulnar nerve distribution is extremely rare. A case associated with cubital tunnel syndrome is reported.     

Strain on the ulnar nerve at the elbow and wrist during throwing motion

BACKGROUND: It is well known that cubital tunnel syndrome frequently occurs in throwing athletes. The cause of cubital tunnel syndrome is considered to be mechanical stimuli on the ulnar nerve in the cubital tunnel. The hypothesis of the present cadaveric study was that the ulnar nerve is subjected to longitudinal strain in the cubital tunnel during the throwing motion. METHODS: Four phases of throwing (stance, wind-up, middle cock-up, and early acceleration) were passively simulated in seven fresh-frozen transthoracic cadaveric specimens that were fixed in an upright position to allow free arm movement. In each throwing phase, the elbow was sequentially flexed from 45 degrees to 90 degrees to 120 degrees to maximum flexion. The longitudinal movement of and strain on the ulnar nerve were measured with use of a caliper and a strain gauge at the proximal aspects of both the cubital tunnel and the canal of Guyon. RESULTS: The movement of the ulnar nerve at the proximal aspect of the cubital tunnel was significantly increased during all throwing phases with increased elbow flexion (p < 0.05). An average maximum movement of 12.4 +/- 2.4 mm was recorded during the wind-up phase with maximum elbow flexion. The movement at the proximal aspect of the canal of Guyon was approximately two-thirds of that at the proximal aspect of the cubital tunnel. The strain on the ulnar nerve at the proximal aspect of the cubital tunnel was significantly increased with elbow flexion in the stance, wind-up, and middle cock-up phases (p < 0.05). An average maximum strain of 13.1% +/- 6.1% was recorded during the early acceleration phase with maximum elbow flexion. The strain at the proximal aspect of the canal of Guyon was approximately half of that at the proximal aspect of the cubital tunnel. CONCLUSIONS: In the present study, the maximum strain on the ulnar nerve during the acceleration phase was found to be close to the elastic and circulatory limits of the nerve.     

The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow

The purpose of this report was to investigate the vascular anatomy of the ulnar nerve at the elbow with a technique of combined India ink and latex injection followed by nondissection chemical debridement. Twenty-two fresh human cadaveric arms were injected with India ink to stain the intraneural microcirculation followed immediately by latex injection and chemical debridement for study of the extraneural vascularization. After clearing with a modified Spalteholtz technique, the intraneural blood supply was studied in 10 of the specimens. The findings demonstrated a consistent but segmental extraneural and intraneural vascular supply from the superior ulnar collateral, inferior ulnar collateral, and posterior ulnar recurrent arteries. No identifiable direct anastomosis was seen between the superior ulnar collateral and posterior ulnar recurrent arteries in 20 of 22 arms. The inferior ulnar collateral artery provided the only direct vascularization to the nerve in the region just proximal to the cubital tunnel. Although the clinical importance of maintaining specific arterial sources to the ulnar nerve has not been determined, these anatomic findings indicate that the arterial contribution from the inferior ulnar collateral artery may be more important than appreciated previously.     

高分辨率超声检测尺神经直径在肘管综合征中的应用

目的：评价高分辨率超声在肘管综合征诊断及预后中的价值。方法：自2018年1月至2019年6月,采用尺神经松解并皮下前置术的方法治疗47例肘管综合征患者。男41例,女6例;年龄27~73岁;右侧31例,左侧15例,双侧1例。术前、术后应用高分辨率超声检测尺神经直径,术中直观下进行测量,以尺神经功能评定试行标准评估患者恢复状态,并调查患者满意度。结果：47例患者术后切口均为Ⅰ级愈合并全部获得随访,于出院后12个月进行随访。术前尺神经受压部位的直径（0.16±0.04） cm,术后为（0.23±0.04） cm。尺神经功能评定结果：优16例,良18例,可13例。术后12个月满意度结果：满意28例,一般10例,不满意9例。结论：高分辨率超声术前检查与术中直观测量一致,术后高分辨率超声检查结果与随访结果一致,高分辨率超声为肘管综合征诊治的有效辅助手段。     

Anterior subfascial transposition of the ulnar nerve

After anterior subfascial transposition, the ulnar nerve lies superficial to the flexor-pronator muscle group but deep to its fascia. Eight patients with cubital tunnel syndrome were treated with this method and reviewed retrospectively. The average age at the time of operation was 52 years. All patients had severe cubital tunnel syndrome based on Dellon's classification. The average follow-up period was 2 years and 9 months. Post-operative outcome assessment was based on the modified Bishop rating system. Six patients had excellent and two had good outcomes. All were back at work by the 5th post-operative week. There were no complications or recurrence of symptoms. Anterior subfascial transposition of the ulnar nerve is an effective method of surgical treatment for patients with severe cubital tunnel syndrome.     

