The Anatomy, Presentation and Management Options of Cubital Tunnel Syndrome.

Cubital tunnel syndrome is the second most common nerve compression syndrome seen in the upper limb. Paresthesia and weakness are the two most common presentations in the hand. If left untreated, compression can lead to irreversible nerve damage, resulting in a loss of function of the forearm and hand. Therefore, recognizing the various clinical presentations of cubital tunnel syndrome can lead to early detection and prevention of nerve damage. Conservative management is usually tried first and involves supporting the elbow using a splint. If this fails and symptoms do not improve, surgical management is indicated. There are 3 main surgical techniques used to relieve compression of the nerve. These are simple decompression, anterior transposition and medial epicondylectomy. Studies comparing the techniques have demonstrated particular advantages to using one or another. However, the overall technique of choice is based on both the clinical scenario and the surgeon's digression. Following primary cubital tunnel surgery, recurrent symptoms can often occur due to a variety of pathological and non-pathological causes and revision surgery is usually warranted. This article provides a complete review of cubital tunnel syndrome.

Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome.

PURPOSE: To prospectively analyze, using validated outcome measures, symptom improvement in patients with mild to moderate cubital tunnel syndrome treated with rigid night splinting and activity modifications. METHODS: Nineteen patients (25 extremities) were enrolled prospectively between August 2009 and January 2011 following a diagnosis of idiopathic cubital tunnel syndrome. Patients were treated with activity modifications as well as a 3-month course of rigid night splinting maintaining 45° of elbow flexion. Treatment failure was defined as progression to operative management. Outcome measures included patient-reported splinting compliance as well as the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short Form-12. Follow-up included a standardized physical examination. Subgroup analysis included an examination of the association between splinting success and ulnar nerve hypermobility. RESULTS: Twenty-four of 25 extremities were available at mean follow-up of 2 years (range, 15-32 mo). Twenty-one of 24 (88%) extremities were successfully treated without surgery. We observed a high compliance rate with the splinting protocol during the 3-month treatment period. Quick Disabilities of the Arm, Shoulder, and Hand scores improved significantly from 29 to 11, Short Form-12 physical component summary score improved significantly from 45 to 54, and Short Form-12 mental component summary score improved significantly from 54 to 62. Average grip strength increased significantly from 32 kg to 35 kg, and ulnar nerve provocative testing resolved in 82% of patients available for follow-up examination. CONCLUSIONS: Rigid night splinting when combined with activity modification appears to be a successful, well-tolerated, and durable treatment modality in the management of cubital tunnel syndrome. We recommend that patients presenting with mild to moderate symptoms consider initial treatment with activity modification and rigid night splinting for 3 months based on a high likelihood of avoiding surgical intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Multiple regression analysis for grading and prognosis of cubital tunnel syndrome: assessment of Akahori's classification.

The purpose of this study was to quantitatively evaluate Akahori's preoperative classification of cubital tunnel syndrome. We analyzed the results for 57 elbows that were treated by a simple decompression procedure from 1997 to 2004. The relationship between each item of Akahori's preoperative classification and clinical stage was investigated based on the parameter distribution. We evaluated Akahori's classification system using multiple regression analysis, and investigated the association between the stage and treatment results. The usefulness of the regression equation was evaluated by analysis of variance of the expected and observed scores. In the parameter distribution, each item of Akahori's classification was mostly associated with the stage, but it was difficult to judge the severity of palsy. In the mathematical evaluation, the most effective item in determining the stage was sensory conduction velocity. It was demonstrated that the established regression equation was highly reliable (R = 0.922). Akahori's preoperative classification can also be used in postoperative classification, and this classification was correlated with postoperative prognosis. Our results indicate that Akahori's preoperative classification is a suitable system. It is reliable, reproducible and well-correlated with the postoperative prognosis. In addition, the established prediction formula is useful to reduce the diagnostic complexity of Akahori's classification.

The high-resolution ultrasonography and electrophysiological studies in nerve decompression for ulnar nerve entrapment at the elbow.

