Wide Awake Revision Cubital Tunnel Release: Is This the New Normal in Nerve Decompression Surgery?

Revision nerve decompression surgery is complicated as it is often fraught with diagnostic dilemmas, surgical risks, and high recurrence rates.[1] We present a case of revision cubital tunnel release (CuTR) done using a wide-awake (WA) approach, which may be the first reported in the literature. This procedure adds another dimension to the already rapidly expanding and evolving bucket list of procedures followed using the principle of WA hand surgery.

A 31-year-old patient presented with symptoms of chronic ulnar nerve compression at the right elbow for which previous neurolysis was done. On evaluation, he had McGowan grade II chronic ulnar nerve compression at the right elbow, which was recurrent and appeared a few months after the initial surgery.

He underwent a revision CuTR using the WA approach. About 150 mL of saline is added to 50 mL mixture of 1% lidocaine with adrenaline (1:100,000) giving a concentration of 0.25% lidocaine with 1:400,000, which is still quite effective, and this is infiltrated around the proposed skin incision sites ([Fig. 1A]).

Fig. 1 Preoperative and intraoperative images (A) showing incision marking, injection of local anaesthetic solution and note the patient's face as he is calm and without any discomfort. (B) Proximal release of the ulnar nerve up to the Arcade of Struthers and medial intermuscular septum. (C) Distal release of the ulnar nerve.

Intraoperatively the ulnar nerve was found entrapped in scar tissue and external neurolysis was performed. Decompression was carried out proximally from the Arcade of Struthers ([Fig. 1B]) distally up to the FCU arch, followed by the release of volar antebrachial fascia ([Fig. 1C]). During this intraoperative decompression, the patient actively contributed with his verbal input, whenever he felt extrasensitivity on touching the nerve, especially at the abovementioned points of compression. This will guide the surgeons about the extent of decompression required and also, to decide whether to proceed with an anterior transposition procedure intraoperatively.

Postoperative period was uneventful; he had a minimal requirement for opioids (visual analog score or VAS for pain was 2/10) in the immediate postoperative period, and he was satisfied with the surgery. At 1 year follow-up, he reported the excellent functional outcomes with the following examination parameters—moving 2-PD of 6 (preoperative value: 11), Semmes-Weinstein monofilament examination was 3.61 (preoperative value: 4.56), handgrip strength was 52.6 (preoperative: 37.2), pinch grip strength was 11.2 (preoperative: 6.7), QuickDASH score of 16, and treatment satisfaction VAS of 2/10.

The main advantage of the WA approach vis-à-vis general anesthesia (GA) and/or brachial plexus block (BPB) is the active, awake patient providing verbal feedback during the procedure, which is indispensable to the surgeon. This will guide the surgeons about the extent of decompression required and also, to make a decision whether to proceed with an anterior transposition procedure intraoperatively.

Lavyne and Bell who perhaps published the first case series (20 patients) of CuTR using the WA approach noted that almost all patients reported marked improvement.[2] Kang et al in their series reported superior outcomes in terms of pain relief, reduced demand for opioids, reduced hospitalization and cost, however, there was no difference in postoperative functional outcome.[3] Del Vecchio et al presented comparable results in terms of postoperative complications and resolution of preoperative symptoms when compared with the GA group, but reported superior pain control in the WA group.[4]

There are risks associated with revision CuTR surgery when performed using the WA approach. Revision CuTR surgery is usually complicated, involves scar tissue, and presents with added difficulties like excessive bleeding, which can be challenging using the no tourniquet, WA approach.[1] Other risks include insufficient pain control in the postoperative period. For patients with joint stiffness or arthritis, arm positioning during the WA approach may cause problems intraoperatively.

The WA approach in nerve decompression surgery is expanding its horizons. Still, with revision CuTR surgery, this must be dealt with caution, and the patient must be counseled about the possibility of conversion to GA and other risks. The benefits of this approach include—less postoperative pain, high patient satisfaction, cost-effectiveness, avoidance of GA or BPB and tourniquet, reduced hospital stay, and earlier return to work.[5] However, further research is required to define the indications and contraindication of using this approach for revision CuTR surgery. Finally, the advantage of WA revision CuTR surgery is that with the patient's feedback, we can correct the problem more effectively during a single procedure, hopefully decreasing the need for future repeat revisions.

Publication History

Article published online:
14 February 2021

• References

• 1 Aleem AW, Krogue JD, Calfee RP. Outcomes of revision surgery for cubital tunnel syndrome. J Hand Surg Am 2014; 39 (11) 2141-2149
• 2 Lavyne MH, Bell WO. Simple decompression and occasional microsurgical epineurolysis under local anesthesia as treatment for ulnar neuropathy at the elbow. Neurosurgery 1982; 11 (1 Pt 1) 6-11
• 3 Kang SW, Park HM, Park JK. et al. Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain. J Pain Res 2019; 12: 2725-2731
• 4 Roberti del Vecchio PM, Christen T, Raffoul W, Erba P. Ulnar nerve transposition at the elbow under local anesthesia: a patient satisfaction study. J Reconstr Microsurg 2015; 31 (03) 187-190
• 5 Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost savings, safety, and patient satisfaction of a clinic-based wide awake hand surgery practice: a critical review of the first 100 procedures.: level 2 evidence. J Hand Surg Am 2016; 41 (09) S4