cme management of secondary cubital tunnel syndrome from prs/0401-cubital... · cme management of...

CME

Management of Secondary Cubital TunnelSyndromeJames B. Lowe, III, M.D., M.B.A., and Susan E. Mackinnon, M.D.St. Louis, Mo.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the general anatomicalfeatures and dynamics of the ulnar nerve, as well as its most common points of potential compression. 2. Describe theclinical presentation associated with secondary cubital tunnel syndrome, with the appropriate differential diagnoses. 3.Discuss the diagnostic test results and physical findings important for determining the correct treatment for patientspresenting for revision surgical treatment. 4. Discuss the different nonsurgical and surgical interventions for patients withrecurrent or persistent ulnar nerve compression at the elbow.

Ulnar nerve compression at the elbow is a peripheralnerve disorder that is second in incidence only to carpaltunnel syndrome. The successful treatment of cubital tun-nel syndrome can at times be unsatisfactory, with clinicalfailure rates of approximately 25 percent after surgicaltreatment. There are a variety of explanations for surgicalfailure or secondary ulnar nerve compression at the el-bow, including improper diagnosis or treatment, incom-plete release of the nerve, postoperative scarring, andimproper postoperative rehabilitation. This article reviewsthe relevant history, anatomical features, and presenta-tion of secondary ulnar nerve compression at the elbow.It also attempts to identify the important risk factors forrecurrent, persistent, and new disease and to make clinicalrecommendations regarding diagnosis, management, andsurgical treatment. (Plast. Reconstr. Surg. 113: 1e, 2004.)

Recurrent or persistent ulnar nerve com-pression at the elbow after cubital tunnel sur-gical treatment is a diagnosis that is difficult toconfirm and even more difficult to treat suc-cessfully. The clinical approach for patientswho present for revision surgical treatment af-ter ulnar nerve release at the elbow involvesfirst ensuring that the diagnosis is correct. Acomplete history and physical examinationusually suggest either persistent symptoms, re-current symptoms after a period of relief, ornew symptoms, such as those related to a post-operative neuroma of the medial antebrachialcutaneous nerve. A thorough understanding ofthe literature, relevant anatomical features,

pathophysiological features, and diagnostictechniques is required for accurate diagnosisand treatment of patients with secondary cubi-tal tunnel syndrome. After a diagnosis and aclear cause have been established, the surgicalapproach depends on the previous surgicaltreatment and the patient’s clinicalpresentation.

HISTORY

In 1816, Earle1 described the excision of asegment of the ulnar nerve for the treatment ofulnar neuritis and reported that the patient’ssevere neuralgia resolved after the surgical in-tervention. In 1833, Calder2 reported treating apatient with severe neuralgia with a similartechnique and confirmed the results reportedby Earle.1 By 1921, however, Sheldon3 warnedthat nerve excision for the treatment of ulnarneuritis was not indicated because of signifi-cant clinical morbidity.

In 1878, Panas4 described a relationship be-tween ulnar nerve compression at the elbowand clinical nerve palsy in three patients. In theearly 1900s, ulnar neuropathy was primarilythought to result from previous trauma andwas often referred to as “posttraumatic ulnarneuritis” or “tardy ulnar palsy.”3,5,6 Primarytreatment of this disorder originally focused onways to free the ulnar nerve from scarring and

From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine. Received for publication October 14,2002; revised January 29, 2003.

DOI: 10.1097/01.PRS.0000097287.10955.CC

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transpose it away from areas of trauma.6–9 Al-though ulnar nerve compression at the elbowwas thought to be related to trauma, therecontinued to be reports of the disease in pa-tients without a history of trauma.3,10,11

In 1898, Curtis7 reported a case of “traumaticulnar neuritis” that was treated with neurolysisand subcutaneous transplantation of the ulnarnerve. In 1918, Adson10 described anterior in-tramuscular transposition of the ulnar nervefor treatment of ulnar nerve compression atthe elbow. In 1942, Learmonth12 described an-terior submuscular transposition of the ulnarnerve to treat the disease. In 1957, Osborne13

claimed that division of the tendinous edge ofthe flexor carpi ulnaris over the ulnar nerve atthe elbow provided the same results as anteriortransposition.

In 1958, Feindel and Stratford14 coined theterm “cubital tunnel” and stressed the impor-tance of that structure for the treatment ofulnar nerve entrapment at the elbow. Theyprovided the first rational explanation for id-iopathic causes of the disease and generatedsupport for simple decompression of the ulnarnerve. In 1959, King and Morgan15 describedmedial epicondylectomy as another approachfor treatment of ulnar nerve compression atthe elbow. Finally, a variation of submusculartransposition with step elongation of the flex-or-pronator mass was described in 198816 andwas later referred to as anterior transmusculartransposition of the ulnar nerve.17

Strong proponents of different surgical tech-niques remain, but no single surgical interven-tion has been fully embraced in the primarysetting. Knowledge of the rich history of thisdisease allows physicians to better understandthe rationale for different surgical approaches.However, there has consistently been a greatdeal more support in the literature for moreaggressive surgical approaches for the treat-ment of recurrent ulnar nerve compression atthe elbow.17–21

ANATOMICAL FEATURES

General Anatomical Features

All potential points of ulnar nerve compres-sion must be recognized and examined forpatients suspected of experiencing recurrentulnar nerve compression at the elbow. Carefulpreoperative and intraoperative examinationsof these potential areas of compression helpensure the proper diagnosis and treatment of

primary or secondary ulnar nerve compressionat the elbow. There are several anatomical ar-eas in which the ulnar nerve is prone to com-pression, and several of these sites are particu-larly problematic after certain types of surgicalinterventions.

