Open versus endoscopic in situ decompression in cubital tunnel syndrome: A systematic review and meta-analysis

Surgical management of cubital tunnel syndrome: A systematic review and meta-analysis of randomised trials

Background

Cubital tunnel syndrome (CUTS) is a common upper limb compression neuropathy with significant consequences when left untreated. Surgical decompression remains gold-standard treatment for moderate to severe disease, however the optimal operative technique remains unclear. This network meta-analysis (NMA) of Level I and II randomised prospective studies aims to discern superiority between open in-situ, endoscopic and anterior transposition (subcutaneous or submuscular techniques) with respect to the primary outcome of response-to-treatment and secondary outcomes which include complications, post-operative chronic pain VAS scale, return to work and re-operation.

Methods

This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Web of Science, Cochrane Central, Science direct and Embase were searched. The MESH database was further searched with the terms 'cubital tunnel' to improve sensitivity of the search. Data pertaining to the primary and secondary outcomes were pooled for NMA.

Results

Following abstract and full-text screening, 10 randomised prospective trials were included. There was no statistical difference in the response-to-treatment between the four studied techniques. Endoscopic decompression conferred a significantly higher complication rate compared to open decompression (Odds Ratio [OR], 4.21; 95% CI, 1.22-14.59). Endoscopic decompression had a statistically significant lower risk of post-operative chronic pain compared to open in-situ decompression (OR, 0.03, 95% CI, 0.00-0.32). There were no differences between techniques with respect to return to work or re-operation rates.

Conclusion

Response-to-treatment was similar between the four operative techniques for CUTS. Endoscopic decompression was found to be more hazardous when compared to open-in situ decompression but conferred significantly less post-operative chronic pain. There was significant heterogeneity in reported outcomes between the included articles. The authors suggest conducting more high-quality research with standardised outcome reporting to facilitate comparison.

Level of evidence ii

Systematic Review and Meta-analysis of Randomised Prospective Trials- Therapeutic study.

Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy

Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient's history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.

A complete analysis of the surgical treatment for cubital tunnel syndrome: an umbrella review

BACKGROUND

Numerous original studies have been presented regarding various surgical treatments for cubital tunnel syndrome (CubTS). The results of these analyses regarding the different surgical treatments for CubTS frequently differ and, in some cases, contradict each other, creating confusion. Therefore, our umbrella review aimed to summarize the evidence from meta-analyses and systematic reviews regarding the surgical treatments of CubTS, and along with the new, more detailed outcomes, provide an evidence-based tool for surgeons performing these procedures.

MATERIALS AND METHODS

To perform this umbrella review, a systematic search was conducted for meta-analyses investigating CubTS in PubMed, Scopus, Embase, Web of Science, Google Scholar, Cochrane Library, BIOSIS, and EBSCO medical databases.

RESULTS

Detailed comparison of surgical outcomes, such as clinical improvement, complications, or reoperation rates, of different treatment methods for CubTS was performed. New risk ratios in all categories were established based on all of the primary studies available in the literature.

DISCUSSION

The goal of the present umbrella review was to gather and summarize all data about the surgical treatments for CubTS in the available literature and provide new outcomes and an evidence-based tool for surgeons performing these procedures. Each comparison of the surgical techniques has been discussed, and the present study's results were compared with the outcomes of the previous studies.

Protocol for Endoscopic Versus Open Cubital tunnel release (EVOCU): an open randomized controlled trial : EVOCU trial: Endoscopic Versus Open Cubital tunnel release

BACKGROUND

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Surgical decompression of the ulnar nerve aims to improve complaints and prevent permanent damage to the nerve. Open and endoscopic release of the cubital tunnel are both used in common practice, but none has proven to be superior. This study assesses patient reported outcome and experience measures (PROMs and PREMs respectively), in addition to objective outcomes of both techniques.

METHODS

A prospective single-center open randomized non-inferiority trial will take place at the Plastic Surgery Department in the Jeroen Bosch Hospital, the Netherlands. 160 patients with cubital tunnel syndrome will be included. Patients are allocated to endoscopic or open cubital tunnel release by randomization. The surgeon and patients are not blinded for treatment allocation. The follow-up time will take 18 months.

DISCUSSION

Currently, the choice for one of the methods is based on surgeon's preferences and degree of familiarity with a particular technique. It is assumed that the open technique is easier, faster and cheaper. The endoscopic release, however, has better exposure of the nerve and reduces the chance of damaging the nerve and might decrease scar discomfort. PROMs and PREMs have proven potential to improve the quality of care. Better health care experiences are associated with better clinical outcome in self-reported post-surgical questionnaires. Combining subjective measures with objective outcomes, efficacy, patient treatment experience and safety profile could help differentiating between open and endoscopic cubital tunnel release. This could aid clinicians in evidence based choices towards the best surgical approach in patients with cubital tunnel syndrome.

