Prospective cohort study of symptom resolution outside of the ulnar nerve distribution following cubital tunnel release

BackgroundResolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after release of the ulnar nerve at the elbow.MethodsTwenty patients with isolated cubital tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones, and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected. The same data were collected at 6-week follow-up. Paired t tests or non-parametric Wilcoxon Signed-Rank tests were used where appropriate to examine for significant (p ≤ 0.05) changes between pre- and post-operative scores.ResultsProbability of resolution was greater outside of the ulnar nerve distribution than within at early follow-up. There was a decrease in pain, numbness, and tingling symptoms both within and outside the ulnar distribution after cubital tunnel release. There was a decrease in pain as measured by several validated questionnaires.ConclusionThis study documents resolution of symptoms in an extra-ulnar distribution after cubital tunnel release. Improvement in pain and function after cubital tunnel release may be associated with an improvement in symptoms both within and outside the ulnar nerve distribution. Future studies could be directed at correlating pre-operative disease severity with probability of extra-territorial symptom resolution using a larger sample population.     

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.     

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.     

Stabilized subcutaneous transposition of the ulnar nerve

We treated 50 patients (average age 47.9 years) with a stabilized subcutaneous transposition of the ulnar nerve. The average follow-up period was 42.4 months. The indication was cubital tunnel syndrome in 19 patients and injuries around the elbow in 31 patients. Postoperatively, satisfactory results were obtained in all the patients, and there was no complication or aggravation of the preoperative symptoms. None of the patients experienced slipping back of the nerve to the cubital tunnel. In the 31 patients with injuries around the elbow, there was only one patient with transient aggravation of parasthaesiae in the ulnar nerve region. Stabilized subcutaneous transposition is a simple and less invasive procedure that can facilitate decompression and prevent slipping back of the nerve. This procedure also can be applied to patients with injuries around the elbow that require ulnar nerve transfer.

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Résumé Nous avons traité 50 malades (âge moyen 47.9 années) avec une transposition sous-cutanée stabilisée du nerf cubital. La durée du suivi moyen était 42.4 mois. L'indication était un syndrome du tunnel cubital chez 19 malades et une blessure autour du coude chez 31 malades. Des résultats post-opératoires satisfaisants ont été obtenus pour tous les malades, et il n'y avait aucune complication ou aggravation des symptômes pré-opératoires. Aucun des malades n'a souffert du recul du nerf cubital en arrière. Chez les 31 malades avec une blessure, seulement un patient a eu une aggravation transitoire des paresthésies dans le territoire cubital. La transposition sous-cutanée stabilisée est une procédure simple et moins envahissante qui peut faciliter la décompression et prévenir le déplacement du nerf en arrière. Cette procédure peut aussi être appliquée aux malades avec une blessure du coude qui exige un transfert cubital.

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First presented at the SICOT World Congress 2002, San Diego, California, USA     

超声检查在肘管综合征诊治中的应用

目的探讨超声检查在诊断和治疗肘管综合征中的临床意义。方法对34例临床及肌电图检测确诊为肘管综合征的患者，分轻、中、重度三期，应用B超进行检测，与30例（60侧）健康人肘管B超检查结果进行对比研究；同时将B超发现的形态学异常表现与术中所见进行对比研究。结果B超检查显示肘管综合征患者尺神经横截面积，尺神经厚度，尺神经横截面积肿胀率，尺神经厚度肿胀率平均值均大于对照组；随着临床症状逐渐加重，尺神经横截面积肿胀率增大，而尺神经肘段运动传导速度减慢。同时B超发现的形态学异常表现，与术中所见一致。结论B超检查对肘管综合征的诊断、尺神经病变程度的分期，以及治疗方式的选择均有参考价值，为临床提供了一种简单、可靠、无创的检测方法。     

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。     

The elbow flexion test. A clinical test for the cubital tunnel syndrome

The elbow flexion test is a little known, inadequately standardized, and poorly understood clinical test for the cubital tunnel syndrome. To evaluate and define this test, 13 patients with clinical and electrophysiologic evidence of cubital tunnel syndrome were tested with elbow flexion in a standardized manner. This consisted of full elbow flexion with full extension of the wrists for three minutes. All patients noted the onset of or the increase in one or more of the symptoms of pain, numbness, or tingling with this test. Numbness and tingling followed the sensory distribution of the ulnar nerve, but pain was not limited to the ulnar nerve distribution. The symptom complex, rapid onset, and rapid resolution of symptoms support a locally induced segmental ulnar nerve ischemia as the cause of symptoms. This study demonstrates the elbow flexion test to be a useful, reliable, and provocative test for the cubital tunnel syndrome.     

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.     

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.     

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.     