The ulnar nerve normally runs on the pos-terior and medial aspects of the upper arm. Ittravels between the brachialis and the medialhead of the triceps posterior to the posteriorintermuscular septum, where it can most easilybe observed during repeated surgical explora-tion. At the elbow, the ulnar nerve travels pos-terior to the medial epicondyle in the postcon-dylar groove of the olecranon, which is coveredby a dense fascia in this region, known as thecubital tunnel.16 The ulnar nerve then travelsdeep to the flexor carpi ulnaris and flexordigitorum superficialis and above the flexordigitorum profundus to the wrist. At the wrist,the ulnar nerve is positioned ulnar to the ulnarartery as it enters Guyon’s canal.

Innervation

The nerve roots from C7, C8, and T1 con-tribute to the medial cord of the brachialplexus, which forms the ulnar nerve. The ulnarnerve has no motor or sensory nerve branchesin the upper arm until it reaches the elbow,where it provides motor function to the flexorcarpi ulnaris and flexor digitorum profundusmuscles. The ulnar nerve provides sensationprimarily to the small finger and the ulnar halfof the ring finger. In the distal forearm, thepalmar branch of the nerve supplies the ulnaraspects of the volar hand and the dorsal branchsupplies the ulnar aspects of the dorsal hand.

In Guyon’s canal, the ulnar nerve dividesinto the superficial and deep branches. Thedeep branch of the ulnar nerve provides motorfunction to the hypothenar muscles, the pal-mar and dorsal interosseous muscles, the thirdand fourth lumbrical muscles, the adductorpollicis, and the deep head of the flexor polli-cis brevis. The superficial branch of the ulnarnerve innervates the small finger and the ulnarside of the ring finger.

The distribution of sensory and motor defi-cits for patients presenting with recurrent ul-nar nerve compression at the elbow can beused to identify specific points of compression.However, patients may have anatomical varia-tions of the ulnar nerve that make the diagno-sis of recurrent disease more difficult. The ul-nar nerve may have anomalous motor

2e PLASTIC AND RECONSTRUCTIVE SURGERY, January 2004

connections in the proximal forearm from themedian nerve, which are referred to as Martin-Gruber anastomoses.22,23 These anomalousconnections have been reported for up to 17percent of patients.24 Riche-Cannieu anasto-moses are motor connections between the ul-nar nerve and the median nerve in the hand,which occur in up to 70 percent of patients.23

Vascular Anatomical Features

The ulnar nerve has both intrinsic and ex-trinsic blood supplies.25,26 The extrinsic bloodsupply to the ulnar nerve is provided by thebrachial and ulnar arteries. Prevel et al.27 dem-onstrated that the superior ulnar collateral ar-tery proximally and the posterior ulnar recur-rent artery distally supplied the majority of theextrinsic blood supply to the ulnar nerve at theelbow. The superior ulnar collateral artery wasnoted to branch from the brachial artery ap-proximately 16 cm above the elbow, and theposterior ulnar recurrent artery was noted tobranch from the ulnar artery approximately 7cm below the elbow. The inferior ulnar collat-eral artery was noted to be a minor pedicle andwas observed in only five of 18 specimens.

The intrinsic blood supply has been noted tobe significant, allowing safe proximal and distaldissection of the ulnar nerve over a long dis-tance.25,28 Maki et al.29 observed, in an experi-mental model, that the diameter/length ratiofor nerve survival based on the intrinsic bloodsupply was approximately 1:63. However, thisdiameter/length ratio may not be applicable tonerves subjected to compression, trauma, orrecurrent or chronic ischemia. Retreated ulnarnerves may become more dependent on theextrinsic blood supply than are untreatednerves.

Several authors have suggested that theblood supply to the ulnar nerve may be injuredduring mobilization.13,30 In a canine model,Sugawara26 demonstrated that anterior trans-position of the ulnar nerve resulted in 80 per-cent of normal flow when the extrinsic bloodsupply was preserved but subsequent epineu-rolysis decreased blood flow by 45 percent.Ogata et al.30 measured blood flow in the ulnarnerve of monkeys after anterior subcutaneoustransposition and reported a significant de-crease in blood flow at 3 days, with resolutionof ischemia by 7 days. In 1988, Sugawara26 re-ported findings for patients undergoing treat-ment of cubital tunnel syndrome and recom-mended preserving the extrinsic blood supply

to the ulnar nerve but was unable to demon-strate a clinically significant benefit.

In most surgical cases, the extrinsic bloodsupply to the ulnar nerve can be maintained tothe level of the medial epicondyle during an-terior transpositions. However, it is importantto attempt to preserve as much of the bloodsupply to the ulnar nerve as possible duringtreatment of either primary or recurrent ulnarnerve compression at the elbow. The approachdescribed below attempts to address issues ofblood supply in the treatment of patients withrecurrent disease.

Medial Antebrachial Cutaneous Nerve

The medial antebrachial cutaneous nerve isa terminal branch of the medial cord of thebrachial plexus. It usually forms anterior andposterior branches that run distal and proxi-mal to the medial epicondyle, respectively. Thebranches of the medial antebrachial cutaneousnerve are at risk during ulnar nerve release atthe elbow and may be particularly problematicin recurrent disease. Leffert18 was one of thefirst authors to encourage surgeons to avoidinjury to the medial antebrachial cutaneousnerve. In our experience, the medial antebra-chial cutaneous nerve has a branch crossingproximal to the medial epicondyle approxi-mately 50 percent of the time and a branchcrossing distal to the medial epicondyle 100percent of the time. Injury to the branches ofthe medial antebrachial cutaneous nerve is of-ten observed during reexploration for revisionulnar nerve release at the elbow (Fig. 1).

