My Surgical Treatment Recommendations for Cubital Tunnel Syndrome

Percutaneous Trigger Finger Release:

Percutaneous release of the A-1 pulley of the finger or thumb has been available for over ten years to a limited degree.  Only a few of us across the United States have been offering this excellent procedure.  I personally have been offering it for eleven years.  As long as a person's finger or thumb is actively triggering at the time of offering the procedure, there is about a 99% success rate with minimal discomfort and immediate return to activities.

Surgeons from China in the Journal of Hand Surgery, Vol. 31A, No 8, October 2006, pg. 1288, reported their results on revision percutaneous A-1 pulley release in patients in whom there was some residual snapping or locking symptoms.  90% were completely free of triggering at follow-up.  They concluded that percutaneous A-1 pulley release is an effective, safe, and convenient technique for primary trigger finger and as a secondary procedure for patients who have residual triggering after the initial attempt.

My experience parallels theirs.  It is pretty rare to have to convert a percutaneous release into an open release, though I have had to on several occasions over the years.  Anyone undergoing open trigger release at this point in time who has not been first offered percutaneous release is making a mistake.  Percutaneous release is so effective and causes such minimal discomfort that it is essentially setting the standard of care.  The cost is markedly reduced as is the inconvenience.  There is still some soreness for up to three months but it is much less, and there is no wound to manage.  Further information regarding this is available in the trigger finger section of this website.

The Volume of Carpal Tunnel Cases: Is it Changing?

An article in the Omaha World-Herald appearing Monday, April 7, 2008, titled "Carpal Tunnel Cases Dipped Sharply", supposedly listing the Associated Press as a source of the information, is seriously flawed and misleading.  I believe it has been reported by someone very inexperienced in the topic with the typical problem of quoting the ignorant.  First is a reference to RSI, or repetitive strain injury, which in essence was a figment of people's imagination "down under."  The courts in Australia threw out the diagnosis and sent many disgruntled workers back to work.  Many of these people probably had carpal tunnel syndrome which went misdiagnosed, with the majority of the people seeking compensation rather than a solution.  According to the Bureau of Labor Statistics, claims were made that carpal tunnel syndrome cases have plummeted, declining 21% in 2006 alone and that among workers in professional business services, the number of carpal tunnel syndrome cases fell by one-half between 2005 and 2006.  In fact, what has occurred is not a decrease in the number of people presenting with carpal tunnel syndrome which is a genetically-influenced, naturally developing, accompaniment of aging in those genetically predisposed, but a decrease in the number of people trying to receive treatment or benefits under worker's compensation.  This is because of:

• (a) the combination of greater awareness via educators such as the Carpal Tunnel Relief Center;
• (b) refusal of the insurers or employers to accept that the problem is work causation;
• (c) wider-spread use of accurate diagnostic methodology with appropriately performed nerve conduction studies;
• (d) employees fearful of claiming a problem under work and thus being treated on a private pay/private insurer basis in fear of loss of their job or seniority on a job, etc.

Thus, overall, the title of the article was incorrect, some of the information in the article was grossly in error, and the concept of "preventative things such as exercise," which are inferred in the article have never been a proven benefit for this spontaneously occurring problem.  The only accurate statement that I encountered and perhaps the most useful one in the entire article was that in the last paragraph which stated that Dr. Hagemann, Director of the Rocky Mountain Center for Occupational and Environmental Health, which sounds like a private, nongovernmental agency claimed that, "Some of the reduction in cases may be due to the realization that it is a common situation; there is no rush to do anything about it."  I differ in my recommendations to do something about it because it will only worsen over time and cause sleep deprivation, and interferes with a person's lifestyle.  Early treatment results in a better outcome and less interference with one's lifestyle.  Certainly it is generally not an emergency condition. 

Why Women Need Better Sleep:

There is a lot of speculation on how much sleep people need, and it seems to me each new article written on sleep needs suggests greater amounts in contrast to what we actually find with the body's natural tendency for sleep in the older individual; i.e. older folks, particularly retirees, tend to really not need as much sleep and thus they are always complaining about awakening early in the morning.  Why not?  They are not worn out and their bodies may not need as much time to refresh themselves.  There is probably a greater individual variation in the need for sleep than a blanket statement for everyone needing such huge amounts of sleep.  Beyond a certain limit, however, the overwhelming majority of the people would feel sleep-deprived.  One way or another, carpal tunnel syndrome and other illnesses which cause pain or sensory disturbances at night and thus interrupt a person's sleep, particularly when it is more than one time, can be very disruptive.  This may result in mood disturbance or in fact frank personality changes, poor attention span, nodding off to sleep at inappropriate times such as while driving, or trying to work, or even interview someone.  It may make it hard for a person to concentrate.  On page 64 of Time magazine, March 31, 2008 issue, an article appeared written by Alice Park, which references Edward Suarez at Duke University with regard to studying 210 healthy men and women and suggests that poor sleep in women is linked to higher levels of fasting insulin, higher rates of insulin resistance in being overweight, with resultant increased risk factor for type II diabetes (adult-onset) because the body fails to break down sugar properly, insulin levels remain high instead of peaking only after meals, and increased risk factors for heart disease, which sounds to me very vague as it was presented. 