肘管综合征的解剖和病因学探讨

[目的]探讨肘管综合征的解剖特点和发病原因。[方法]对65例肘管综合征患者的临床资料和术中所见,以及其中25例患者术前肌电图检查的结果进行综合研究分析。[结果]术中见60例患者存在肘管弓状韧带的肥厚增生,卡压磨损尺神经导致炎性病变;术前肌电图检查发现25例患者的尺神经传导速度均减慢,平均传导速度为27.97m/s;运动反应波幅降低,平均电压为1.95mv;潜伏期延长,平均时间为5.41ms;65例肘管综合征患者,继发于肘部创伤25例,慢性劳损15例,慢性骨关节炎14例,占位病变5例,先天异常有6例。[结论]肘部的创伤及慢性劳损可以导致肘管弓状韧带出现肥厚增生,引起尺神经卡压磨损,这是肘管综合征最常见的病因;其他病因还包括慢性骨关节炎,占位病变和先天异常;尺神经可被机械性卡压和磨损,出现慢性缺血缺氧,导致肘管综合征的发生;详细的体格检查和术前的肌电图检查是诊断肘管综合征的主要手段,在诊断时应注意该病与其他部位迟发性尺神经麻痹的鉴别。     

Ulnar nerve entrapment neuropathy at the elbow: simple decompression

Ulnar nerve entrapment neuropathy at the elbow, or the cubital tunnel syndrome, is frequently encountered in neurosurgical practice as the second most common peripheral nerve entrapment after carpal tunnel syndrome. Patients typically present with weakness or atrophy of the hand as well as paresthesias in the ulnar nerve distribution. The diagnosis can be confirmed with a careful clinical examination and electrophysiological studies. Patients who have failed conservative therapy are considered for surgery. Although a number of surgical options are available, simple decompression of the ulnar nerve can achieve satisfactory results with appropriate patient selection. We describe the relevant anatomy and surgical techniques for simple in situ decompression of the ulnar nerve at the elbow.     

Operative Therapie des Sulcus-ulnaris-Syndroms am osteoarthrotischen Ellbogengelenk

Objective Decompression of the ulnar nerve and removal of osteophytes and free bodies to improve function, to relieve symptoms, and to lessen signs of cubital tunnel syndrome through a single incision. Indications Cubital tunnel syndrome secondary to a progressing osteoarthritis, with chronic pain, impaired function and grade II or III symptoms of an ulnar entrapment neuropathy. Contraindications Neglected cubital tunnel syndrome with advanced muscle atrophy and marked sensory disturbances. Severe osteoarthritis of elbow joint. Surgical Technique Single posteromedial skin incision with longitudinal splitting of the common tendon of the triceps brachii muscle. To perform these procedures in a combined fashion: medial epicondylectomy; fenestration of the olecranon fossa to debride osteophytes; medial capsulotomy to resect loose bodies or osteophytes. Postoperative Care The elbow is immobilized in 90° of flexion in a cast for 2 weeks. After removal of the sutures, hydrotherapy and active and passive range of motion exercises. Results Between 1978 and 1992, 25 patients (23 men and two women, age range 15–70 years with a mean of 53 years) underwent combined cubital tunnel decompression and surgical debridement of the elbow joint. Follow-up assessments of all patients were completed after an average of 68 (26–170) months following surgery. Based on the criteria proposed by the British Nerve Injuries Committee, the clinical results were graded as: excellent in six patients, good in 14, fair in four, and failure in one patient. The activity-related pain had improved markedly in ten patients, slightly in four, and was unchanged in six patients. Paresthesia improved in 20 patients and remained unchanged in five patients. The average preoperative grip strength was 26.4 kg and improved to an average of 29 kg.     

Anconeus epitrochlearis as a source of medial elbow pain in baseball pitchers

Medial elbow pain is reported in 18% to 69% of baseball players aged of 9 and 19 years. This is due to the large valgus stresses focused on the medial side of the elbow during overhead activities. In overhead throwers and pitchers, pain can be attributed to valgus extension overload with resultant posteromedial impingement, overuse of the flexor-pronator musculature resulting in medial epicondylitis, or occasional muscle tears or ruptures. The anconeus epitrochlearis is a known cause of cubital tunnel syndrome and has been postulated as a source of medial elbow pain in overhead athletes. This article describes the cases of 3 right-handed baseball pitchers with persistent right-sided medial elbow pain during throwing despite a prolonged period of rest, physical therapy, and nonsteroidal anti-inflammatory drugs. Two patients had symptoms of cubital tunnel syndrome as diagnosed by electromyogram and nerve conduction studies and the presence of the anconeus epitrochlearis muscle per magnetic resonance imaging. All patients underwent isolated release of the anconeus muscle without ulnar nerve transposition and returned to their previous levels of activity. The diagnosis and treatment of pitchers who present with medial-sided elbow pain can be complex. The differential should include an enlarged or inflamed anconeus epitrochlearis muscle as a possible cause. Conservative management should be the first modality. However, surgical excision with isolated release of the muscle can be successful in returning patients with persistent pain despite a trial of conservative management to their previous levels of function.     

Elbow ganglion arising from medial epicondyle pseudarthrosis.

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.     

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.     

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.     

程序化操作在尺神经皮下前置术中的应用

目的 探讨程序化手术操作在尺神经皮下前置术中的应用效果.方法 我院自2017年1月至2019年12月采用尺神经松解皮下前置术治疗肘管综合征病人34例.所有病人均采用程序化操作处理前臂内侧皮神经、Struthers弓、内侧肌间隔、Osborne韧带、尺侧腕屈肌两头、指浅屈肌筋膜、尺神经伴行血管、尺侧屈腕肌肌支及关节支、屈...