A small surgical incision, a bloody wound, orscarring near the ulnar nerve at the elbow maycontribute to medial antebrachial cutaneous

FIG. 1. Multiple medial antebrachial cutaneous neuro-mas noted during revision ulnar nerve release at the elbow.

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nerve injury. Persistent pain after surgical treat-ment of the ulnar nerve may be attributable toinjury to a branch or branches of the antebra-chial cutaneous nerve.31,32 The clinical manifes-tations of medial antebrachial cutaneous nerveinjury include hypesthesia, painful scarring,and hyperalgesia.32 The medial antebrachialcutaneous nerve should be examined in allpatients being evaluated for revision ulnarnerve release at the elbow. Patients typicallyexperience altered sensibility in the medial as-pects of the forearm. A Tinel sign-like responseelicited over the course of the medial antebra-chial cutaneous nerve, adjacent to the basilicvein and medial to the biceps tendon, mayreflect a painful neuroma. We call this a prox-imal Tinel sign, because it is located severalinches proximal to the site of the medial ante-brachial cutaneous nerve injury along thecourse of the nerve. A simple nerve block withlocal anesthetic carefully placed along theproximal course of the medial antebrachialcutaneous nerve may facilitate confirmation ofthe diagnosis in the office.

Ulnar Nerve Dynamics

The ulnar nerve is normally subjected torepeated friction, traction, and compressionwith elbow flexion.33–35 The resiliency of theulnar nerve is reflected in its ability to toleratethe physiological stresses of normal daily activ-ities. Recurrent ulnar nerve compression at theelbow must be understood in the context ofnormal ulnar nerve dynamics, whereas thetreatment of compression should focus on waysto alter those dynamics.

Elbow flexion has been demonstrated to de-crease the area within the cubital tunnel by upto 55 percent.33 When the elbow is flexed, thewrist is extended, and the shoulder is ab-ducted, the pressure within the cubital tunnelincreases 600 percent and the length of theulnar nerve increases 4.7 mm.34 If the ulnarnerve does not elongate because of inflamma-tion or recurrent compression, then the intra-neural pressure increases even more duringelbow flexion. Gelberman et al.36 used mag-netic resonance imaging to evaluate cubitaltunnel pressures during elbow flexion and ob-served that the mean intraneural pressure wassignificantly higher than the extraneural pres-sure when the elbow was flexed more than 90degrees in human cadavers.

It is clear that the ulnar nerve undergoessignificant pressure and length changes during

normal activity. It seems that repetitive traumaor activity in this area is better tolerated bysome people than by others. Once the symp-toms of recurrent cubital tunnel syndrome arepresent, they progress unless patients modifytheir activities to decrease pressure on the ul-nar nerve at the elbow. It is not surprising thatthe ulnar nerve is subject to the same dynamicstresses after surgical treatment if the anatom-ical features of this region are not altered insome way.

Compressive Neuropathy

It is important to understand the pathogen-esis of compressive neuropathy to properly di-agnose and treat patients with recurrent ulnarnerve compression at the elbow. The his-topathological changes associated with nervecompression often parallel the clinical progres-sion of the disease. The connective tissue andnerve injuries increase with increasingamounts and duration of compression.37 Thehistological changes associated with ulnarnerve compression can range from mild tosevere.

The histological changes associated withnerve compression first involve injury to theblood-nerve barrier, resulting in subperineur-ial edema and fibrosis. Renault bodies, whichare histological markers of a nerve’s responseto trauma, can be observed in areas of com-pression after traction or repetitive motion.The external and internal epineurium thick-ens, large myelinated fibers demonstrate seg-mental demyelination, and small unmyelinatedfibers progressively degenerate. As the com-pression persists, the entire nerve is affecteddistally and Wallerian degeneration is diffuselypresent.37

The clinical symptoms of nerve compressionoften depend on the amount of injury to thenerve’s individual fascicles. The greatest de-gree of injury to the nerve from compressionoften determines the clinical presentation. Fas-cicles within the ulnar nerve that lie on theperiphery are more susceptible to injury fromcompression.38 Sunderland39 described the in-ternal topographical features of the ulnarnerve as consisting of multiple fascicles con-nected with plexus formation. Sunderland39

also observed the motor fibers to the hand tobe more superficial than the sensory fibers.This high degree of plexus formation at theelbow may inhibit full movement of the fasci-cles, thus contributing to fibrosis or scarring.


Diffuse or nonspecific clinical complaintsthat do not completely indicate a specific neu-ropathy may result from multiple-nerve com-pression.40 In 1973, Upton and McComas41 firstdescribed the double-crush hypothesis, inwhich one site of nerve compression wasthought to render other sites along the nerveless tolerant to compression. Systemic illnesses,such as diabetes mellitus, have also been re-ported to increase the susceptibility of nervesto compression.42–44

Patients who present with marked symptomsconsistent with recurrent ulnar nerve compres-sion but demonstrate normal electrodiagnosticstudy results may have a neuropathy that in-volves a combination of normal and abnormalfascicles and that cannot be clearly identified.The pain may be unrelated to the ulnar nerveand may be the result of a painful medial an-tebrachial cutaneous nerve neuroma. Al-though pain associated with traction injuries orextrinsic scarring that prevents normal glidingof the ulnar nerve can be significant, electro-diagnostic studies often fail to demonstrate ev-idence of axonal injury (changes in amplitudeor fibrillation) or demyelination (prolongedlatency). Unfortunately, there are multiplepoints of potential ulnar nerve compression,which can cause symptoms ranging from mildto severe. If no single area of compression

explains the clinical symptoms, then multiplesites of compression should be considered.The diagnosis of secondary ulnar nerve com-pression at the elbow can be quite difficult andrequires a thorough examination of the mostlikely sites of nerve compression that might nothave been fully addressed during surgical treat-ment or might have occurred after surgicaltreatment.

