Endoscopic Ulnar Nerve Decompression after Cubital Tunnel Syndrome:
Posted by Dolf Ichtertz on Sat, Jul 19, 2008 @ 06:00 AM
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.