Introduction
Cubital tunnel syndrome is prevalent among the white population and can present with varying symptoms that can affect the individual’s routine activities. In most patients, it is left undiagnosed due to a lack of accurate diagnostic procedures. In most cases, it resolves through conservative techniques such as NSAIDs (nonsteroidal anti-inflammatory drugs) prescriptions, splint or brace application, positional manipulation, and reduced elbow flexion. However, in severe cases, surgical management is crucial.
What Is Cubital Tunnel Syndrome?
Cubital tunnel syndrome, also known as ulnar nerve entrapment or ulnar neuropathy, is caused due to ulnar nerve compression or irritation. It manifests symptoms such as pain, paresthesia, numbness, or tingling. Some individuals also complain of a pin and needle sensation in their ring or small fingers and the dorsoulnar hand. The symptoms are aggravated at night and also while changing to certain positions, such as elbow flexion and rotational movements, such as while opening a jar. The severity of this condition varies among individuals, and they can even lose their fine motor skills in case of severe disease. Known causes of this condition are repetitive actions like stretching, flexion, pressure, or trauma to the elbow joint.
What Are the Surgical Techniques Employed for Cubital Tunnel Syndrome?
Surgical management of cubital tunnel syndrome aims to decompress the nerve. This is done by either diverting the nerve apart from its course of compression or releasing the nerve on its current course. However, decompression of the nerve in its current course is considered to be the best strategy currently. In refractory cases, conservative management surgery is considered the last resort. There are two main techniques to treat cubital tunnel syndrome:
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In Situ Decompression: Along with this procedure, a medial epicondylectomy is done as a supplemental procedure. In situ, the decompression procedure involves the release of tissue at the level of compression in the ulnar nerve. Both open and endoscopic techniques can be employed to achieve decompression. In the open technique, an incision that is approximately 3.15 inches to 3.94 inches in size is made longitudinally over the cubital tunnel for the purpose of exposing the medial aspect of the elbow. This will help the surgeons visualize the course of the nerve and compression sites so as to relieve them. In the endoscopic method, 0.79 to 1.18 inches incisions are placed between the olecranon and medial epicondyle. Endoscope and retractors are manipulated to inspect the course of the ulnar nerve through the site of the incision. After identifying the compression point, the surgeon will release pressure on the nerve by cutting the overlying tissue. Medial epicondylectomy is an additional procedure done along with it and can be total, partial, or minimal. Medial epicondylectomy, when done, has been shown to improve the outcomes like less pain and great satisfaction significantly.
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Decompression With Anterior Transposition of the Ulnar Nerve: In this procedure, the ulnar nerve is anteriorly mobilized concerning the medial epicondyle. The sites for placing the ulnar nerve can be submuscular, intramuscular, and subcutaneous. Submuscular and intramuscular transposition involves placing the ulnar nerve deep or within the flexor carpi ulnaris muscles or pronator teres, respectively. The subcutaneous method involves the creation of a sling with muscular fascia for holding the ulnar nerve below the subcutaneous tissue.
What Are the Prerequisites for Cubital Tunnel Syndrome Surgery?
The indication for undergoing surgery include the following:
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In case of failure of conservative treatments such as splinting, medications, and physiotherapy.
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Surgery is recommended in case of persistent or worsening symptoms in spite of management through non-surgical techniques.
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If there is an evident nerve compression that is evident in the diagnostic tests such as electromyography.
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In patients with functional limitations like weakness and loss of muscle control.
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When there is significant muscle atrophy, surgical intervention is important for preventing further deterioration.
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If the patient is willing for surgery or does not want to undergo non-operative management.
How Long Does It Take To Recover From Cubital Tunnel Syndrome?
Surgery will be done as an outpatient procedure and performed under regional anesthesia. So the patient does not need an overnight stay in the hospital. It can also be done under general anesthesia or local anesthesia with or without sedation. The whole upper extremity is prepped and sterile draped. Immediately after the procedure, the patients can get relief from the numbness, pain, or tingling in their fingers.
After surgery, the physician might advise wearing a soft splint or bandage with padding for some weeks. Post-operative pain will subside within a few months after surgery. Most of the patients can resume their routine activities and return to work in two to three months. Endoscopic techniques and the application of smaller incisions have significantly decreased the recovery time and improved surgical outcomes. Active rest and following the medications are necessary for a swift recovery. The doctor may advise sleeping with the arms straight, using pads under the elbow, and wearing a splint.
What Are the Risks Associated With Cubital Tunnel Syndrome?
There can be risks associated with all kinds of surgeries. The open method of decompression poses a high risk of iatrogenic injury to the median antebrachial cutaneous nerve. This can result in loss of sensation over the medial aspect of the forearm and elbow. Infection can occur as a result of larger incisions, and postoperative pain is also highly possible. Uniquely, in the endoscopic technique, a postoperative hematoma is possible. This can be due to poorly visualizing the vessels that are possibly bleeding during the surgical closure.
Decompression with transposition of the ulnar nerve has led to complications like soft tissue infections in the superficial and deep layers, cubital tunnel syndrome recurrence, and a need for a second surgery. Elbow instability and elbow flexion contracture are also associated risks of this condition. Nerve damage can lead to permanent numbness around the forearm or the elbow.
What Is the Prognosis for Cubital Tunnel Syndrome?
Based on studies, in situ, compression showed significant pain relief in about 80 to 90 percent of the patients, and only a minor range of 7 to 15 percent of patients reported minimal or no relief. In this 7 to 15 percent of the patients, a second surgery involving anterior transposition of the ulnar nerve has given better clinical outcomes. The endoscopic ulnar release also has given similar results to those in patients who underwent open procedures, and these patients have reported minimal post-operative pain.
Conclusion
Cubital tunnel syndrome is a common disease that can affect the patient’s quality of life if left untreated. In case of failure of conservative measures or when the disease is severe and affects the patient’s quality of life, a surgical approach is indicated. Healthcare professionals, based on their clinical knowledge and their expertise in anatomical aspects, will choose the appropriate method after discussion with the patients.
