Aktueller Stand der Diagnostik und Therapie des Kubitaltunnelsyndroms[*]

Zusammenfassung

Das Kubitaltunnelsyndrom (KuTS) ist das zweithäufigste Kompressionssyndrom eines peripheren Nervs. Die im deutschsprachigen Raum übliche Bezeichnung Sulcus-ulnaris-Syndrom ist anatomisch inkorrekt, da der Kubitaltunnel über den retrokondylären Sulkus hinausgeht und zusätzlich den Bereich des Kubitaltunnelretinakulums (Lig. arcuatum oder Osborne-Band), der Faszie zwischen den Flexorenköpfen und der tiefen Flexorenfaszie, umfasst. Nach Sunderland [159] wird es eingeteilt in eine primäre Form, zu der auch die Ulnarisluxation und der M. epitrochleoanconaeus zählen, und eine sekundäre Form infolge knöcherner Veränderungen des Ellenbogengelenks und anderweitiger raumfordernder Prozesse. Zur Diagnose ist eine differenzierte neurologische Untersuchung durch eine elektrophysiologische Untersuchung zu ergänzen. Neurosonografie und MRT gewinnen durch die verbesserte Auflösung zunehmend an Bedeutung und erlauben den direkten Nachweis morphologischer Veränderungen. Wichtigste Differenzialdiagnose sind das C8-Syndrom und die Ulnarisdruckparese. Überschneidungen kommen als Doppelkompressionssyndrom („double crush“) nicht selten vor. Die operative Behandlung ist wirksamer als die konservative, die sich im Wesentlichen auf eine Verminderung der Exposition beschränkt. Aufgrund neuerer randomisiert-kontrollierter Studien ist die Dekompression bei der primären Form einschließlich der meisten Fälle einer nicht schmerzhaften Ulnarisluxation und einem M. epitrochleoanconaeus der Verlagerung vorzuziehen. Die Dekompression muss bis auf eine Strecke von mindestens 5 cm distal des medialen Epikondylus ausgedehnt werden und kann auch endoskopisch erfolgen – beide Techniken in Lokalanästhesie oder Leitungsanästhesie. Eine Verlagerung des N. ulnaris ist bei schweren narbigen und knöchernen Veränderungen wie zum Beispiel Kubitus valgus zu empfehlen. Als Primäreingriff ist jedoch auch die In-situ-Dekompression möglich. Es kommen für die Verlagerung sowohl subkutane als auch submuskuläre Techniken infrage. Risiken der Verlagerung sind neben der Beeinträchtigung der Durchblutung vor allem das Abknicken des Nervs durch ungenügende proximale und distale Mobilisierung. Die Epikondylektomie spielt hierzulande keine Rolle. Rezidive sind nicht ungewöhnlich.

Abstract

The cubital tunnel syndrome is one of the most widespread compression syndromes of a peripheral nerve. In German-speaking countries it is known as the sulcus ulnaris syndrome (retrocondylar groove syndrome), which is anatomically incorrect. The cubital tunnel consists of the retrocondylar groove, the cubital tunnel retinaculum (Lig. arcuatum or Osborne band), the humeroulnar arcade and the deep flexor/pronator aponeurosis. According to Sunderland [159] it can be divided into a primary form (including the ulnar luxation and the epitrocheoanconaeus muscle) and a secondary form caused by deformation or other processes of the elbow joint. The diagnosis has to be confirmed by a thorough clinical examination and nerve conduction studies. Neurosonography and MRI are becoming more and more important with improving resolution and enable the direct identification of morphological changes. Differential diagnosis is essential in atypical cases, especially C8 syndrome and pressure palsy. Double crush (double compression syndrome) may occur. Operative treatment is more effective than conservative treatment, which consists primarily of the prevention of exposure to external noxes. According to actual randomised controlled studies the therapy of choice of the primary form in most cases is the simple in situ decompression of the ulnar nerve in the cubital tunnel. This has to be extended at least up to 5–6 cm distally of the medial epicondyle and can be performed in the open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. In cases of severe bony or tissue changes of the elbow (especially cubitus valgus) the volar transposition of the ulnar nerve may be indicated. This can be performed in a subcutaneous or submuscular technique. Risks of transposition are impairment of perfusion and, above all, kinking caused by insufficient proximal or distal mobilisation of the nerve has to be avoided. In these cases revision surgery is necessary. The epicondylectomy is not common in our country. Recurrences may occur.

Schlüsselwörter

Kubitaltunnelsyndrom - Sulcus‐ulnaris‐Syndrom - Ulnarisneuropathie am Ellenbogen (UNE) - Elektrodiagnostik - endoskopische Dekompression - Ulnarisverlagerung

Key words

cubital tunnel syndrome - sulcus ulnaris syndrome - ulnar neuropathy at the elbow - nerve conduction studies - endoscopic release - transposition

1 Die Übersicht basiert auf der S3-Leilinie der beteiligten 7 Fachgesellschaften, die – ergänzt durch Empfehlungsgrade – unter www.leitlinien.net abrufbar ist.

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1 Die Übersicht basiert auf der S3-Leilinie der beteiligten 7 Fachgesellschaften, die – ergänzt durch Empfehlungsgrade – unter www.leitlinien.net abrufbar ist.