OBJECTIVE: To discuss a combination of high-resolution ultrasound and electrophysiological examination in diagnosis and evaluation of ulnar nerve entrapment at the elbow. METHOD: We retrospectively reviewed 20 healthy volunteers and 278 patients of ulnar nerve entrapment divided into three groups by McGowan grade, and we treated patients with subcutaneous or modified submuscular ulnar nerve transposition randomly. All the patients were followed for 2 years. The diagnosis and effects were confirmed by preoperative or postoperative cross-sectional area (CSA), motor conduction velocity (MCV), sensory conduction velocity, and nerve action potential (NAP). RESULTS: Healthy volunteers and grade I patients had significant differences in CSA, MCV, and NAP; grade I, II, and III patients had significant differences in CSA, MCV, and NAP; all patients had significant differences in CSA, MCV, and NAP before and after operations. CONCLUSION: High-resolution ultrasound and electrophysiological examination can be used in diagnosis and evaluation of operations of ulnar nerve entrapment at the elbow.

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.

Sindrome del tunel cubital: descompresion in situ y cierre del canal epitrocleo-olecraniano / Cubital tunnel syndrome: in situ decompression and epithroclear-olecranon groove closure

Introduccion: El síndrome del túnel cubital responde, en la gran mayoría de los casos, a un tratamiento conservador. Cuando debe recurrirse al tratamiento quirúrgico existen dos categorías de procedimientos: la descompresión (in situ y la epitroclectomía) y la transposición (subcutánea, submuscular o intramuscular). En este trabajo se propone la descompresión in situ y el cierre del canal epitrócleo-olecraniano que modifica los dos mecanismos de producción en forma conjunta: compresión y tracción. Materiales y metodos: Entre 1996 y 2004 fueron operados 64 pacientes con síndrome del túnel cubital primario de ambos sexos, cuya una edad promedio era de 42 años (10-75). Se incluyeron 15 pacientes de tipo I, 33 de tipo II y 16 de tipo III de la clasificación de McGowan. La tecnica consistio en: apertura del ligamento de Osborne y de la fascia del flexor carpi ulnaris; liberación amplia del nervio cubital con preservación de su irrigación extrínseca y las ramas motoras del flexor carpi ulnaris y cierre del canal epitrócleo-olecraniano. Todos los pacientes fueron operados con la tecnica propuesta comenzando en el posoperatorio inmediato con movimientos de pronosupinación completa, asociados con flexion-extension limitada durante tres semanas. En todos los casos el seguimiento fue de al menos 6 meses. Resultados: Fueron satisfactorios en 62 pacientes (97 por ciento). Dos pacientes (tipo III) no mostraron ninguna mejoría. Aunque algunos presentaron hiperestesia en la cicatriz, todos retomaron sus actividades habituales. Ninguno debio ser reoperado. Conclusiones: El procedimiento propuesto actua por undoble mecanismo. La descompresión in situ corrige la compresion y el cierre del canal epitrocleo-olecranianoevita el mecanismo de tracción. Es un procedimiento simple y seguro que permite una amplia movilidad del nervio, aunque manteniendo íntegra su vascularización y sin riesgos para las ramas motoras proximales. Evita la subluxacion recidivante del nervio cubital, por lo que no necesita epitroclectomía asociada que, al igual que las técnicas de transposición, requiere pasos adicionales que aumentan el riesgo de complicaciones. Asimismo, permite la inmediata movilizacion controlada posoperatoria por parte del propio paciente, con pronta recuperación y reinsercion a las actividades habituales

Sindrome del tunel cubital: descompresion in situ y cierre del canal epitrocleo-olecraniano / Cubital tunnel syndrome: in situ decompression and epithroclear-olecranon groove closure