Potential Points of Compression

The specific area of compression is oftenunknown in primary or recurrent ulnar nervecompression at the elbow, but it is important tobe familiar with the most common potentialpoints. Amadio and Gabel45,46 described fivepotential points of compression of the ulnarnerve in the region of the elbow. The treat-ment of recurrent disease requires completeassessment of each potential site of compres-sion, both preoperatively and intraoperatively.The potential sites of compression are dis-cussed as they occur along the course of theulnar nerve in the arm, in the proximal-to-distal direction (Fig. 2).

The “arcade of Struthers” has been de-scribed as a thick fascial structure located ap-proximately 8 cm proximal to the medial epi-condyle, between the medial head of thetriceps and the medial intermuscular sep-

FIG. 2. Potential points of ulnar nerve compression at the elbow.


tum.47,48 Spinner49 noted the arcade of Struth-ers in up to 70 percent of patients with ulnarnerve compression at the elbow. Mackinnonand Dellon16 thought that this structure actu-ally represented the most proximal edge of apreviously undivided fascia, observed primarilyduring the treatment of recurrent cubital tun-nel syndrome.

The medial intermuscular septum is a poten-tial point of ulnar nerve compression that isobserved primarily in recurrent disease. Theulnar nerve does not normally cross the inter-muscular septum unless it is transposed anteri-orly. Compression of the ulnar nerve may re-sult from a failure to excise the septumproximal to the elbow.16,45 The cubital tunnel isformed by a dense fascia that covers the ulnarnerve as it travels in the postcondylargroove.14,16 The tunnel begins just proximal tothe elbow, in an area where the ulnar nerve liessuperficially, and ends just proximal to the twoheads of the flexor carpi ulnaris. Osborne’sband, which is the next potential point of com-pression, is composed of the leading edge ofthe fascia that connects the ulnar and humeralheads of the flexor carpi ulnaris.13,14 The inci-dence of Osborne’s band was noted to be ap-proximately 77 percent bilaterally in a study ofnormal cadavers.50 This band may result incompression of the ulnar nerve at the elbow,and a kink is even more likely to occur afteranterior transposition if the band is not fullyreleased during surgical treatment.

Finally, the ulnar nerve can be compressedas it passes through the aponeurosis of theflexor-pronator mass.46,51 The fascial bandwithin the flexor-pronator mass is particularlyproblematic during surgical treatment of ulnarnerve compression with anterior transposi-tion.17,46 The fascial bands within the flexor-pronator mass must be completely excised toavoid the creation of a new compression pointwithin the muscle after transposition of theulnar nerve. This fascia is thin but strong, andit must be aggressively excised, particularly inrecurrent disease.

A number of other potential causes of ulnar

nerve compression have been described. Symp-toms of ulnar nerve compression may resultfrom subluxation of the nerve at the level ofthe medial epicondyle. Childress52 reportedthat 16 percent of the normal population dem-onstrated subluxation of the ulnar nerve at theelbow. Hypermobility of the ulnar nerve maybe related to ulnar neuropathy attributable toincreased susceptibility of the nerve to traumaor frictional injury.33 A hypermobile tricepsmuscle is also thought to contribute to theproblem of ulnar nerve subluxation. Ulnarnerve compression at the elbow may resultfrom compression by the epitrochleoanconeusmuscle in the cubital tunnel, which may occurin up to 30 percent of patients.53 A recent studydemonstrated that the epitrochleoanconeusmuscle was present bilaterally in approximately12 percent of cadaveric dissections and oftenpresented in combination with a prominentmedial triceps head.50 Space-occupying lesions,arthritis, synovitis, and trauma have all beendescribed as potential causes of compressionand should be explored for all patients pre-senting with recurrent disease.3,10,11,54

CLINICAL PRESENTATION

The diagnosis of primary ulnar nerve com-pression at the elbow can usually be made witha brief clinical history and physical examina-tion. However, secondary ulnar nerve compres-sion at the elbow often represents a more dif-ficult diagnostic dilemma, and the differentialdiagnosis is often elusive. A patient who hasundergone one or more ulnar nerve proce-dures may present with a variety of symptomsthat are clinically difficult to identify and dif-ferentiate. Patients who present for possiblerevision ulnar nerve release can usually be cat-egorized as having persistent, recurrent, ornew disease. Each category of secondary cubi-tal tunnel syndrome is associated with a specificclinical presentation, symptom profile, andlikely cause, which can facilitate the overalltreatment of the patient (Table I).

Persistent disease is often associated withparesthesia and weakness that never resolved

TABLE IClinical Categorization of Secondary Cubital Tunnel Syndrome

Category Presentation Symptoms Primary Causes

Persistent No improvement Paresthesia and weakness Incomplete release, wrong diagnosis, and concomitant diseaseRecurrent Period of symptomatic resolution Paresthesia and weakness Postoperative scarring, traction, and new compression pointNew Worse symptoms New pain Medial antebrachial cutaneous or ulnar nerve neuroma or injury


after surgical treatment. Patients usually com-plain that previous ulnar nerve release at theelbow was unsuccessful, because they never ex-perienced clinical relief or improvement aftersurgical treatment. Patients who are catego-rized as having persistent symptoms might havereceived the wrong diagnosis, might have dem-onstrated concomitant untreated symptoms, ormight have undergone inadequate surgical de-compression. Patients with recurrent diseasealso experience paresthesia and weakness, butthese symptoms typically occur after a shortperiod of clinical relief. Recurrent symptomsof ulnar nerve compression usually becomeevident within 6 months after surgical treat-ment, as a result of scarring, traction, or thedevelopment of a new compression point. Newsymptoms after ulnar nerve release at the el-bow are often associated with the developmentof significant pain, which may result from aninjury to the medial antebrachial cutaneousnerve or the ulnar nerve itself.

