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Ulnar Nerve Surgery - Cubital Tunnel Syndrome

Ulnar NerveWhat is It?

Cubital tunnel syndrome is a condition that involves the ulna nerve as it crosses the elbow. Cubital tunnel syndrome is the effect of pressure on the ulnar nerve, one of the main nerves of the hand. It can result in a variety of problems, including pain, swelling, weakness or clumsiness of the hand and tingling or numbness of the ring and small fingers. It also often results in elbow pain on the side of the arm next to the chest. Learn more about this condition in the "Anatomy and Causes" section of this web site.

The condition can be treated with various procedures. Learn about the various options below.

In situ decompression

Indications for in situ decompression of the ulnar nerve at the elbow are as follows:

  • Mild ulnar nerve compression
  • Documented mild slowing on EMG as the ulnar nerve passes into and through the proximal FCU
  • Absence of pain around the medial epicondyle
  • A nerve that does not sublux with elbow flexion
  • Normal osseous anatomy and retrocondylar groove at the elbow and findings at surgery consistent with compression under the fibrous arcade

Advantages of simple decompression are that it is simple and easy to perform. The complication rate is low. In contrast to other methods, in situ decompression avoids damage to the vascular supply of the nerve. The operation is less traumatic to the patient, and the documented results are equally successful to those of other decompression procedures. In situ decompression requires minimal or no postoperative immobilization.

The advantages of the modified in situ technique include the ability to release the ulnar nerve in areas of compression with minimal disturbance of the blood supply. This procedure avoids subluxation of the ulnar nerve, which may lead to recurrence of symptoms secondary to repeated contusion of the nerve as it snaps over the medial epicondyle.

The disadvantages of simple decompression are the potentially higher recurrence rate and the risk of continued subluxation of the ulnar nerve over the medial epicondyle, if that was present preoperatively.

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Medial epicondylectomy

The best indication for a medial epicondylectomy is nonunion of an epicondyle fracture with ulnar nerve symptoms. Other indications are a poor bed for the ulnar nerve in the retrocondylar groove or ulnar nerve subluxation.

The advantages of a medial epicondylectomy are that it provides a more thorough decompression of the ulnar nerve than a simple release. This results in a minitransposition of the ulnar nerve. Compared to an anterior transposition, a medial epicondylectomy better preserves the blood supply to the nerve, results in less injury to the nerve, and preserves the small proximal nerve branches that might be sacrificed with an anterior transposition.

The disadvantages of a medial epicondylectomy are that it allows greater migration of the ulnar nerve with elbow flexion. Potential exists for elbow instability if the collateral ligaments are damaged. Bone pain and nerve vulnerability at the epicondylectomy site may occur. Compared to a simple decompression, the possibility of elbow stiffness or an elbow flexion contracture developing is greater. In addition, a medial epicondylectomy often is a poor choice for athletes who throw because of the significant stresses placed on the medial aspect of the elbow joint.

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Anterior transposition

The three types of anterior transposition are subcutaneous, intramuscular, and submuscular.

Indications for an ulnar nerve transposition are an unsuitable bed for the nerve secondary to the presence of osteophytes, a tumor, a ganglion, an accessory anconeus epitrochlears muscle, heterotopic bone, significant bursal tissue or other mass. Other indications are significant tension on the ulnar nerve as implicated with a positive elbow flexion test result or symptoms aggravated by activities requiring flexion, subluxation of the ulnar nerve with elbow flexion, a deformity at the elbow secondary to a valgus elbow or a tardy ulnar palsy, and the presence of valgus instability at the elbow. Soft tissue coverage must be adequate for the transposition of the nerve and a medial elbow that is not subjected to repeated minor trauma.

The advantages of an anterior transposition are that it moves the ulnar nerve from an unsuitable bed to one that is less scarred. The nerve is effectively lengthened a few centimeters with transposition. This decreases tension on the nerve with elbow flexion.

The disadvantages of an anterior transposition are that it is a more technically demanding procedure than a simple ulnar nerve decompression. The risk of complications is increased when the nerve is moved from its natural bed and there is a potential for devascularization of the ulnar nerve.

With an anterior subcutaneous transposition, several modifications are used to maintain the nerve in the transposed position. These include the use of epineural sutures, the creation of a fascial dermal or myofascial sling, or the creation of a subcutaneous fascial sling.

A subcutaneous transposition may be the procedure of choice in athletes who throw who do not have muscular atrophy. These athletes may lose forearm strength from a submuscular transposition and a simple decompression may not provide adequate relief of symptoms.

The advantages of a subcutaneous transposition include that it is easy to perform. It is a good procedure when subluxation and traction on the nerve are contributing to the patient's symptoms.

The disadvantages of a subcutaneous transposition include that the nerve may be hypersensitive after surgery because of its new superficial location. Potential exists for disruption of the ulnar nerve blood supply with the transposition.

Intramuscular transposition is the least popular decompression method. It yields the fewest excellent results and the most recurrences with severe ulnar nerve compression.

The advantages of an intramuscular transposition include that it buries the nerve deeply, yet provides a tunnel for the nerve to pass through. It also allows the nerve to be entirely surrounded by vascularized muscle tissue.

The disadvantages of an intramuscular transposition include that it is a complicated procedure. It involves significant soft tissue dissection. Risk of perineural scar is increased, and the procedure may expose the nerve to repeated muscular contractions.

A submuscular transposition offers the best results with the fewest recurrences with severe ulnar nerve compression.

A submuscular transposition is the best salvage procedure when previous surgery has failed because it places the nerve in an unscarred bed. It also works well for patients who are very thin, in whom a subcutaneous transposition may result in an area of hypersensitivity over the transposed nerve. Many consider it the procedure of choice for symptomatic athletes who throw.

Contraindications for submuscular transposition include significant scarring or distortion of the elbow joint capsule, such as in a malunited fracture or in a patient who has undergone excisional arthroplasty.

The disadvantages of a submuscular transposition are that it is a technically demanding procedure. Because of the extensive dissection, recovery for the patient is more difficult and risk of elbow flexion contracture is 5-10%. Patients also may develop extensive scar formation from the procedure, and it is a difficult procedure to revise if the patient has a recurrence.

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