Introduccion: El síndrome del túnel cubital responde, en la gran mayoría de los casos, a un tratamiento conservador. Cuando debe recurrirse al tratamiento quirúrgico existen dos categorías de procedimientos: la descompresión (in situ y la epitroclectomía) y la transposición (subcutánea, submuscular o intramuscular). En este trabajo se propone la descompresión in situ y el cierre del canal epitrócleo-olecraniano que modifica los dos mecanismos de producción en forma conjunta: compresión y tracción. Materiales y metodos: Entre 1996 y 2004 fueron operados 64 pacientes con síndrome del túnel cubital primario de ambos sexos, cuya una edad promedio era de 42 años (10-75). Se incluyeron 15 pacientes de tipo I, 33 de tipo II y 16 de tipo III de la clasificación de McGowan. La tecnica consistio en: apertura del ligamento de Osborne y de la fascia del flexor carpi ulnaris; liberación amplia del nervio cubital con preservación de su irrigación extrínseca y las ramas motoras del flexor carpi ulnaris y cierre del canal epitrócleo-olecraniano. Todos los pacientes fueron operados con la tecnica propuesta comenzando en el posoperatorio inmediato con movimientos de pronosupinación completa, asociados con flexion-extension limitada durante tres semanas. En todos los casos el seguimiento fue de al menos 6 meses. Resultados: Fueron satisfactorios en 62 pacientes (97 por ciento). Dos pacientes (tipo III) no mostraron ninguna mejoría. Aunque algunos presentaron hiperestesia en la cicatriz, todos retomaron sus actividades habituales. Ninguno debio ser reoperado. Conclusiones: El procedimiento propuesto actua por undoble mecanismo. La descompresión in situ corrige la compresion y el cierre del canal epitrocleo-olecranianoevita el mecanismo de tracción. Es un procedimiento simple y seguro que permite una amplia movilidad del nervio, aunque manteniendo íntegra su vascularización y sin riesgos para las ramas motoras proximales. Evita la subluxacion recidivante del nervio cubital, por...(AU)

Sindrome del tunel cubital: descompresion in situ y cierre del canal epitrocleo-olecraniano / Cubital tunnel syndrome: in situ decompression and epithroclear-olecranon groove closure

Introduccion: El síndrome del túnel cubital responde, en la gran mayoría de los casos, a un tratamiento conservador. Cuando debe recurrirse al tratamiento quirúrgico existen dos categorías de procedimientos: la descompresión (in situ y la epitroclectomía) y la transposición (subcutánea, submuscular o intramuscular). En este trabajo se propone la descompresión in situ y el cierre del canal epitrócleo-olecraniano que modifica los dos mecanismos de producción en forma conjunta: compresión y tracción. Materiales y metodos: Entre 1996 y 2004 fueron operados 64 pacientes con síndrome del túnel cubital primario de ambos sexos, cuya una edad promedio era de 42 años (10-75). Se incluyeron 15 pacientes de tipo I, 33 de tipo II y 16 de tipo III de la clasificación de McGowan. La tecnica consistio en: apertura del ligamento de Osborne y de la fascia del flexor carpi ulnaris; liberación amplia del nervio cubital con preservación de su irrigación extrínseca y las ramas motoras del flexor carpi ulnaris y cierre del canal epitrócleo-olecraniano. Todos los pacientes fueron operados con la tecnica propuesta comenzando en el posoperatorio inmediato con movimientos de pronosupinación completa, asociados con flexion-extension limitada durante tres semanas. En todos los casos el seguimiento fue de al menos 6 meses. Resultados: Fueron satisfactorios en 62 pacientes (97 por ciento). Dos pacientes (tipo III) no mostraron ninguna mejoría. Aunque algunos presentaron hiperestesia en la cicatriz, todos retomaron sus actividades habituales. Ninguno debio ser reoperado. Conclusiones: El procedimiento propuesto actua por undoble mecanismo. La descompresión in situ corrige la compresion y el cierre del canal epitrocleo-olecranianoevita el mecanismo de tracción. Es un procedimiento simple y seguro que permite una amplia movilidad del nervio, aunque manteniendo íntegra su vascularización y sin riesgos para las ramas motoras proximales. Evita la subluxacion recidivante del nervio cubital, por...

[Is a differentiated treatment depending on the degree of severity justified in cubital tunnel syndrome?]. / Ist eine unterschiedliche Behandlung bei verschiedenen Schweregraden des Sulcus nervi ulnaris-Syndroms sinnvoll?

