Modified simple decompression in the treatment of cubital tunnel syndrome: avoiding ulnar nerve subluxation

ABSTRACT

Objective

In this study, we propose a modification to the simple decompression technique that contains the ulnar nerve in the cubital fossa, thus preventing subluxation during forearm flexion movements.

Methods

Five consecutive patients with leprosy-associated cubital tunnel syndrome underwent surgery with the modified technique between July 2011 and October 2012.

Results

The most common symptoms were neuropathic pain and sensory changes (both 60%). On the McGowan scale, three patients maintained their preoperative score and two patients improved by two points, while on the Louisiana State University Health Sciences Center scale, two patients maintained the same scores, two improved by two points, and one improved by one point. Four patients were able to discontinue corticosteroid use. The mean follow-up time was 25.6 months (range 2-48 months). There were no recurrences or subluxations in the long-term.

Conclusion

This alternative technique resulted in excellent functional results, as well as successful withdrawal from corticosteroids. Furthermore, it resulted in no ulnar nerve subluxations.

RESUMO

Objetivo

Neste manuscrito apresentamos uma modificação da técnica de descompressão simples do nervo ulnar no túnel cubital que impede a subluxação do nervo em movimentos de flexão do antebraço.

Métodos

Foram incluídos cinco pacientes consecutivos acometidos por síndrome do túnel cubital (Hanseníase) submetidos à cirurgia entre 2011 e 2012.

Resultados

Os sintomas mais comuns foram dor neuropática e alterações sensitivas (60%). No pós-operatório, três pacientes mantiveram o mesmo escore e dois melhoraram dois pontos na escala de McGowan, enquanto na escala Louisiana State University Health Sciences Center, dois pacientes mantiveram o mesmo escore, dois melhoraram dois pontos e um melhorou um ponto. Os corticosteróides foram descontinuados em quatro pacientes. O tempo médio de seguimento foi 25,6 meses (variação 2-48 meses). Não foram observadas recorrência ou subluxação no longo prazo.

Conclusões

A técnica alternativa apresentou excelentes resultados funcionais e foi bem sucedida na retirada dos corticosteróides. Ademais, subluxações do nervo ulnar não foram observadas.

cubital tunnel syndrome - decompression - leprosy - peripheral nerves - ulnar nerve

síndrome do túnel ulnar - descompressão - hanseníase - nervos periféricos - nervo ulnar

• References

• 1 Assmus H, Antoniadis G, Bischoff C, Hoffmann R, Martini AK, Preissler P et al. Cubital tunnel syndrome - a review and management guidelines. Cent Eur Neurosurg. 2011;72(2):90-8. https://doi.org/10.1055/s-0031-1271800
• 2 Bartels RH. History of the surgical treatment of ulnar nerve compression at the elbow. Neurosurgery. 2001;49(2):391-9.
• 3 Seror P, Nathan PA. Relative frequency of nerve conduction abnormalities at carpal tunnel and cubital tunnel in France and the United States: importance of silent neuropathies and role of ulnar neuropathy after unsuccessful carpal tunnel syndrome release. Ann Chir Main Memb Super. 1993;12(4):281-5. https://doi.org/10.1016/S0753-9053(05)80027-4
• 4 Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89(12):2591-8. https://doi.org/10.2106/JBJS.G.00183
• 5 Martyn CN, Hughes RAC. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry. 1997;62(4):310-8. https://doi.org/10.1136/jnnp.62.4.310
• 6 Garbino JA. [Clinical management of diferents forms of compromising of neuropaty leprosy]. Hansen Int. 1998;98:93-9. Portuguese.
• 7 Job CK. Nerve damage in leprosy. Int J Lepr Other Mycobact Dis. 1989;57(2):532-9.
• 8 Husain S. Decompression of peripheral nerve trunks in leprosy prevents the development and progression of deformities? Indian J Lepr. 2013;85(4):163-9.
• 9 Ministério da Saúde (BR). [Manual of rehabilitation and surgery in leprosy]. 2a ed. Brasília, DF: Ministério da Saúde; 2008 [cited 2016 Jun 15]. (Cadernos de preenção e reabilitação em haseníase, vol 4). Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_reabilitacao_cirurgia_hanseniase.pdf
• 10 Bartels RH, Verhagen WI, Wilt GJ, Meulstee J, Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005;56(3):522-30. https://doi.org/10.1227/01.NEU.0000154131.01167.03
• 11 Huang JH, Samadani U, Zager EL. Ulnar nerve entrapment neuropathy at the elbow: simple decompression. Neurosurgery. 2004;55(5):1150-3. https://doi.org/10.1227/01.NEU.0000140841.28007.F2 PMID:15509321
• 12 McGowan AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. 1950;32-B(3):293-301.
• 13 Kim DH, Han K, Tiel RL, Murovic JA, Kline DG. Surgical outcomes of 654 ulnar nerve lesions. J Neurosurg. 2003;98(5):993-1004. https://doi.org/10.3171/jns.2003.98.5.0993
• 14 Kang HJ, Oh WT, Koh IH, Kim S, Choi YR. Factors influencing outcomes after ulnar nerve stability- based surgery for cubital tunnel syndrome: a prospective cohort study. Yonsei Med J. 2016;57(2):455-60. https://doi.org/10.3349/ymj.2016.57.2.455
• 15 Keith J, Wollstein R. A tailored approach to the surgical treatment of cubital tunnel syndrome. Ann Plast Surg. 2011;66(6):637-9. https://doi.org/10.1097/SAP.0b013e318219183d
• 16 Bimmler D, Meyer VE. Surgical treatment of the ulnar nerve entrapment neuropathy: submuscular anterior transposition or simple decompression of the ulnar nerve? Long-term results in 79 cases. Ann Chir Main Memb Super. 1996;15(3):148-57. https://doi.org/10.1016/S0753-9053(96)80004-4
• 17 Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. 2006;58(2):296-304. https://doi.org/10.1227/01.NEU.0000194847.04143.A1
• 18 Lane LB, Greenberg AS. Use of a fascial flap to stabilize an unstable ulnar nerve in its bed during in situ decompression. J Surg Orthop Adv. 2015;24(3):193-7.
• 19 Palmer BA, Hughes TB. Cubital tunnel syndrome. J Hand Surg Am. 2010;35(1):153-63. https://doi.org/10.1016/j.jhsa.2009.11.004
• 20 O’Driscoll SW, Horii E, Carmichael SW, Morrey BF. The cubital tunnel and ulnar neuropathy. J Bone Joint Surg Br. 1991;73(4):613-7.
• 21 Babusiaux D, Laulan J, Bouilleau L, Martin A, Adrien C, Aubertin A et al. Contribution of static and dynamic ultrasound in cubital tunnel syndrome. Orthop Traumatol Surg Res. 2014;100(4 Suppl):S209-12. https://doi.org/10.1016/j.otsr.2014.03.008
• 22 Okamoto M, Abe M, Shirai H, Ueda N. Morphology and dynamics of the ulnar nerve in the cubital tunnel. Observation by ultrasonography. J Hand Surg [Br]. 2000;25(1):85-9. https://doi.org/10.1054/jhsb.1999.0317