Ulnar Nerve : What Should I Do? John J. Fernandez, MD, FAAOS Assistant Professor Orthopaedic Surgery Hand & Microvascular Surgery Rush-Presbyterian-St. Luke s Medical Center Disclosure I have nothing to disclose Cubital Tunnel Syndrome Incidence Anatomy Etiology Pathophysiology Diagnostic Studies Treatment Options Surgical Techniques 1
Cubital Tunnel Syndrome Second most common compressive neuropathy After CTS 21 cases per 100,000 person/yrs EMG anomalies occur at 33% the rate of CTS patients are 4 times more likely to present with more advanced disease Extrinsic Risk Factors 15% at risk workers Prevalence 2.8%, to 6.8% floor cleaners, to 42% vibrating tool operators Forceful use Repetitive exposure Vibration Intrinsic Risk Factors Smoking Obesity Hand dominance Diabetes Gender 2
Nerve CuTS: Anatomy Surgery Nerve Injury Animal Studies 20-30 mmhg Impaired flow in epineural venules Sloing intracellular axonal support 60-80 mmhg Nerve ischemia If relieved in 2 hours -- reversible Prolonged -- permanent damage Ulnar Nerve Blood Supply Effect of Vascular Pedicle Preservation on Blood Flow and Clinical Outcome Following Ulnar Nerve Transposition JHS, Vol 39, 2014, Nakamura, et al 36 pts randomized, laser doppler flow both pre and post transposition Preop same, Intraop non-pedicle group down 28-52% NO difference in clinical results; DASH better vascular group 3
Ulnar Nerve Physiology Elbow ulnar nerve 2.2 cm excursion strain of 15% Nerve cross-sectional area shrinks 30-40%with elbow flexion shape goes from ovoid to elliptical Intraneural pressure lowest at 40-50 degrees of flexion increase sharply beyond 90º flexion Ulnar Nerve Compression Cubital Tunnel Anatomy 4
CUTS: Compression Sites Subjective Complaints Physical Examination 5
Physical Examination Sensory Exam Two-point Discrimination Semmes-Weinstein Monofilaments Sensory Exam Two-point Discrimination Semmes-Weinstein Monofilaments 6
9/9/2018 Motor Exam Pinch and Grip Strength Intrinsic Motor Testing Motor Exam Motor Exam 7
Electrodiagnostics Differential Diagnosis Amyotrophic Lateral Sclerosis (ALS) Cervical Radiculopathy Thoracic Outlet Syndrome Pancoast Tumor Peripheral Neuropathy Alcoholism, diabetes, Vitamin B12 deficiency, hypothyroidism Conservative Treatment 8
Conservative Treatment Systematic review of treatment results for ulnar nerve entrapment at the elbow JHS 1989 Dellon Review of 50 published studies 58% of patients with mild CUTS had relief with nonsurgical treatment Discontinue triceps exercises Avoid direct pressure to medial elbow Maintain resting position 45-50 degress Nighttime towel orthosis to prevent elbow flexion Surgical History 1816 Henry Earl Described first surgical technique to treat cubital tunnel syndrome sectioning the nerve proximal to the cubital tunnel NOT MANY GOOD RESULTS!!! Conservative treatment became VERY popular and had many supporters Surgical History 1898 Benjamin Farquhar Curtis Anterior subcutaneous transposition (AST) Quickly became method of choice Frequent criticism superficial position of nerve 9
Surgical History 1917 Rudolf Klaussner Transposing nerve INTO a muscular bed Anterior intramuscular transposition (IMT) During first half 20 th century both techniques popular Surgical History 1942 Learmonth A Technique for Transplanting the Ulnar nerve. Surg Gynecol Obstet 1942 Transposing nerve UNDER a muscular bed Anterior SUBmuscular transposition (SMT) Surgical History 1957 Geoffrey Vaughan Osborne The Surgical Treatment of Tardy Ulnar Neuritis JBJS, 1957 Ulnar nerve palsy caused by COMPRESSION and not traction/friction Described existence of band of fibrous tissue bridging heads of the FCU Division of the band sufficient to relieve symptoms 10
