Recurrent Cubital Tunnel Syndrome

State of the art review. Upper extremity revision nerve compression surgery

Although surgical release of upper extremity nerve compression syndromes is highly effective, persistence or recurrence of symptoms and signs may occur. Thorough investigation is necessary in this situation before treatment is recommended. If the symptoms cannot be explained by other pathology than compression of the affected nerve and if conservative management has not provided improvement, reoperation may be considered. This review provides an overview of the diagnostic and surgical considerations in the revision of carpal tunnel syndrome, cubital tunnel syndrome and thoracic outlet syndrome.Level of evidence: V.

Comparison of in-situ release and submuscular anterior transposition of ulnar nerve for refractory cubital tunnel syndrome, previously treated with subfascial anterior transfer-A retrospective study of 24 cases

BACKGROUND

Although cubital tunnel syndrome is the second most common type of compressive neuropathy in the upper extremities, the indication and optimal surgical method for recurrent or refractory cubital tunnel syndrome remains controversial. This study evaluates the functional outcomes of revision surgery for cubital tunnel syndrome.

MATERIAL & METHODS

This study was a retrospective observational multicenter single-institution study including 660 patients who underwent surgery for cubital tunnel syndrome from 2010 to 2019. Among the 660 patients, 42(6.4%) received revision surgery due to remaining or recurrent symptoms confirmed with electromyography(EMG). After excluding those with concurrent elbow fracture, dislocation, osteoarthritis and wound infection, a total of 24 patients were included in the study. The patients were evaluated of disease severity, revision surgical method, time interval to recurrence, underlying diseases and postoperative functional outcomes.

RESULTS

All patients received ulnar nerve subfascial anterior transposition for the initial cubital tunnel syndrome surgery. Among the 24 patients (3.7%) who received revision surgery, nine received in situ neurolysis, 12 received submuscular transposition, and three received subcutaneous transfer. 21 patients (88%) reported improved mean VAS score of 4.3, while three patients complained of remaining symptoms that did not improve even after revision surgery. The patients with remaining symptoms all had underlying diabetes mellitus and were treated with subcutaneous transfer. The difference of surgical outcomes between the in situ neurolysis group and the nerve transfer groups were non-significant (p = 0.23). The most common cause of recurrent or persistent symptoms was adhesion and fibrosis at sling area. The mean follow up period before revision surgery was 26.3 months and postoperative follow up period after revision surgery was 8.5 months.

CONCLUSION

The outcomes of this study imply that in-situ neurolysis may be as effective as anterior submuscular transfer of ulnar nerve for refractory cubital tunnel syndrome after anterior subfascial transfer.

Adipose-derived stem cells modulate neuroinflammation and improve functional recovery in chronic constriction injury of the rat sciatic nerve

Introduction

Compressive neuropathy, a common chronic traumatic injury of peripheral nerves, leads to variable impairment in sensory and motor function. Clinical symptoms persist in a significant portion of patients despite decompression, with muscle atrophy and persistent neuropathic pain affecting 10%-25% of cases. Excessive inflammation and immune cell infiltration in the injured nerve hinder axon regeneration and functional recovery. Although adipose-derived stem cells (ASCs) have demonstrated neural regeneration and immunomodulatory potential, their specific effects on compressive neuropathy are still unclear.

Methods

We conducted modified CCI models on adult male Sprague-Dawley rats to induce irreversible neuropathic pain and muscle atrophy in the sciatic nerve. Intraneural ASC injection and nerve decompression were performed. Behavioral analysis, muscle examination, electrophysiological evaluation, and immunofluorescent examination of the injured nerve and associated DRG were conducted to explore axon regeneration, neuroinflammation, and the modulation of inflammatory gene expression. Transplanted ASCs were tracked to investigate potential beneficial mechanisms on the local nerve and DRG.

Results

Persistent neuropathic pain was induced by chronic constriction of the rat sciatic nerve. Local ASC treatment has demonstrated robust beneficial outcomes, including the alleviation of mechanical allodynia, improvement of gait, regeneration of muscle fibers, and electrophysiological recovery. In addition, locally transplanted ASCs facilitated axon remyelination, alleviated neuroinflammation, and reduced inflammatory cell infiltration of the injured nerve and associated dorsal root ganglion (DRG). Trafficking of the transplanted ASC preserved viability and phenotype less than 7 days but contributed to robust immunomodulatory regulation of inflammatory gene expression in both the injured nerve and DRG.

Discussion

Locally transplanted ASC on compressed nerve improve sensory and motor recoveries from irreversible chronic constriction injury of rat sciatic nerve via alleviation of both local and remote neuroinflammation, suggesting the promising role of adjuvant ASC therapies for clinical compressive neuropathy.

Imaging the intermuscular septum in the context of ulnar neuropathy

Impingement/entrapment of the ulnar nerve by the intermuscular septum at the distal arm is a common cause of recurrent or recalcitrant ulnar neuropathy following ulnar nerve decompression or anterior transposition. Primary entrapment/impingement of the ulnar nerve along the intermuscular septum may also occur. Evaluation with both ultrasound (US) and MRI can identify entrapment of the ulnar nerve at the intermuscular septum, while dynamic assessment with US can also identify dynamic subluxation of the ulnar nerve over the intermuscular septum.

