New-onset ulnar symptoms after carpal tunnel release: It's not infrequent to have a patient complaining of first noting some numbness or tingling or burning in the small and ring finger side of the hand after carpal surgery. Usually the person can be forewarned to expect this if they are carefully examined including thorough nerve conduction studies preoperatively. People tend to focus on what they are noticing the most; i.e. who is talking the loudest, the squeaky hinge, etc. thus, they tend to be very aware of the symptoms from the carpal tunnel which relate more to the "eyes" of the hand - the thumb, index, and long fingers for dexterity and only after those symptoms are eliminated with carpal tunnel release will they then become aware of the less noticeable decreased sensibility in the ulnar side of the hand. Aside from the sensory symptoms in the fingers in the ulnar side of the hand, clumsiness, aching in the hand or forearm, and sometimes even the aching or numbness radiating up to the shoulder and neck in addition to awakening at night due to your hands may be experienced with either median nerve entrapment or ulnar nerve entrapment.
Pressure-Specified Sensory Device (PSSD)
Dr. Ichtertz visited with A. Lee Dellon, M.D., Professor of Plastic Surgery and Neurosurgery at John Hopkins University Medical Center and author of over 250 scientific articles. The goal was to gain a full understanding of the technique and application of quantitative sensory examinations using the NMT Pressure-Specified Sensory Device (PSSD) which had been thoroughly developed and studied in the diagnosis of peripheral neuropathy - most specifically diabetic peripheral entrapment neuropathy. Dr. Ichtertz has added this to his clinical armamentarium and has utilized the technology to further enhance the diagnosis and improve the treatment of ulnar nerve entrapment, both nonoperative and operative - specifically cubital tunnel syndrome. The results of this work are intended to be presented and publish
ed in t
he near future.
Misdiagnosis of Cubital Tunnel Syndrome
The second most frequent misdiagnosis for cubital tunnel syndrome is an incorrect diagnosis of thoracic outlet syndrome (TOS). Thoracic outlet syndrome is an extremely rare condition known as a diagnosis of exclusion, meaning that there is no way of proving it is present but any other diagnosis that the person may have that explains the symptoms is more likely to be the cause than TOS. Thoracic was the original diagnosis ascribed to anyone with what ultimately turned out to be carpal tunnel syndrome in the early 1900's before a good understanding of nerve entrapment had been developed and before the advent of nerve conduction studies. The treatment for confirmed thoracic outlet syndrome is removal of the patient's 1st rib. Removal of the 1st rib takes the tension off of the entire C8 and T1 roots. These roots ultimately contribute all the fibers to the ulnar nerve. Thus, it is possible to decrease or eliminate cubital tunnel symptoms by decreasing the tension on the ulnar nerve at the cubital tunnel indirectly by taking out a person's 1st rib. However, the overwhelming majority of people presenting with ulnar nerve symptoms and signs are usually eliminated with time treatment of the compressed nerve at the elbow; i.e. from a practical standpoint, thoracic outlet syndrome is very rare, especially when patients are carefully scrutinized for the presence of cubital tunnel syndrome which will account for the majority of patients who are incorrectly diagnosed with having thoracic outlet syndrome.
The cause of cubital tunnel syndrome is almost exclusively prolonged - but not repetitious - elbow flexion.
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Studies beginning in the 1950s (see references) confirm that flexing the elbow beyond 70 degrees puts tension and pressure on the ulnar nerve behind the medial epicondyle of the elbow; while the space at the elbow for the nerve in the retrocondylar groove (cubital tunnel) diminishes as the tension increases in the elbow with further flexion. The most eloquent paper on this topic was published by Seror in the Journal of Bone and Joint Surgery, British Edition, 1992. However, Dr. Dellon at Johs Hopkins has reported the most detailed analysis of a large series of patients. Maximum tension and pressure on the nerve occur when the person's shoulder is elevated away from the body, elbow flexed fully, hands above the head. This position is demonstrated by a person sitting or lying with their hands above their head, elbows flexed, or lying facedown with an arm above the head, elbow flexed. Often the patients who present with cubital tunnel sit in the office exhibiting this very same maladaptive posture! Multiple researchers have proven that prevention of this posture by use of an elbow splint at night to hold the elbow straight and to gain the cooperation of the patient has about a 7 out of 10 chance of eliminating the symptoms of cubital tunnel syndrome if a person is cooperative and if they present before a certain amount of nerve damage has occurred. The remaining 3 out of 10 people will go on to require surgical decompression of the ulnar nerve with an expectation of a good to excellent result in 85-90% of the people as long as they don't have muscle wasting at the time of presentation.