Surgical History 1959 King and Morgan Late Results of Removing the Medial Humeral Epicondyle for Traumatic Ulnar Neuritis. JBJS 1959. Medial epicondylectomy Cubital Tunnel Release Trends Trends in the Surgical Treatment of Cubital Tunnel Syndrome: An Analysis of the National Survey of Ambulatory Surgery Database JHS 2013, Soltani et al NSAS 1994-2006 Increase CUTR s 47% 26,000 to 52,000 In Situ: Females 70% :: Males 51% Surgical time 48m in situ v 59m Transpositions decreased 49% to 38% TECHNIQUE: Meta-Analysis Surgical Management of Ulnar Nerve Compression at the Elbow: An Analysis of the Literature J Neurosurg, 1998 Review literature from 1970 to 1997 SD, ME, AST (SQ, IM, SM) Analyze the results of each study and compare 192 papers 60 included only 3 prospective; most NOT comparative 11
TECHNIQUE: Meta-Analysis (cont) Surgical Management of Ulnar Nerve Compression at the Elbow: An Analysis of the Literature J Neurosurg, 1998 McGowan grades not equally divided Lower grades treated with SD, ME, AST Higher grades treated with SMT, IMT SD best outcome followed my ME AST had worst outcome TECHNIQUE: Meta-Analysis AT Compared with SD for Treatment of CUTS. A Meta-Analysis of Randomized Controlled Trials. JBJS 2007 Zlowodzki et al 4 RCTs comparing SD to AT No significant differences on clinical scores 2 reports included EMGs and no difference TECHNIQUE: Meta-Analysis Simple Decompression Versus Anterior Subcutaneous and Submuscular Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Meta-Analysis JHS 2008 Macadam et al. 10 RCTs and comparative 449 SD, 342 SCNT, 115 SMT Analyze the results of each study and compare NO statistically significant difference Trend toward improved outcome with transposition 12
SEVERITY: SD v SMT Simple Decompression Versus Anterior Submuscular Transposition of the Ulnar Nerve in Severe Cubital Tunnel Syndrome: A Prospective Randomized Study Neurosurgery 2005 Gervasio et al 70 pts (severe) PRCT Dellon Grade 3 35 SD; 35 SMT One blinded evaluator (neurologist) PE and EMG Followed almost 2 years similar outcomes 54% Excellent / 26% good /20% fair SD 51% Excellent / 31% good / 17% fair SMT Complication rates similar INSTABILITY: SD v AST PRCT Comparing Simple Decompression Versus Anterior for Idiopathic Neuropathy of the Ulnar Nerve at the Elbow Neurosurgery 2005 Bartels et al 152 pts PRCT 75 SD and 77 AST -- Followed 1 year; McGill PQ and SF-36 SD 65-48% Excellent to good; AST 70-59% Outcome not related to preoperative grade or nerve instability 16% subluxated and 10% dislocated 9.6% complications versus 31.1% sensory complaints 20/75 had hypermobile nerves with 8 fully dislocating COMPLICATIONS: SD v SMT Randomized, Prospective Study Comparing Ulnar Neurolysis IN SITU with Submuscular Tranposition Neurosurgery 2006 Biggs and Curtis 44 pts PRCT 23 SD and 21 SMT Followed 1 year 61% SD; 67% SMT improvements Outcome not related to preoperative grade or nerve instability Significant difference in complications 13
FAILURES: In Situ Release Predictors of Surgical Revision after In Situ Decompression of the Ulnar Nerve JSES 2015, Krogue et al 44 failures case-controlled study 19% revision surgery rate History elbow fracture/dislocation McGowan stage I disease Concurrent surgery protective FAILURES: In Situ Release Predicting Revision Following In Situ Ulnar Nerve Decompression for Patients with Idiopathic Cubital Tunnel Syndrome JHS 2016, Gaspar et al 216 elbows in 201 pts overmean 22 months 3% (7 pts) revision surgery rate 4 patients had subluxating nerve Age less than 50 years old Duration symptoms 12m v 26m NOT DM, smoking, WC, McGowan, BMI, etc UCL: Cubital Tunnel Release Medial Instability of the Elbow in the Throwing Athletes Conway, Jobe, et al; Am J Sports Med 2008 1992 JBJS 71 patients repair and reconstruction 21% (15 pts) incidence of postop ulnar neuropathy Less than 50% had preop symptoms Transient in 40%(6) Reoperation in 60%(9) Submuscular Transposition Half unable to return to sport 14