TRIAL REGISTRATION

This study is registered prospectively with the Dutch Trial Registration under NL9556. Universal Trial Number (WHO-UTN) U1111-1267-3059. Registration date 26-06-2021. The URL: https://www.trialregister.nl/trial/9556.

Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters

BACKGROUND

Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement.

METHODS

The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery.

RESULTS

The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not.

CONCLUSIONS

Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, III.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Endoscopic cubital tunnel decompression: state of the art

Cubital tunnel syndrome is a common compressive neuropathy of the upper limb. Surgical decompression is indicated for patients who failed conservative therapy. Decompression in situ has shown to achieve comparable outcomes as decompression with anterior transposition in idiopathic cubital tunnel syndrome. Endoscopic cubital tunnel decompression has gained popularity in recent years, as surgeons can attain decompression of the ulnar nerve along its course using a small incision. Results from randomised controlled studies and systematic reviews, comparing endoscopic with open decompression in situ, are promising. Cases in which anterior transposition of the ulnar nerve is needed, an endoscopic technique can still be used by creating an additional volar portal, for the mobilisation of ulnar nerve. Early short-term results are encouraging. Further adequately powered, prospective, preferably double-blinded, randomised study are needed.

Endoscopic cubital tunnel decompression - Review of the literature

Cubital tunnel syndrome is the second most common compressive neuropathy of the upper limb. Endoscopic cubital tunnel decompression has gained popularity in recent years as this enables surgeons to achieve decompression of the ulnar nerve along its course using a small incision. This article describes the technical peals in performing endoscopic cubital tunnel decompression. In conditions which anterior transposition of the ulnar nerve is needed, subcutaneous transposition can be performed under endoscopic guidance. In addition, current literature is reviewed, and outcomes are presented. While short term results are encouraging, further prospective randomized study with longer follow-up is recommended.

Sonographic Follow-Up of Patients With Cubital Tunnel Syndrome Undergoing in Situ Open Neurolysis or Endoscopic Release: The SPECTRE Study

Background:The measurement of cross-sectional area (CSA) is a diagnostic tool to detect entrapments syndrome. The aim of this study was to compare the clinical outcome in elbows undergoing endoscopic and "in situ" open cubital tunnel release for cubital tunnel syndrome (CuTS) using ultrasound-related changes in the largest CSA of the ulnar nerve. The purpose is to determine the association between clinical outcome and CSA. Methods: From May 2011 to April 2016, 60 patients with CuTS were prospectively followed and not randomly divided in two groups: 30 patients undergoing an endoscopic release (ER) and 30 patients with "in situ" open neurolysis (OR). A sonographic examination was performed by the senior authors at baseline and 3, 6, and 12 months after surgical decompression. Results: CSA values were statistically significantly lower in the ER. Hand grip strength difference with Jamar test was not statistically significant a 12 months (39 kg vs 27 kg). Static-2 point discrimination test difference was only statistically significant lower in the endoscopic group at 3, 6 and 12 months but not clinically relevant (5 mm vs 6 mm). The American Shoulder and Elbow Surgeons-Elbow questionnaire (ASES-e) function score, ASES-e Pain score, and ASES-e Satisfaction score were not statistically significant different between the two groups at 3, 6, and 12 months post operatively. Conclusions: The study confirms that in spite of lower values of CSA in the ER, there is not a statistically significant difference between the two techniques in terms of subjective outcomes. Ultrasound (US) measurements seem to have a limited value in clinical results of patients treated for entrapment neuropathy of the ulnar nerve.Type of study/LOE: Prognostic Level III.

Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis

IMPORTANCE

Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications.

OBJECTIVE

To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure.

DATA SOURCES

PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies.

STUDY SELECTION

Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact.

MAIN OUTCOMES AND MEASURES

The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence.

RESULTS

A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates.

CONCLUSIONS AND RELEVANCE

In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.

The impact of pre-existing ulnar nerve instability on the surgical treatment of cubital tunnel syndrome: a systematic review

BACKGROUND

The decision to perform nerve transposition (NT) or in situ decompression (SD) during surgical treatment of cubital tunnel syndrome is often based on nerve subluxation through elbow motion. This review assesses what impact nerve instability has on study design and reported outcomes.

METHODS

A search was performed with Boolean operators: "ulnar nerve" OR "cubital tunnel" AND "decompression" OR "transposition" on PubMed, Clinical Key, and CINAHL to identify primary studies comparing NT and SD that report pre-existing nerve instability. Primary outcome was the effect of instability on study design. Secondary outcomes were nerve instability, patient-reported scores, and complications.