The differential diagnosis for patients pre-senting for revision ulnar nerve release at theelbow must be placed in the context of thepresenting symptoms. Patients with persistentulnar nerve neuropathy after surgical treat-ment might have untreated ulnar nerve com-pression in the cervical region, brachial plexus,or Guyon’s canal. Perhaps the ulnar nerve wasnever completely released at the elbow duringsurgical treatment. Recurrent symptoms in-volve a period of relief followed by a return ofthe same symptoms as before surgical treat-ment. Recurrent disease is often the result ofsurgical scars, new trauma, or new compressionof the ulnar nerve. Patients who present forrevision after ulnar nerve release at the elbowmight have an associated polyneuropathy, mul-tiple-crush syndrome, or occasionally uppermotor neuron disease, which could complicatethe clinical findings. A variety of non-neurolog-ical conditions must also be ruled out in theinitial evaluations, including rotator cuff syn-drome, localized tendonitis (medial or lateralepicondylitis), and a subluxating triceps mus-cle or tendon.

Patients who present for revision after ulnarnerve release at the elbow often present withnumbness and tingling in the small and ringfingers. A small number of patients report ach-ing and pain in the forearm and elbow region.Significant elbow pain in this region or overthe surgical scar may reflect an injury to themedial antebrachial cutaneous nerve or ulnar

nerve. The sensory changes associated with ul-nar nerve compression at the elbow are usuallynoted at night, when patients flex their elbowsduring sleep. In primary ulnar nerve compres-sion, sensory deficits usually precede the loss ofmotor function. In patients presenting withrecurrent or persistent ulnar nerve compres-sion at the elbow, however, motor deficits areusually more pronounced, with most patientscomplaining of a loss of fine motor skills in theaffected hand.

Many patients who experience failure of aprevious ulnar nerve release at the elbow neverexhibit significant symptomatic improvementafter surgical treatment. Such patients oftenreport progressive sensory and motor distur-bances in the distribution of the ulnar nerve. Areview of previous operative reports and diag-nostic evaluations should assist the surgeon indetermining the cause of the patient’s symp-toms. During evaluation of a patient present-ing for revision ulnar nerve release at the el-bow, it is important to exclude the possibility ofother upper-extremity disease processes andcompressive syndromes with a complete physi-cal examination and electrodiagnostic studies.

PHYSICAL EXAMINATION

A complete upper-extremity examinationshould be performed for all patients present-ing for evaluation of recurrent ulnar nervecompression at the elbow. Two-point discrimi-nation, pinch and grip strength, and motorstrength should be evaluated. Maneuvers usedto evaluate different potential points of nervecompression include assessment of Tinel’s signand provocative tests. Positive responses tothese tests include tingling, “electric shock,” oralteration of sensation in the distribution ofthe involved nerve.

Tinel’s sign can be used to identify axonaldamage in a variety of areas, and assessmentsshould not be restricted to patients being ex-amined for carpal tunnel syndrome at thewrist. Patients with significant nerve injury thatresults in Wallerian degeneration often dem-onstrate Tinel’s sign at the level of the regen-eration or injury. Tinel’s sign can be elicitedover the ulnar nerve with four to six manualtaps over the course of the nerve, at the level ofthe brachial plexus, elbow, or wrist. The radialand median nerves should also be examinedwith this technique, to exclude the possibilityof other neuropathies.

Provocative tests should be used to examine


all of the nerves of the upper extremity. Theulnar nerve can be examined at the distal wristcrease for compression at Guyon’s canal byapplying pressure and checking for symptomson the ulnar side of the hand. A flexion/pressure test at the elbow is the most accurateprovocative test to identify ulnar nerve com-pression at the elbow.55 The elbow is flexed,with the wrist and forearm in the neutral posi-tion, and manual pressure is applied to theulnar nerve just proximal to the cubital tunnel(Fig. 3).

Brachial plexus compression can be identi-fied by having patients elevate their arms abovetheir head to increase the pressure on the bra-chial plexus.56 A positive response occurs whenthe patient notes sensory alterations in thehands with the arms raised over the head, withthe wrists in the neutral position and the el-bows extended. Cervical root compression canbe evaluated by performing Spurling’s test,which involves the application of axial com-pression to the head with slight extension tothe right or left. When paresthesia or shock isidentified with this procedure, further evalua-tion of the cervical spine is required.

DIAGNOSTIC STUDIES

Electrodiagnostic studies can be used to con-firm the diagnosis of recurrent ulnar nerve

compression at the elbow, to determine theseverity of the disease, to localize the area ofcompression, and to exclude other sites ofcompression or neuropathy. Patients who dem-onstrate clinical evidence of recurrent or per-sistent ulnar nerve compression at the elbowshould undergo bilateral electrodiagnostic ex-amination of the ulnar nerve, and their preop-erative and postoperative electrodiagnosticstudy results should be compared, if possible.This allows the physician to determine the ex-tent of the disease and to look for evidence offunctional improvement.

Some authors have claimed that primary ul-nar nerve compression at the elbow is a clinicaldiagnosis that does not require electrodiagnos-tic studies before surgical intervention.57–59

However, many authors will not operate onpatients with ulnar nerve compression at theelbow without first obtaining documented evi-dence of disease in electrodiagnostic stud-ies.60–63 Craven and Green61 even suggestedthat normal study results represent a contrain-dication to surgical treatment. We recommendelectrodiagnostic studies for every patient sus-pected of having primary or secondary ulnarnerve compression at the elbow, but patientswith significant pain are not necessarily deniedsurgical treatment because of normal electro-diagnostic study results.