The management of failed cubital tunnel decompression

Cubital tunnel decompression is a commonly performed operation with a much higher failure rate than carpal tunnel release.

Failed cubital tunnel release generally occurs due to an inadequate decompression in the primary procedure, new symptoms due to an iatrogenic cause, or development of new areas of nerve irritation.

Our preferred technique for failed release is revision circumferential neurolysis with medial epicondylectomy, as this eliminates strain, removes the risk of subluxation, and avoids the creation of secondary compression points.

Adjuvant techniques including supercharging end-to-side nerve transfer and nerve wrapping show promise in improving the results of revision surgery.

Limited quality research exists in this subject, compounded by the lack of consensus on diagnostic criteria, classification, and outcome assessment.

Cite this article: EFORT Open Rev 2021;6:735-742. DOI: 10.1302/2058-5241.6.200135

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition - A Case Series

BACKGROUND

Various surgical techniques have been attempted to treat patients with failed anterior subcutaneous transposition performed for cubital tunnel syndrome.

OBJECTIVE

To analyze intraoperative findings of failed anterior subcutaneous transposition and to report the outcome of in Situ neurolysis of ulnar nerve.

METHODS

Patients who, under diagnosis of failed anterior subcutaneous transposition of ulnar nerve, underwent in Situ neurolysis between 2001 and 2018 were included in this study. We excluded patients with follow-up of less than one year, records of traumatic ulnar nerve injury, and concomitant double crush syndrome such as cervical spondylosis causing radicular pain, ulnar tunnel syndrome, or thoracic outlet syndrome. Surgical outcomes were evaluated using visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder, and Hand (DASH) score, which were assessed before and after surgery. A total of 28 elbows in 27 patients whose average age was 58.5 (range, 31-76) yr were enrolled, and the duration of follow-up was 5.8 (range, 1.0-14.9) yr.

RESULTS

The most common pathologic finding identified during operation was severe adhesion of the transposed nerve in all elbows, followed by incomplete decompression of deep flexor-pronator aponeurosis in 26 elbows (93%). The average VAS pain score improved from 4.9 (range, 2-7) to 1.3 (range, 0-5), and the average DASH score from 31.7 (range, 18.1-66.7) to 14.1 (range, 5.0-46.6). Of the 28 elbows, 27 (96.4%) showed improvement of preoperative symptoms.

CONCLUSION

In Situ neurolysis of ulnar nerve for patients with failed anterior subcutaneous transposition resulted in satisfactory outcome.

Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial

OBJECTIVE

To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE).

DESIGN

Prospective, randomized, double-blind, controlled trial (6-month follow-up).

SETTING

Outpatients of local medical center settings.

PARTICIPANTS

Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis.

INTERVENTIONS

Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively.

MAIN OUTCOME MEASURES

The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection.

RESULTS

Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward.

CONCLUSIONS

We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.

The Deep Fascia of the Forearm and the Ulnar Nerve: An Anatomical Study

Introduction

A reoperation for a cubital tunnel syndrome is not uncommon. Patients often complain of sensorimotor symptoms in the ulnar nerve distribution after their primary surgery. The documented etiologies for such a phenomenon include a “new” kinking of the distal ulnar nerve and a “new” compression of the ulnar nerve by the fascial septum in between or tendinous bands over the muscles of the forearm. The deep fascial plane along which the ulnar nerve travels in the forearm has had scant attention. We present an anatomical study to provide a better understanding of such etiologies to aid physicians in performing successful primary ulnar nerve release that does not lead to risky reoperations and ultimately yields improved patient satisfaction.

Materials and methods

The forearms of 12 fresh frozen cadavers (24 arms) underwent dissection, during which the fascial relationships between the ulnar nerve and muscles of the anterior compartment were explored with a blunt technique. The relationship between the fascial planes and the ulnar nerve was quantitatively and qualitatively documented. The ranges of motion of the elbow were also observed for any potential compression points on the nerve during the movement.

Results

In all specimens (n = 24), the ulnar nerve entered the forearm between the humeral and ulnar heads of the flexor carpi ulnaris, after which it routed deep to a deep fascia between the anterior surface of the flexor carpi ulnaris and the posterior surface of the flexor digitorum superficialis. Ulnar nerve branches to the flexor carpi ulnaris pierced this fascial septum while en route to the posterior surface of the muscle. Medially, the branches to the flexor digitorum profundus also pierced this fascial plane. In most arms, the fascia became thinner near the junction between the proximal two-thirds and distal one-third of the forearm. On no side was the ulnar nerve found to be grossly compressed by this deep fascia. However, with the extension of the elbow, a degree of angulation of the proximal ulnar nerve was observed due to its compact connection with the deep fascia.

Conclusion

Our study revealed that there is an intimate relationship between the ulnar nerve and the deep fascia of the forearm. Since the ulnar branches to the overlying flexor carpi ulnaris pierce this deep structure, a care should be given to its anatomical course during surgery in this region to prevent denervation of the muscle.