In fact, it is believed that about 1/3 of the patients who have bad enough cubital tunnel syndrome to go on to require surgery will have normal nerve conduction studies because of the limitations in our ability to test the nerves. Generally it is considered that only 5-10% at most patients presenting with carpal tunnel syndrome are not going to be able to be confirmed to have entrapped nerves on nerve conduction study using the best electrodiagnostic technique and equipment.
Diagnosis of Cubital Tunnel Syndrome
The diagnosis of cubital tunnel syndrome is dependent on a keen awareness of it as a possible cause of symptoms and careful clinical examination (local squeezing of the nerve for signs of tenderness, or tingling or burning radiating down into the ulnar side of the hand and forearm), the elbow flexion test which temporarily increases the pressure of the nerve, assessment for weakness of pinch, weakness or decreased ability to abduct and adduct - draw together or place apart the fingers, and in a more advanced case a positive Froment or positive Wartenberg sign
which generally would be considered to have a poor prognosis because of the evident muscle wasting that is usually occurring simultaneously. Clawing of the hand is a late and usually essentially irreversible manifestation of untreated, late to present cubital tunnel syndrome.
Memo to Doc: Give clinical case examples and video testimonial on treatment of cubital tunnel syndrome, early versus late, and use Bamberger on that one, and on the TOS, improper treatment of, use the woman from North Platte for cubital tunnel misdiagnosis as TOS, and also use the photos for congenital anomaly that can result in.
Surgical Treatment of Cubital Tunnel Syndrome Memo to Doc: Put Dena and others as anomalous muscles, put the North Platte lady with anomalous arteries across the nerve along with cubitus valgus.
Surgery for cubital tunnel syndrome is necessary with ongoing symptoms and should be offered in short order to somebody who presents with obvious weakness of pinch and/or grip with demonstrated nerve conduction anomaly confirming nerve entrapment at the cubital tunnel because of the poor prognosis for late treatment of this entity. Additionally, if a person has ongoing symptoms in the absence of weakness, they should still be given the option of surgical decompression if they are unable or unwilling to comply with elbow extension splinting at nighttime. A rare person who fails to benefit from elbow splinting and swears to complying with that means of treatment is noted to have a congenital anomaly which has led to the ulnar nerve entrapment. Occasionally a childhood injury resulting in a broken elbow (supracondylar humerus fracture) will heal with angular deformity (cubitus varus), also known as a gunstock deformity. This has been much less common in the last 15-20 years because of more aggressive surgical intervention of this entity for improved outcome. Angular deformity may cause greater tension on the ulnar nerve at the elbow. It is unclear what contribution vigorous forceful muscle activity in the upper extremity such as a laborer might contribute to the development of or ongoing symptoms of cubital tunnel syndrome. There is no question that people who are more physically active at the time of presenting with carpal and cubital tunnel syndrome will tend to complain of more symptoms. It is unclear whether that is in any way actually worsening the problem rather than just making the person aware of the underlying problem. This to a large extent is what is construed as occupational aggravation of the problem under worker's compensation for a minority of patients presenting with either carpal or cubital tunnel syndrome.
The research done on entrapment neuropathy, particularly that not funded by groups primarily benefiting from the outcome of that research; i.e. people receiving multiple NIH grants in Michigan, etc., tend to suggest that the majority of entrapment neuropathy is age and genetics and possibly general health related (age over 30, female rate of presentation 2-3 women per men, strong family histories frequently obtainable, much higher rate in diabetics and in the obese. There is no direct link to any occupation with the exception of sorting diamonds or working under a microscope or holding a telephone receiver on a prolonged basis for the development of cubital tunnel syndrome).
Congenital variations in anatomy such as lumbrical muscles on the flexor profundus tendons in the hand that may be enlarged and may be oriented closer to the carpal tunnel may be choking off the median nerve and simultaneously the ulnar nerve at the wrist with vigorous use of the hand in select small group of patients. In a patient with arthritis at the base of the thumb (nine times more common in women than men, generally age over 40, associated with entrapment of the median nerve at the wrist over 50% of the time).
Causes: Thyroid dysfunction as a cause of carpal tunnel syndrome has largely been debunked. This is a misdiagnosis; it turns out that most people with hypothyroidism are women who usually present in the third and fourth decade of life at the same time when they are of childbearing age.
The only other good endocrine-related association with carpal tunnel syndrome is that of diabetes; a condition wherein people are either not producing insulin (juvenile onset) or their body is not responding to insulin because of obesity or because of as yet undetermined physiologic factors.