A standard electrodiagnostic study of the ul-nar nerve includes sensory and motor compo-nents, with motor conduction velocities beingcalculated above, below, and across the elbow.The motor conduction velocities across the el-bow are considered the most useful data forconfirming the diagnosis of primary or recur-rent ulnar nerve compression at the el-bow.16,61,64,65 Unfortunately, 80 percent of pa-tients with mild symptoms and 47 percent ofpatients with severe symptoms have been re-ported to have normal conduction velocitiesacross the elbow.64 When the conduction veloc-ity across the elbow is observed to be normal,an electromyographic study demonstrating fi-brillation in the ulnar intrinsic muscles can beused to confirm the diagnosis. Although thereis no decrease in motor conduction velocitythat is diagnostic of cubital tunnel syndrome,we think that any value for conduction velocityacross the elbow of less than 50 m/second isabnormal.

It is important to note that repeat electrodi-agnostic studies may not demonstrate improve-ments after ulnar nerve release at the elbow.

FIG. 3. Elbow flexion test for the diagnosis of ulnar nerveentrapment at the elbow.


Wilson and Krout66 reported that postoperativeelectrodiagnostic study results failed to corre-late with clinical outcomes. Failure of the elec-trodiagnostic study results to improve after sur-gical treatment can be explained on the basisof permanent axonal loss secondary to chronicnerve entrapment.67 Therefore, electrodiag-nostic study results do not always clarify thediagnosis of recurrent or persistent ulnar nervecompression at the elbow and must be placedin the context of the clinical findings.

TREATMENT OF SECONDARY CUBITAL

TUNNEL SYNDROME

Overview

All patients with symptoms of recurrent ul-nar nerve compression can be better under-stood with a review of previous operative re-ports. We think that patients who haveundergone a small incision, limited release ofthe cubital tunnel, subcutaneous transposition,or a classic Learmonth submuscular transposi-tion12 are potentially good candidates for re-peat exploration with a modification of ourtransmuscular approach. In the past decade,we elected to reoperate on only one patient

who had undergone our transmuscular trans-position for treatment of primary disease.17

In general, our management of primary cu-bital tunnel syndrome is usually conservativefor a period of 6 months. Patients with motorconduction velocities across the elbow of morethan 40 m/second are closely monitored for 8weeks more, and elective surgical treatment isplanned if symptoms persist. Patients with re-current ulnar nerve compression at the elbowwith motor conduction velocities of less than40 m/second are scheduled for elective surgi-cal treatment, those with velocities of less than30 m/second undergo surgical treatmentwithin 3 months, and those with velocities ofless than 20 m/second undergo surgical treat-ment as soon as possible (Fig. 4). This treat-ment algorithm is used for patients presentingfor revision ulnar nerve release when symp-toms are determined to be persistent. How-ever, patients with symptoms consistent withrecurrent disease are treated with conservativemanagement for a period of at least 6 monthsbefore surgical revision is considered. Al-though conservative management is often suc-cessful in the treatment of primary cubital tun-

FIG. 4. Algorithm for the treatment of primary ulnar nerve compression at the elbow. Reprinted with per-mission from Lowe, J. B., III, Novak, C. B., and Mackinnon, S. E. Current approach to cubital tunnel syndrome.Neurosurg. Clin. North Am. 12: 267, 2001.


nel syndrome, it is rarely therapeutic forrecurrent disease.

Nonoperative Management

Conservative therapy is initiated for all pa-tients who present with symptoms of recurrentor persistent ulnar nerve compression at theelbow. Conservative management is primarilyaimed at activity modifications that are in-tended to improve symptoms and stop diseaseprogression. It is our experience that patientswith mild/moderate symptoms of ulnar nervecompression are more likely to benefit from non-operative management and patients with severesymptoms rarely exhibit improvement.

Conservative management of secondary cu-bital tunnel syndrome begins with patient ed-ucation. Patients are taught that the ulnarnerve lies in a vulnerable position at the elbowand is prone to pressure and trauma. They aretaught that the ulnar nerve is loose, like theoverlying skin, when the elbow is straight andthe nerve is tight, like the overlying skin, whenthe elbow is flexed. Patients are encouraged tostraighten their arms during the day and par-ticularly at night and to wear soft elbow padsfor protection. Workstations can be modifiedto avoid flexion of the elbows during writing,talking on the telephone, or using computerkeyboards. When initiated slowly, stretchingexercises focusing on the flexor carpi ulnarisare often helpful. If conservative measures donot improve the clinical symptoms, then a re-peat electrodiagnostic study should be per-formed and the results compared with previousstudy results, if available.

Surgical Options

There is a great deal of controversy regard-ing the appropriate treatment of primary ulnarnerve compression at the elbow, and personalbias often determines the technique chosen.68

The surgical options include simple decom-pression, medial epicondylectomy, subcutane-ous transposition, submuscular transposition,intramuscular transposition, and transmuscu-lar transposition. A recent meta-analysis of 30studies was used to determine the optimal sur-gical treatment on the basis of clinical presen-tation.69 Patients with minimal symptoms ben-efited equally from all modalities, patients withmoderate symptoms benefited most from sub-muscular transposition, and patients with se-vere symptoms did not benefit from one tech-nique compared with another. Recurrent ulnar

nerve entrapment at the elbow is most oftentreated with submuscular transposition or amodification of that technique.18–21

It seems that failed ulnar nerve release at theelbow is often the result of incomplete releaseof potential points of compression. Broudy etal.70 reviewed 10 failed anterior transpositionprocedures and observed that nine failureswere caused by compression by the medial in-termuscular septum. Rogers et al.71 reviewed 14cases of failed ulnar nerve release at the elbow,which resulted from failure to resect the inter-muscular septum in 12 cases, injury to the me-dial antebrachial cutaneous nerve in sevencases, fibrosis in five cases, and recurrent sub-luxation in one case. All patients experiencedimprovement after anterior submuscular trans-position. Gabel and Amadio46 operated on 30patients with recurrent disease (average, 1.5previous procedures per patient) and observedthat two recurrences followed medial epicon-dylectomy, three followed submuscular trans-position, four followed simple decompression,six followed internal neurolysis, six followedsimple decompression, and 25 followed subcu-taneous transposition.

