Smoking is associated with ulnar nerve entrapment: a birth cohort study

The Unpredictable Ulnar Nerve-Ulnar Nerve Entrapment from Anatomical, Pathophysiological, and Biopsychosocial Aspects

Peripheral nerves consist of delicate structures, including a rich microvascular system, that protect and nourish axons and associated Schwann cells. Nerves are sensitive to internal and external trauma, such as compression and stretching. Ulnar nerve entrapment, the second most prevalent nerve entrapment disorder after carpal tunnel syndrome, appears frequently at the elbow. Although often idiopathic, known risk factors, including obesity, smoking, diabetes, and vibration exposure, occur. It exists in all adult ages (mean age 40-50 years), but seldom affects individuals in their adolescence or younger. The patient population is heterogeneous with great co-morbidity, including other nerve entrapment disorders. Typical early symptoms are paresthesia and numbness in the ulnar fingers, followed by decreased sensory function and muscle weakness. Pre- and postoperative neuropathic pain is relatively common, independent of other symptom severity, with a risk for serious consequences. A multimodal treatment strategy is necessary. Mild to moderate symptoms are usually treated conservatively, while surgery is an option when conservative treatment fails or in severe cases. The decision to perform surgery might be difficult, and the outcome is unpredictable with the risk of complications. There is no consensus on the choice of surgical method, but simple decompression is relatively effective with a lower complication rate than transposition.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment

PURPOSE

Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied.

METHODS

The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year.

RESULTS

A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks.

CONCLUSIONS

Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear-avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear-avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Socioeconomic Differences between Sexes in Surgically Treated Carpal Tunnel Syndrome and Ulnar Nerve Entrapment

We aimed to investigate socioeconomic differences between sexes and the influence on outcome following surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE) at the elbow. Patients with CTS (n = 9000) or UNE (n = 1266) registered in the Swedish National Register for Hand Surgery (HAKIR) 2010-2016 were included and evaluated using QuickDASH 12 months postoperatively. Statistics Sweden (SCB) provided socioeconomic data. In women with CTS, being born outside Sweden, having received social assistance, and more sick leave days predicted worse outcomes. Higher earnings and the highest level of education predicted better outcomes. In men with CTS, more sick leave days and having received social assistance predicted worse outcomes. Higher earnings predicted better outcomes. For women with UNE, higher earnings predicted better outcomes. In men with UNE, only sick leave days predicted worse outcomes. In long-term follow up, socioeconomic status affects outcomes differently in women and men with CTS or UNE.

Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication

We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.

Possible points of compression of the ulnar nerve: Tricks and traps that await clinicians from an anatomical point of view

The ulnar nerve can be subject to numerous types of compression. The most common are cubital tunnel and ulnar tunnel syndromes, but there are many others with more uncommon etiologies. The existence of additional communicating branches, median nerve involvement, various types of injuries, and unusual anatomical variations can be a challenge for both diagnosis and treatment. This review presents a comprehensive depiction of ulnar nerve entrapment syndromes with particular reference to their anatomical background, risk factors, and clinical evaluation. Even common disorders can result from atypical morphological changes. It is important to be familiar with them as it is a key ability in daily medical practice.

Work-related risk factors for ulnar nerve entrapment in the Northern Finland Birth Cohort of 1966

Ulnar nerve entrapment (UNE) is the second most common entrapment neuropathy in the upper extremity. The aetiology of UNE is multifactorial and is still not fully understood. The aim of the study was to identify occupational risk factors for UNE and to determine whether smoking modifies the effects of work-related factors on UNE. The study population consisted of the Northern Finland Birth Cohort of 1966 (NFBC1966). In total, 6325 individuals active in working life participated at baseline in 1997. Occupational risk factors were evaluated by a questionnaire at baseline. The data on hospitalizations due to UNE were obtained from the Care Register for Health Care between 1997 and 2018. The incidence rate of hospitalization due to UNE was 47.6 cases per 100,000 person-years. After adjusting for confounders, entrepreneurs (Hazard ratio (HR) = 3.68, 95% CI 1.20–11.27), smokers (HR = 2.51, 95% CI 1.43–4.41), workers exposed to temperature changes (HR = 1.72, 95% CI 1.00–2.93), workers with physically demanding jobs (HR = 3.02, 95% CI 1.39–6.58), and workers exposed to hand vibration (HR = 1.94, 95% CI 1.00–3.77) were at an increased risk of hospitalization for UNE. Exposure to work requiring arm elevation increased the risk of hospitalization due to UNE among smokers (HR = 2.62, 95% CI 1.13–6.07), but not among non-smokers. Work-related exposure to vibration and temperature changes, and physically demanding work increase the risk of hospitalization for UNE. Smoking may potentiate the adverse effects of work-related factors on UNE.