RESULTS

Five studies met criteria after screening 134 articles. In 3 studies, nerve instability dictated treatment. Prospective randomization was maintained in 1 study. Included cases totaled 464 SD and 304 NT. The complication rate was 8.6% overall, 4.3% for SD and 21.1% for NT. Bishop scores were 56.9% excellent and 37.3% good for stable nerves and 62.0% excellent and 29.3% good for unstable nerves.

CONCLUSIONS

Very few studies report ulnar nerve instability, and study design is biased by ulnar nerve subluxation. Outcomes showed similar symptomatic improvement for both decompressed and transposed groups with higher complication rates for the transposed group.

A systematic review and meta-analysis comparing open versus endoscopic in situ decompression for the treatment of cubital tunnel syndrome

To examine whether endoscopic in situ decompression (EISD) or open in situ decompression (OISD) would have superior outcomes with lower morbidity in patients with idiopathic cubital tunnel syndrome, we reviewed all studies compared both surgical techniques with regard to postoperative outcomes and complication profile in a systematic review design with meta-analysis. Two independent reviewers conducted a PRISMA-compliant search of PubMed, EMBASE, and the Cochrane Library databases for relevant studies about clinical comparisons of OISD and EISD in cubital tunnel syndrome. We performed all meta-analyses with the Review Manager 5.3 software. For dichotomous variables, the risk ratio (RR) and 95% confidence intervals (CIs) were calculated. For continuous variables, the mean difference (MD) and 95% CIs were calculated. The level of significance was set as p < 0.05. Finally, 8 articles with 582 patients finally were included in this meta-analysis. Pooled analysis showed that the difference in Bishop score, visual analogue scale score reduction, postoperative satisfaction, postoperative hematoma rate and secondary surgical procedures were not statistically significant between the EISD group and the OISD group (p > 0.05). However, pooled results showed that patients who underwent EISD had a greater improvement in the scar tenderness/elbow pain than did those who underwent OISD with statistical significance (p < 0.0001). This meta-analysis demonstrated that EISD and OISD for surgical treating cubital tunnel syndrome had equivalent efficacy regarding postoperative clinical recovery, whereas the incidences of adverse events of EISD were also same as those with the OISD technique.

Ultrasound-Guided Cubital Tunnel Decompression in a Collegiate Swimmer: A Case Report

A 19-year-old female collegiate swimmer presented to our sports medicine clinic with a history and physical examination consistent with right ulnar neuropathy at the cubital tunnel. Diagnostic ultrasound (US) revealed compression of the ulnar nerve under the cubital tunnel retinaculum (CTR) with nerve swelling proximal to the site of compression. Electrodiagnostic studies confirmed the diagnosis of a moderate to severe ulnar neuropathy at the elbow. Treatment consisted of an US-guided decompression of the ulnar nerve in the cubital tunnel by cutting the CTR using a rotated stylet "v" cutting technique. The patient's symptoms resolved, and she was able to begin a swimming progression 2 weeks after the procedure. After completion of this progression, she was able to successfully resume full, unrestricted competitive collegiate swimming without return of her symptoms. To the best of our knowledge, this is the first description of an US-guided cubital tunnel decompression surgery.

Retrospective, nonrandomized analysis of subcutaneous anterior transposition versus in situ decompression of the ulnar nerve of military service members

HYPOTHESIS

The objective of this study was to compare the subjective and objective midterm functional clinical outcomes of subcutaneous anterior transposition (SAT) vs. in situ decompression (SD) of the ulnar nerve for the treatment of cubital tunnel syndrome.

METHODS

The US Military Health System was queried to identify all cases of ulnar neuroplasty (Current Procedural Terminology code 64718) between 2006 and 2010. Patient charts were reviewed to identify cases of isolated SAT and SD, and demographic and surgical variables were collected. The primary outcome variable was the Disabilities of the Arm, Shoulder and Hand score. The inclusion criteria were isolated primary SAT or SD and adult active-duty service members with a minimum 6-year telephone follow-up. Terminal follow-up was determined by a telephone interview. The exclusion criteria were revision procedures, trauma, cases that included other procedures (eg, medial epicondylectomy, submuscular transposition, arthroscopy, or fracture fixation), non-active-duty service members, patients without a minimum 6-year telephone follow-up, and patients who had incomplete medical records or could not be reached to complete the survey.

RESULTS

A total of 65 SD and 67 SAT patients met the inclusion and exclusion criteria, with a 72% telephone interview response rate. The average age was 32.3 years for all patients, with an average follow-up period of 6.5 years for SD patients and 6.3 years for SAT patients. SD patients had a lower mean Disabilities of the Arm, Shoulder and Hand score than SAT patients. No difference in reoperation rate was found.

CONCLUSION

The active-duty cohort reported positive outcomes and a low reoperation rate at 6-year follow-up both after SAT and after SD. SD patients had mildly superior clinical outcomes compared with SAT patients.