We have observed that the majority of surgi-cal failures are the result of incomplete resec-tion of the fascia from the flexor-pronator massor painful neuromas along the medial antebra-chial cutaneous nerve. We have also observedthat subcutaneous transposition is the opera-tive technique most often associated with failedulnar nerve release at the elbow. Although pre-vious operative reports assist the surgeon informing the operative plan, no assumptionsshould be made regarding the course of theulnar nerve. We prefer to use a modification ofthe submuscular transposition that we de-scribed as the transmuscular transposition,which includes myofascial lengthening of theflexor-pronator mass.17

Preferred Surgical Treatment for Secondary CubitalTunnel Syndrome

In our experience, anterior transmusculartransposition, with early postoperative range-of-motion exercises, provides the best clinicalresults for recurrent ulnar nerve entrapment atthe elbow. Transmuscular transposition ad-dresses all potential points of compression, al-ters the harmful dynamic stresses on the ulnarnerve at the elbow, and provides a fresh mus-cular bed for the ulnar nerve during healing.The surgical technique used for the treatment


of recurrent disease is essentially the same asour technique for the treatment of primarydisease, with a few modifications. Transmuscu-lar transposition attempts to apply the bestcomponents of various techniques to achieve

consistently good clinical results and has notbeen modified in more than 7 years17 (Fig. 5).A review of the surgical technique demon-strated that approximately 77 percent of pa-tients exhibited significant improvement after

FIG. 5. Transmuscular transposition of the ulnar nerve at the elbow. (Above, left) The operative incision is marked just posteriorto the medial epicondyle. (Above, right) The medial intermuscular septum is held with the hemostat. A vessel loop is placed arounda branch of the medial antebrachial cutaneous nerve. The ulnar nerve is compressed by the roof of the cubital tunnel and theleading edge of the flexor carpi ulnaris. (Center, left) The marking for the fascial lengthening is noted, and the distal fascial flapsare elevated (inset). (Center, right) The proximal motor branches have undergone neurolysis from the main ulnar nerve, to allowsatisfactory anterior transposition. (Below) The ulnar nerve in this transposed position is not kinked at its proximal and distalsites. The fascial flaps have been closed in a lengthened position. Reprinted with permission from Mackinnon, S. E. Submusculartransposition of the ulnar nerve at the elbow. Neurosurg. Oper. Atlas 4: 227, 1995.


surgical treatment, and the results did not sig-nificantly change for patients undergoing revi-sion surgical treatment.72

The surgical treatment is usually performedwith general endotracheal anesthesia. Thetourniquet is inflated, and bretylium (1.25mg/kg lean body weight) is administered in-travenously, to decrease the risk of postopera-tive pain syndromes.73–75 The previous incisionis usually extended, the soft tissue is dissected,and the branches of the medial antebrachialcutaneous nerve are identified. If a neuroma isobserved on the medial antebrachial cutane-ous nerve, then it is excised and the nervebranch is cauterized and transposed into themuscle of the upper arm. The skin and subcu-taneous tissue are elevated to expose the prox-imal aspects of the flexor-pronator mass, andthe ulnar nerve is identified behind the inter-muscular septum in the upper arm. The ulnarnerve often closely adheres to the underlyingfascia and is very prone to injury in patientswho have undergone previous subcutaneousanterior transpositions.

The ulnar nerve is carefully dissected proxi-mally and distally, to ensure complete releaseof all potential points of compression. The lig-ament of Struthers is evaluated, the intermus-cular septum is excised, the cubital tunnel isopened, Osborne’s band is cut, and the fasciaand muscle of the flexor carpi ulnaris aretransected as necessary. The ulnar nerve maybe tethered at the level of the elbow because ofincomplete release of the motor branch to theflexor carpi ulnaris. The motor branches to theflexor carpi ulnaris are preserved and neuro-lyzed, to facilitate complete anterior transposi-tion of the ulnar nerve. Watchmaker et al.76

reported that internal neurolysis of these mo-tor branches could be performed up to 6.7 cmabove the medial epicondyle.

A step-lengthening incision in the flexor-pronator mass is used to develop fascial flaps,and a transmuscular tunnel is created throughthe muscle. Fibrous bands within the flexor-pronator mass are resected as the tunnel iscreated just superficial to the brachialis mus-cle. The ulnar nerve is transposed withoutkinks or pressure and is allowed to rest in thetransmuscular muscle bed. The ends of thefascial flaps are then loosely reapproximated,to prevent subluxation of the ulnar nerve.

The transmuscular transposition procedureis modified for patients who have undergonesubmuscular or intermuscular transposition. In

such patients, the muscle overlying the ulnarnerve is preserved as much as possible by firstfreeing the nerve on both sides of the flexor-pronator mass. A step-lengthening incision,with elevation of fascial flaps, is performed, thetendinous bands within the flexor-pronatormuscle are excised if necessary, and the nerveis freed along its course. Because the ulnarnerve is already submuscular or intermuscular,a tunnel is created by preserving some looseoverlying flexor-pronator muscle, if possible(Fig. 6). Complete circumferential dissectionof the ulnar nerve after multiple surgical fail-ures should be avoided, if possible, to preventnerve ischemia. In patients who have under-gone multiple ulnar nerve releases, the poste-rior surface of the ulnar nerve should be pre-served at different intervals along its course, forthe same reasons.