Socioeconomic Factors in Patients with Ulnar Nerve Compression at the Elbow: A National Registry-Based Study

AIMS

To investigate demographics and socioeconomic status in patients with ulnar nerve compression and the influence of socioeconomic factors on patient-reported outcome measurements (PROM) as evaluated by QuickDASH (short version of Disabilities of Arm, Shoulder and Hand) after surgery for ulnar nerve compression at the elbow.

METHODS

Patients operated for primary ulnar nerve compression from 2010 to 2016 were identified in the National Quality Registry for Hand Surgery Procedures (HAKIR). Patients filled out questionnaires before and at three and 12 months after surgery. A total of 1346 surgically treated cases were included. Data from HAKIR were linked to data from Statistics Sweden (SCB) on socioeconomic status (i.e., education level, earnings, social assistance, immigrant status, sick leave, unemployment, and marital status).

RESULTS

Patients surgically treated for ulnar nerve compression at the elbow differed from the general population with lower levels of education, higher social assistance dependence, a high proportion of unemployment, and lower earnings. However, the results were not clear concerning the influence of socioeconomic factors on the outcome of surgery, except for long-term sick leave.

CONCLUSION

Patients surgically treated for ulnar nerve compression at the elbow are socioeconomically deprived, but only a history of long-term sick leave influences the outcome of surgery. This information is crucial in the diagnosis and treatment of these patients.

Diabetes mellitus as a risk factor for compression neuropathy: a longitudinal cohort study from southern Sweden

INTRODUCTION

Compression neuropathies (CN) in the upper extremity, the most common being carpal tunnel syndrome (CTS) and ulnar nerve entrapment (UNE), are frequent among patients with diabetes mellitus (DM). Earlier studies have shown contradicting results regarding DM as a risk factor for CN. Thus, the aim of the present population-based, longitudinal study was to explore potential associations between DM, CTS, and UNE during long-term follow-up.

RESEARCH DESIGN AND METHODS

A total of 30 466 participants aged 46-73 years, included in the population-based Malmö Diet and Cancer Study during 1991-1996, were followed up in Swedish national registries regarding incident CTS and UNE until 2016. Associations between prevalent DM at baseline and incident CTS or UNE were calculated using Cox proportional hazard models, adjusted for baseline confounders, such as sex, age at study entry, smoking, hypertension, use of antihypertensive treatment, alcohol consumption, and body mass index (BMI). HbA1c and fasting plasma glucose levels had been measured at baseline in a subgroup of 5508 participants and were related to incident CTS and UNE in age and sex-adjusted binary logistic regression models.

RESULTS

A total of 1081 participants developed CTS and 223 participants developed UNE during a median follow-up of 21 years. Participants with incident CTS or UNE had higher prevalence of DM and higher BMI at baseline. Using multivariate Cox regression models, prevalent DM at baseline was independently associated with both incident CTS (HR 2.10; 95% CI 1.65 to 2.70, p<0.0001) and incident UNE (HR 2.20; 95% CI 1.30 to 3.74, p=0.003). Higher levels of HbA1c and plasma glucose were associated with an increased risk for CTS, but not for UNE.

CONCLUSION

This study establishes DM as a major risk factor in the development of both CTS and UNE. Furthermore, a higher BMI is associated with both CTS and UNE. Finally, hyperglycemia seems to affect the median and ulnar nerves differently.