BACKGROUND: Cubital tunnel syndrome is the second most common chronic nerve entrapment of the upper extremity, yet both diagnosis and staging of the severity of the progression of the disease rely mostly on the keen observation and interpretation of clinical signs and symptoms. To be valid, a staging system must correlate well with the known pathophysiological mechanisms of chronic nerve compression, have objective parameters available to quantify differing degrees of sensory and motor dysfunction, and finally must allow different therapeutic consequences. PATIENTS AND METHODS: In this study we have prospectively evaluated 44 patients who presented with the clinical diagnosis of cubital tunnel syndrome. Quantitative Sensory Testing was performed using a computer-assisted testing system (Sensory-Management Services L. L. C., Baltimore). Classic two-point discrimination, one point pressure threshold, pinch and grip strength were measured. Progression of disease was staged according to the gradual loss of sensory and motor function. After an average of 15 months postoperatively, ulnar nerve function was re-evaluated using the same parameters and outcome measured with the modified Bishop rating scale. RESULTS: The results of this study indicate that 100 % of patients in the moderate group had a good and excellent outcome, whereas only 74 % of the severe group were rated as good and excellent with 17 % moderate and 9 % poor outcome.

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.

[Clinical review of thirty-nine cases of ulnar tunnel syndrome].

OBJECTIVE: To discuss the concept of ulnar tunnel at the wrist, the types, causes, traits of compression, diagnosis, and clinical significance of ulnar tunnel syndrome (UTS). METHODS: Thirty-nine cases diagnosed as having UTS from 1986 were retrospectively reviewed combined with previous relevant literature. RESULTS: Ulnar tunnel included Guyon's canal, piso-hamate tunnel and hypothenar segment. There were 8 types and many causes of UTS. Some patients had compression in more than one zones and might be associated with carpal tunnel syndrome or cubital tunnel syndrome. UTS could be diagnosed through clinical manifestations and electrophysiological examination. CONCLUSION: Defining the concept of ulnar tunnel and the knowledge of the complexity and rarity of UTS can effectively guide diagnosis and treatment.

Treatment of cubital tunnel syndrome by frontal partial medial epicondylectomy. A retrospective series of 55 cases.

The outcomes of 55 cases of cubital tunnel syndrome treated by a partial frontal epicondylectomy are presented at a mean follow-up of 38 months follow-up. According to McGowan classification, 25 cases were grade I (45%), 12 grade II (22%) and 18 grade III (33%). The results (Wilson and Krout classification) were excellent or good in 41 patients (75%), fair in nine patients and unchanged in five, without any worsening or recurrence. Total relief was reported in 80% of grade I, 75% of grade II and 66% of grade III patients. Seven painful scars and one persistent 15( composite function) elbow extension deficit were the only complications. The satisfaction rate was 93%. This technique preserves bony protection, the blood supply and gliding tissues for the nerve and nerve recovery were comparable to other surgical procedures. Residual pain at the osteotomy site was not a serious problem.

Clinical grading of peripheral nerve problems.

To treat peripheral nerve problems appropriately, and to evaluate outcomes of peripheral nerve surgery, it is necessary to be able to stage the degree of nerve impairment. This article describes quantitative sensory testing that permits the necessary measurements for clinical grading of peripheral nerve functions.

The evaluation of pre- and post-operative classification system for cubital tunnel syndrome.

Pre- and post-operative classification systems for cubital tunnel syndrome are discussed in this study. Although there are several pre-operative evaluations, a suitable system should be easy to categorise, simple, reliable and reproducible. McGowan's grading system has been widely used for these reasons; however, grade II included complicated cases. Accordingly, McGowan's grade II is divided into two groups, such as grade II-A (relatively good prognostic group) and group II-B (relatively poor prognostic group). As far as the post-operative classification system is concerned, 4 grade (excellent, good, fair, and poor) classification is the most useful and easy to understand.

The management of cubital tunnel syndrome: a meta-analysis of clinical studies.

Despite extensive clinical experience in treating cubital tunnel syndrome, optimal surgical management remains controversial. A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. Patients were staged preoperatively into minimum, moderate, and severe groups on the basis of clinical presentation. Treatment modalities included nonoperative management, surgical decompression, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition. Statistical analysis using a standard SAS database with analysis of variance and chi-square tests was used to assess the efficacy of each therapeutic modality. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result. This article reveals statistically significant differences in outcomes among therapeutic modalities, which may assist in treatment planning; it introduces standardized methods to aid in determining, analyzing, and communicating treatment outcomes.