Medial Epicondylitis
Medial epicondylitis or "golfer's elbow" is a degenerative condition of the flexor muscle origin in the "medical epicondyle" of the humerus of the elbow. The majority of people presenting with inner elbow pain, however, do not have "medial epicondylitis" which actually implies an inflammatory condition, but they are experiencing the manifestation of entrapment of the ulnar nerve at the cubital tunnel; i.e. a variation in cubital tunnel syndrome. Medial epicondylalgia (pain at the medial elbow) is the best terminology applied to this until an absolute diagnosis is confirmed by nerve conduction studies. Medial epicondylosis is best treated by corticosteroid injection and avoidance of pressure on the inner elbow along with making certain that the person is sleeping with the elbows extended (straight). Ultimately, failure to respond to nonoperative treatment benefits from medical epicondyle removal (medial epicondylectomy), at which time formal ulnar nerve decompression can be carried out to ensure that the symptoms are completely eliminated.
Operative Treatment of Cubital Tunnel Syndrome
Over the years, about seven different operations have been reported and discussed in medical literature regarding surgical treatment of cubital tunnel syndrome. Learmonth, who in my opinion has had a great influence on the misdiagnosis of carpal tunnel syndrome as TOS historically was also the early proponent for submuscular transposition; i.e. moving the ulnar nerve beneath the muscle bed, bringing it away from the inner side of the elbow and away from the stretching and compressing that would occur there. This is probably one of the least performed procedures because it is so aggressive and necessarily invasive, and takes so long to heal with weeks off of work and in most hands a large surgical scar. There has been no proven added benefit. In situ decompression of the ulnar nerve at the elbow is a technique wherein the arcuate ligament directly upon the ulnar nerve is simply released. This has gained a lot of press in the last few years without long-term follow-up. In my experience based upon the cause of cubital tunnel syndrome and failure of nonoperative treatment, in situ decompression of the ulnar nerve at the cubital tunnel is not a good treatment option in the overwhelming majority of the patients because a large percentage will continue to have symptoms because of the continued tension on the ulnar nerve when the elbow is flexed. As you can see in the diagram, the nerve is wrapped around the epicondyle and the further the elbow is bent after 70°, the more tension is on the nerve. Medial epicondylectomy alone has a good track record and has been unfairly condemned by a few due to the remote potential for causing instability and in fact, this has not been a significant reported side effect. Medial epicondylectomy, however, does not address potential tension that might occur higher above the cubital tunnel or below it. Cubital tunnel syndrome has an extremely low recurrence rate once operatively treated. It is so small it has not been accurately determined. Before declaring a person has recurrence of cubital tunnel syndrome, the patient must be given ample time to address their sleeping posture and they must also prove that they do not have entrapment of the ulnar nerve at the wrist level; i.e. Guyon's canal. Recurrence is much more likely to occur in a diabetic than a nondiabetic person.
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I only know of one prospective study of surgical treatment on cubital tunnel syndrome, and the researchers concluded that cubital decompression with medial epicondylectomy gave superior results to the other surgical treatment option.
There are advocates of early surgical treatment of cubital tunnel syndrome, even for patients with negative electrodiagnostic studies because of the good results that may be achieved while avoiding irreversible deformity and disability.
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.
Resumption of Activity
A person may resume most of their normal activity within a few days of surgery with the exception of forceful pounding or throwing. Pounding should probably be avoided for approximately 2-3 weeks and throwing for about six weeks to allow the healing and scarring to protect the stability of the elbow. In the case of a very athletic person who develops cubital tunnel syndrome, cubital tunnel decompressive surgery is offered in the form of full decompression of the ulnar nerve with subcutaneous anterior transposition (sliding the nerve forward around the medial epicondyle and securing it between two layers of tissue) and avoidance of certain activities for a few weeks after surgery. I modify the subcutaneous anterior transposition by recessing the nerve in the flexor pronator muscle at the elbow; i.e. not a formal intramuscular/submuscular transposition, and particularly those who may be doing a lot of throwing sports with that extremity or those who are so lean as to have no soft tissue to pad the nerve and thus would irritate the nerve if they were to rest their elbow on anything firm.
Athletes And Cubital Tunnel Syndrome
For the most part, an athlete needs to be protected from inner elbow instability. My suspicion is that a lot of people who are undergoing "Tommy John" elbow surgery actually have cubital tunnel syndrome and an integral portion of that surgery involves decompression of the ulnar nerve at the elbow. I have never had to reconstruct the inner elbow because of instability developing as a result of cubital tunnel decompression. I do think that it is a good idea to avoid any weakening of the medial elbow ligaments in the throwing arm of a throwing athlete. Therefore perhaps the best method of decompressing an athelete's cubital tunnel is anterior subcutaneus nerve transposition. This involves freeing the nerve of overlying constriction and sliding it forward of the medial epicondyle and securing it in the new location. The majority of people who present with cubital tunnel syndrome are beyond the age of being involved to a great extent in these types of activities that are at risk for developing elbow instability.