In Situ Decompression of Cubital Tunnel

Abstract

Cubital tunnel syndrome is the second only to carpal tunnel syndrome as the most common compression neuropathy in the upper-extremity (Bozentka, Clin Orthop Relat Res (351):90–94, 1998). Patients complain of numbness, elbow pain, and intrinsic weakness leading to a loss of fine motor dexterity in the hand. Severe, chronic nerve compression leads to significant weakness, atrophy, and contractures due to muscle imbalances. Decompression of the ulnar nerve can stop the progression of the disease and prevent significant functional limitations.

Multiple surgical treatments exist (Boone et al., J Hand Surg Am 40(9):1897–1904; quiz 904, 2015). In contrast to some disease entities, where multiple treatments exist because a good solution has yet to be discovered, most of these techniques lead to improved clinical outcomes. In situ decompression, transposition of the ulnar nerve and medial epicondylectomy have all been shown to be effective in the alleviating symptoms and improving hand function. Comparative studies have demonstrated similar outcomes with all of these techniques, with no one technique showing superiority (Geutjens et al., J Bone Joint Surg Br 78(5):777–779, 1996; Staples et al., J Hand Surg Am 43(3):207–213, 2018; Watts and Bain, J Hand Surg Am 34(8):1492–1498, 2009; Zhang et al., J Hand Surg Am 42(4):294.e1–294.e5, 2017; Gervasio et al., Neurosurgery 56(1):108–117; discussion 17, 2005; Caliandro et al., Cochrane Database Syst Rev (7):CD006839, 2012; Bartels et al., Neurosurgery 56(3):522–530; discussion –30, 2005; Nabhan et al., J Hand Surg Br 30(5):521–524, 2005; Chen et al., Clin Neurol Neurosurg 126:150–155, 2014). Some may take this as evidence that in situ release is therefore superior, as it is the “simplest” option and has equivalent outcomes to the other techniques. This would be a misunderstanding of the data. As a statistically significant difference has not yet been identified between these techniques it means that there is no superior technique.

Multiple factors will need to be considered when choosing a technique. Patient complaints, surgeon experience and preference, and the underlying cause for ulnar nerve dysfunction must all be considered when choosing an operative intervention. A discussion of options with the patient, as well as the risks associated with different approaches, should be considered in arriving upon a final surgical plan.