The external compression syndrome of the ulnar nerve at the cubital tunnel

Diagnosis of the cubital tunnel external compression syndrome, and subsequent avoidance of further external pressure, minimizes the possibility of progressive crippling of the hand. The usual clinical features are local tenderness over the cubital tunnel, often accompanied by distal paresthesias, and neurological deficit in the ulnar nerve distribution with sparing of the flexor digitorum profundus and flexor carpi ulnaris muscles; the elbow flexion test, described by the author, awaits evaluation in the diagnosis of the syndrome. Clinicians and others concerned with positioning patients on the operating room table or caring for patients in the ward should be aware of the syndrome. Avoidance of a position of the elbow which predisposes to external compression of the cubital tunnel is mandatory and active elbow movement should be encouraged in bedridden and chair-bound patients. Surgical treatment is sometimes indicated, at least to halt progression of the palsy. A classification of the cubital tunnel syndrome is proposed: physiological, acute and subacute due to external pressure (both forming the cubital tunnel external compression syndrome) and chronic (space-occupying lesions and loss of volume due to lateral shift of the ulnar as a consequence of childhood injury to the capitular epiphysis). Nerve conduction studies may be helpful in the diagnosis of the doubtful cubital tunnel syndrome, particularly when there is definite impairment of power or sensation in the hand.     

Endoscopically assisted release of the ulnar nerve for cubital tunnel syndrome

Purpose  

Recently, the simple decompression of the ulnar nerve has been advocated as the best surgical approach for the treatment of the cubital tunnel syndrome. Encouraged by the positive results observed with the use of the endoscopic approach for the treatment of the carpal tunnel syndrome, there have been reports about the use of endoscopes for decompression of the ulnar nerve at the level of the elbow since 1999. The objective of this study was to demonstrate the surgical results obtained with a simple and replicable technique employed for endoscopic release of the ulnar nerve in cases of cubital tunnel syndrome.     

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.     

Diagnostic ultrasonography of the ulnar nerve in cubital tunnel syndrome

Thirty-two elbows in 31 patients diagnosed as having cubital tunnel syndrome underwent ultrasonographic examination to assess morphological changes in the ulnar nerve and its surrounding tissues. On longitudinal images, the site of constriction due to the fibrous band and proximal swelling of the nerve were observed by ultrasonography and were confirmed intraoperatively. On axial images, the lengths of the major axis [7.2 (SD 1.6) mm] and the minor axis [3.7 (0.9) mm] of the nerve at the medial epicondyle were greater than those in normal subjects. There was a correlation between the stage of ulnar nerve palsy and the diameter of the major axis. Preoperatively, ganglia were detected by ultrasonography in the cubital tunnel in three cases and an anconeus epitrochlearis muscle in two.     

Intraneural ganglion in the peroneal nerve]

Report of a case of an intraneural ganglion in the peroneal nerve. Reviewing the literature this rare case of peroneal nerve palsy is discussed. The therapy consists in an operative decompression of the nerve by excision or incision of the ganglion cyst.     

Intraneural ganglion cysts: a case of sciatic nerve involvement.

The pathogenesis of intraneural ganglion cysts is unknown. Some authors have established a connection between the cysts and the joint, while others have failed to find this communication. Most intraneural ganglion cysts occur in the proximity of a joint. We present the case of a 53-year-old Caucasian male with an intraneural cyst of the sciatic nerve located high above its bifurcation and without a connection to the joint. The lesion was microsurgically removed in toto. There was no recurrence of the cyst at follow-up 9 months postoperatively; complete resolution of the clinical symptoms occurred within 8 months of surgery. This case shows that ganglion cysts can occur in locations far from a joint, supporting the extra-articular embryonic synovial remnant theory of their genesis.     

Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression.

In it's native position, deep to Osborne's ligament, within the retrocondylar groove of the elbow, the ulnar nerve courses with a significant lever distance posterior to the elbow axis of rotation. In this position, flexion of the elbow places longitudinal traction and local compression forces on the nerve. This biomechanical consideration, as well as variations in anatomy, may potentially contribute to a decrease in the nerve's microcirculation and partial pressure of oxygen, leading to cubital tunnel syndrome. Anterior transposition of the ulnar nerve at the elbow for cubital tunnel syndrome will eliminate natural as well as pathological traction and compression forces; the procedure relieves the nerve of potential microcirculation compromise. Risks of mobilizing the nerve for transposition, however, include iatrogenic ischemia from segmental separation of the nerve from its mesentery-like extrinsic blood supply. Intrinsic interstitial "step-ladder" vessels within the substance of the ulnar nerve allow it to be separated from its extrinsic circulation safely, making anterior transposition a logical and reasonable choice for cubital tunnel syndrome requiring operative intervention.