UCL: Cubital Tunnel Release Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review Vitale and Ahmad; Am J Sports Med 2008 Overall 10% complication rate 6% postoperative ulnar neuropathy Improvement attributed muscle-splitting approach 9% with ANT versus 4% SD 8% with figure 8 versus 3% with docking UCL: Cubital Tunnel Release Ulnar Collateral Ligament Reconstruction: The Rush Experience Erickson, Bach, Cohen, Bush-Joseph, Cole, Verma, Nicholson, and Romeo; OJSM 2016 187 patients 94% return to sport Preoperative nerve symtpoms 37% Subluxation in 4% AST in 42% at time of surgery 4% needed postop SCT Avoided Ulnar Nerve Transposition in 50% UCL: Cubital Tunnel Release Ulnar Nerve Complication After UCL Reconstruction of the Elbow: A Sytematic Review Clain et al, Am J Sports Med 2018 Systematic review and meta-analysis. Seventeen articles (n = 1518 cases) met the inclusion criteria 77% had AT and 33% SD Overall rate of postoperative ulnar nerve complication was 12% 15
UCL: Cubital Tunnel Release Ulnar Nerve Complication After UCL Reconstruction of the Elbow: A Sytematic Review Clain et al, Am J Sports Med 2018 Approach with highest rate of neuropathy detachment flexor pronator mass (FPM) 21.9% muscle retraction 15.9% muscle splitting 3.9% UCL: Cubital Tunnel Release Ulnar Nerve Complication After UCL Reconstruction of the Elbow: A Sytematic Review Clain et al, Am J Sports Med 2018 Technique with highest rate of neuropathy modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%) interference screw (5.0%) docking technique (3.3%) hybrid suture anchor-bone tunnel (2.9%) modified docking (2.5%) UCL: Cubital Tunnel Release Ulnar Nerve Complication After UCL Reconstruction of the Elbow: A Sytematic Review Clain et al, Am J Sports Med 2018 Concomitant ulnar nerve transposition HIGHER neuropathy rate (16.1%) versus no handling of ulnar nerve (3.9%) submuscular transposition higher rate reoperation (12.7%) compared with subcutaneous transposition (0.0%) 16
Stability Based Decompression A Tailored Approach to the Surgical Treatment of Cubital Tunnel Syndrome Ann Plast Surg, 2011, Keith and Wollstein 63 patients retrospective review based on algorithm 22% nerves AST and 78% nerves SD 14% had unstable nerve NO difference in outcomes 90% improvement subjectively 70% improved Sensation/2PD (15% normal) 95% contralateral grip strength Stability Based Decompression Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome via Small Incision: a Comparison with Classic Anterior Nerve Transposition JOSR, 2015, Kang, et al 107 pts randomized; 1 year clinical outcome NO difference in nerve outcome Complication rate higher AST Cubital Tunnel Recommendation Risk Factors In Situ Release (SD) Unstable -- Transpose Early ROM 17
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9/9/2018 Submuscular Tranpsition Submuscular Tranpsition 25
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9/9/2018 Submuscular Tranpsition Submuscular Tranpsition Submuscular Tranpsition 27
Submuscular Tranpsition In Situ Ulnar Nerve Release In Situ Ulnar Nerve Release 28
Endoscopic Nerve Release Endoscopic Nerve Release Ulnar Nerve Laxity/Instability 29
Ulnar Nerve Laxity/Instability In Situ Ulnar Nerve Release Epicondylitis 30
In Situ Ulnar Nerve Release In Situ Ulnar Nerve Release 31