After the tourniquet is released and com-plete hemostasis is achieved, a closed suctiondrain and Marcaine pain pump are placedwithin the wound. The patient is placed in aposterior splint with the elbow flexed at 90percent, the forearm in slight pronation, andthe wrist neutral. Patients are typically admit-ted for overnight observation, and the drain isremoved the following morning, when the out-put is less than 30 ml/24 hours. On the secondto third postoperative day, the splint and painpump are removed and the patient is in-structed regarding early range-of-motion exer-cises. The patients are encouraged to showerafter the dressings are removed, and scar pre-vention techniques are initiated at 3 weeks,with direct massage of the incision.

FIG. 6. Intraoperative photograph of the preserved flexor-pronator muscle during treatment for a failed submusculartransposition.


POSTOPERATIVE REHABILITATION

Postoperative rehabilitation is dependent onthe type of surgical treatment performed and isoften incorrectly considered irrelevant. Wethink that early range-of-motion exercises rep-resent one of the most important factors forsuccessful treatment of patients undergoingsurgical treatment of recurrent ulnar nervecompression at the elbow. Various authorshave advocated long periods of elbow immobi-lization after cubital tunnel release. Klein-mann77 recommended immobilization for 3weeks after revision ulnar neuroplasty. Dellon78

recommended 8 days of immobilization forsuccessful treatment of ulnar nerve entrap-ment at the elbow.

A number of authors have recommendedimmediate range-of-motion exercises after sur-gical treatment for ulnar nerve entrapment atthe elbow. Warwick and Seradge79 reportedthat early range-of-motion exercises at 3 days,compared with 15 days, postoperatively did notadversely affect grip strength and resulted inless flexion contracture after medial epicondy-lectomy. Nathan et al.80 recommended range-of-motion exercises on the first postoperativeday after simple decompression of the ulnarnerve. We think that failure of surgical treat-ment for cubital tunnel syndrome can resultfrom extended postoperative immobilization.17

We recommend that all patients beginrange-of-motion exercises for the hand, wrist,elbow, and shoulder within 2 to 3 days aftersurgical treatment. Patients are given a sling towear at night for 3 weeks and during the dayfor comfort. They are cautioned against heavylifting and are instructed to slowly stretch theirforearm into supination and their elbow intoextension. Stretching exercises can cause somediscomfort for the first week, and patients areinstructed to perform range-of-motion exer-cises within their comfort range. Patientsachieve full range of motion by 2 to 3 weeksafter surgical treatment. At 1 month after sur-gical treatment, patients begin strengtheningexercises. Early, aggressive, range-of-motionexercises prevent excessive scarring of the ul-nar nerve in the surgical bed and ensuregreater excursion of the nerve.

POSTOPERATIVE PAIN CONTROL

Patients with preoperative complaints ofpain begin to receive Neurontin (gabapentin;Pfizer, New York, N.Y.), which is typically initi-

ated at a dose of 300 mg at bedtime and thenincreased to 300 mg three times per day, ad-ministered orally, during a 1-month period. Acomplete pain evaluation is performed to de-termine the location, duration, and severity ofthe discomfort.81 Patients often require reas-surance that postoperative paresthesia is typi-cal of nerve regeneration after surgical treat-ment. Patients with chronic pain after multipleulnar nerve releases at the elbow may be can-didates for the placement of a peripheral nervestimulator when aggressive medical and surgi-cal interventions have failed. A peripheralnerve stimulator has been recommended forpatients with ongoing pain that originates froma peripheral nerve and is resistant to conven-tional treatments.82–88

The stimulation is thought to improve thesymptoms of pain on the basis of the gatecontrol theory. Nerve stimulators provide painrelief through the direct application of contin-uous, high-frequency, electrical stimulation toperipheral nerves, usually proximal to the levelof injury. We place the electrode on the ulnarnerve in the upper arm, and the battery ispermanently placed beneath the skin if thetrial system proves to be beneficial. The periph-eral nerve stimulator is useful in decreasingpain levels for carefully selected patients, suchas those with pain after ulnar nerve surgicaltreatment at the elbow.89 However, we thinkthat nerve stimulators should be used only forpatients with failed ulnar nerve release at theelbow who have experienced failure of otherreasonable medical and surgical options.

CONCLUSIONS

Complaints after ulnar nerve release at theelbow are frequent and often challenging di-agnostic problems. Each patient’s clinicalsymptoms must be carefully categorized, to de-termine the most likely cause and the appro-priate treatment plan. It is important that pa-tients who present for revision after cubitaltunnel surgical treatment undergo completeevaluations, to clearly establish the diagnosisand likely causes of the disease. Patients diag-nosed as having recurrent disease should bemonitored for at least 6 months before surgicalreexploration. Patients with recurrent diseaseshould undergo aggressive physical therapy,nonoperative management, and medical man-agement before surgical treatment. Electrodi-agnostic studies are always indicated for pa-tients being considered for secondary cubital


tunnel surgical treatment. Patients with new orworse symptoms after surgical treatment maybenefit from nerve blocks to relieve or evendiagnose specific areas of pain or neuromaformation. All patients who complain of signif-icant pain should undergo a full pain evalua-tion, and pain management may include treat-ment with Neurontin (gabapentin) for severalmonths. If there is a significant psychologicalcomponent to the patient’s symptoms, a psy-chiatric evaluation is indicated. Patients whoexperience failure of repeated ulnar nerve re-lease at the elbow may require a peripheralnerve stimulator to relieve severe persistentpain in this region.

James B. Lowe, III, M.D.Division of Plastic and Reconstructive SurgerySuite 17424, East PavilionOne Barnes-Jewish Hospital PlazaSt. Louis, Mo. [email protected]

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