Women are twice as likely as men to present with carpal tunnel syndrome and with about 1 out of 6 adults ultimately presenting with carpal tunnel syndrome, I believe this is probably the most common cause of sleep disturbance encountering modern life.  Anyone complaining of sleep disturbance should be questioned about the symptoms of carpal tunnel syndrome and the significance of sleep interruption resulting from carpal tunnel syndrome should not be minimized.  This report is another good reason to try and improve peoples' sleep by eliminating carpal tunnel syndrome.  Lethargy resulting in a person falling asleep while driving resulting in auto accidents is reported to cause over a million auto accidents per year in the United States.  Thus, anything we can do to improve the quality of sleep may be very important to our overall functioning in terms of productivity and the safety and comfort of our lifestyles. 

Endoscopic Ulnar Nerve Decompression after Cubital Tunnel Syndrome:

Over the past six years, there have been some sporadic reports of endoscopic release of the ulnar nerve through the cubital tunnel.  I believe this was first reported on by Tsu Man Tsai, M.D. at the Christine Kleinert Institute in Louisville, Kentucky.  There have been three other reports on variations on this theme.  The technique, unfortunately, only allows simple decompression of the ulnar nerve and the incision utilized for this is really no smaller than the incision that I use for routine comprehensive decompression of the ulnar nerve with or without medial epicondylectomy.  From a practical standpoint, in my opinion, the added cost of the equipment utilized and the limitations of what is being performed in the absence of any significant benefit achieved here over other techniques make this an avenue best not traveled.  When the surgical technique can demonstrate marked advantage to a patient either by decreasing pain or disability or, and more importantly, better long-term outcomes without substantially increasing risk, it should be given considerable attention.  When it is just a means of adding a new technical enterprise to prevent boredom of the doctor or to obtain notoriety for its introduction, I don't really think it has a valid position in our armamentarium. 

Endoscopic cubital tunnel decompression, which is basically an in situ release, takes as long or longer to perform results in the same incision size and has no significant benefit beyond in situ release of the ulnar nerve performed in other techniques.  In contrast, endoscopic carpal tunnel release (ECTR) results in marked reduction in discomfort, marked improvement in use of one's hand and early return to work, and a more aesthetically pleasing surgical site which is often invisible to the bystander and even the patient themselves after six months to a year postop.  Early return to work is possible.  Proper technique and application and optimization of anti-inflammatory and analgesic medication at the time of surgery result in thousands of dollars of savings to the carpal tunnel patient in minimizing time off work while not crimping their lifestyle or interfering with their activities.  Endoscopic cubital tunnel release normally doesn't interfere with one's lifestyle much or have a very noticeable incision because of its location behind the midline of the forearm on its inner side. My cubital tunnel patients typically return to work within two days of their operation without any significant limitations.  I have not heard any other advantages of endoscopic carpal tunnel release promulgated by those who are flag-bearers for the technique.  At the same time, when a surgeon is pushed to use a minimal incision technique, it does run an added risk of increased complications in unskilled hands.  Though I am not completely writing off the possibility of utilizing an endoscopic cubital tunnel technique, so far I am underwhelmed with the concept and the data provided by the surgeon promoting it, including questionable data on methodology of making the diagnosis in the first place.

Cubital tunnel surgery

My Surgical Treatment Recommendations for Cubital Tunnel Syndrome

For the past 17 years, I have been predominantly performing comprehensive decompression of the ulnar nerve through about a 2-inch incision (larger patients require a slightly larger incision for their own protection) which is placed behind the midline of the inner arm such as to be invisible most of the time.  This is done as an outpatient, preferably under a light anesthetic to prevent inadvertent additional problems of the ulnar nerve from administration of a regional anesthetic such as an axillary block.[1]  The surgery is done as an outpatient.  A lot of bruising occurs about the inner elbow but disappears over a couple of weeks.  Regardless of the methodology and surgical treatment, there is a broad range of complaints from people having no pain to others complaining vociferously of pain lasting anywhere from a few weeks to more than six months.  No one requires medication for pain in the elbow beyond a few days at most.

 

Braces for Cubital Tunnel?

Carpal tunnel (aka carpal tunnel syndrome or CTS) is very common.  The next most common nerve entrapment syndrome , cubital tunnel, occurs in as many as one out of five carpal tunnel sufferers.  Careful evaluation at the time of seeing the hand surgery specialist will reveal tenderness of the ulnar nerve behind the "funny bone" or medial epicondyle. A firm tap with a finger may send a tingle down the forearm to the small finger side of the hand.  Problems with this nerve precipitate the complaint of your hand going to sleep right away when talking on the phone, aching or cramping, loss of dexterity and dropping things also occur as with CTS.  The two problems frequently occur simultaneously The main difference being that carpal tunnel does not cause weakness, cubital tunnel does in advanced cases and the small and ring fingers rather than the thumb, index, and long tingle, burn or ache.

Dr. Ichtertz has been providing a special elbow splint to prevent prolonged elbow flexion at night-the culprit in causing cubital tunnel.  Splinting of th wrist has never solved a case of carpal tunnel but it often does for cubital tunnel.  Use of a good quality telephone head set for those continuously on the phone is also a good idea. This can be monitored with a pressure specified sensory exam (PSSD).  Note that about three out of ten afflicted people are going to go o to require a minor surgery to solve this problem; so if the symptoms are bad or do not respond promptly you need to consider evaluation by a board certified hand surgeon (Certificate of Added Qualifications in Surgery of the Hand).  Though a neurologist may perform electrodiagnostic tests for nerve entrapment they can not treat carpal tunnel-it is a surgical disease.