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Surgical Treatment for Ulnar Nerve Entrapment at the Elbow

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Surgical Treatment for Ulnar Nerve Entrapment at the Elbow Neurol Med Chir (Tokyo) 45, 240¿245, 2005 Surgical Treatment for Ulnar Nerve Entrapment at the Elbow Shunji ASAMOTO, Dieter-Karsten BOKERÄ ,andAndreasJODICKEÄ Department of Neurosurgery, Justus-Liebig University of Gießen, Gießen, Germany Abstract The outcomes of 81 operations were assessed for the treatment of ulnar nerve entrapment at the elbow performed on 55 males (bilateral operations in one) and 25 females during the period from January 1995 to December 2000. Before operation, neurophysiological examination was performed in all patients. Simple ulnar nerve decompression or anterior transposition of the ulnar nerve (subcutaneous or intramuscular) was performed with or without the operating microscope. Nine patients were lost to follow up. The outcome was excellent or good in 63 of 72 cases, no change in eight cases, and poor in one case. The outcomes of procedures performed with the operating microscope tended to be superior. Key words: ulnar nerve entrapment, elbow, surgical treatment Introduction Patients and Methods Ulnar nerve entrapment (UNE) is the second most I. Patient population common nerve entrapment syndrome of the upper The outcomes of 81 operations for UNE per- extremity.8–10,27,29,31,32,34–36,39,42) The initial treatment formed in 80 patients, 55 males aged 21 to 80 years of acute and subacute neuropathy is conservative. (mean53.7years)and25femalesaged28to73years Rest and avoidance of pressure on the nerve may (mean 52.3 years), including one male who under- suffice, but if symptoms persist, splint immobiliza- went bilateral operations during the period from tion of the elbow is warranted.12,33,40) Surgery is January 1995 to December 2000 in our department usually necessary to treat chronic neuropathy were analyzed. No cases were associated with associated with muscle weakness or neuropathy that trauma.Thefollow-upperiodrangedfrom1to24 does not respond to conservative measures. Several months (mean 2.2 months). surgical and non-surgical treatments have been proposed for the treatment of this neuropathy.6,7,13,17) II. Diagnosis Deciding on the most effective procedure can be After enrollment in the study and prior to surgery, difficult, given the excellent results claimed.1,2,14,18) patients completed a detailed preoperative question- Despite the high frequency of UNE, there is no clear naire regarding the presence of pain or numbness, consensus on the indications for surgery or the most the location of the symptoms, and work-related appropriate surgical technique.14–16,19,20,23–25,30,41) issues. Preoperative electromyography (EMG) and Operative management includes simple decompres- nerve conduction velocity studies were performed sion (or ``decompression in situ''); medial epicon- bilaterally in all patients using standard techniques. dylectomy, either alone or in combination with Electrodiagnostic studies are useful to confirm the simple decompression; and anterior transposition. diagnosis of cubital tunnel syndrome, and to deter- We present a retrospective study of the outcomes mine the severity of the disease, to localize the area of surgical treatment for UNE. of compression in some cases, and to exclude other sites of compression. Motor and sensory conduction velocities were determined in a standardized fashion, evaluating the ulnar nerve across the elbow Received July 2, 2004; Accepted December 3, 2004 Author's present address: S. Asamoto, M.D., Department of Neurosurgery, Tokyo Mita Hospital, International University of Health and Welfare, Tokyo, Japan. 240 Surgical Treatment for UNE 241 and from below the elbow to wrist.3,5,8,21,25,35) random by the operator. Because few patients had relatively mild preoperative neurological findings, III. Indication for surgical intervention thereweredifferencesinthenumberofpatientsin In our hospital, the decision for surgical treatment the simple decompression and anterior transposi- is made by a neurosurgeon in cooperation with a tion groups. neurologist. Treatment of UNE was divided into non-operative (conservative) and operative strate- Results gies. Generally, patients reporting only intermittent paresthesia and normal clinical findings were Table 2 summarizes the results of surgery for UNE. managed conservatively. Non-operative manage- Neurologists and neurosurgeons evaluated the ment included educating the patient to avoid pres- postoperative neurological findings. Nine patients sure on the elbow, to avoid prolonged elbow flexion were lost to follow up. Outcome was excellent or as during reading or telephoning, to modify the good in 63 of 72 cases, without changes in signs or work environment by optimizing the height of the symptoms in eight cases and poor in one case. Since work surface, and to pad surfaces on which the the mode of operation was selected under the elbow and the forearm rest. Patients with fixed conditions mentioned above, no comparison was sensory loss, pain, weakness, or significant denerva- made for different modes of operation. However, a tion on EMG were considered for surgical treat- comparative study was performed of individual ment. modes of operation with or without use of a micro- scope. As a result, it was found that the outcomes IV. Surgical technique of surgery with or without use of the operating Surgical intervention was performed under gener- microscope also showed no significant difference, al anesthesia by well-trained neurosurgeons in our but the outcomes with microscopic technique tend- institute. Patients were positioned supine, and the ed to be superior. All patients without improvement externally rotated arm was placed on the arm-table of neurological findings had severe preoperative with the elbow flexed and the forearm in the supine symptoms. Therefore, cases of poor outcome may be position. An omega skin incision of about 10 cm in related to preoperative changes in the perineural length was made about the medial epicondyle. Two vessels. Of course, no complication was observed in different operative procedures were used: simple the perioperative findings and procedures in cases ulnar nerve decompression without epicondylec- of poor outcome. Though only a speculation, it is es- tomy, and anterior transposition of the ulnar nerve timated that patients with poor outcome were in a (subcutaneous or intramuscular) with or without use hypersensitive state, so easily suffered damage ofamicroscope(Table1).Thechoiceofprocedure was made at the surgeon's discretion, but simple Table 1 Operative procedures for ulnar nerve decompression was performed only in patients who entrapment had mild symptoms. Except for simple decompres- sion, anterior transposition of the ulnar nerve was With Without performed as a rule. However, submuscular anterior microscope microscope transposition was selected in some patients with Simple decompression 5 8 severely tensed ulnar nerve due to cubitus valgus Anterior transposition over 309or those engaging in work using the inside subcutaneous 25 33 of the elbow or those receiving re-operation. In addi- intramuscular 3 7 tion, the decision to use a microscope was made at Table 2 Results of surgery for ulnar nerve entrapment With microscope Without microscope Excellent Good No change Poor Excellent Good No change Poor Simple decompression 4/4 0/4 0/4 0/4 4/8 3/8 1/8 0/8 Anterior transposition subcutaneous 17/20 2/20 1/20 0/20 20/31 5/31 6/31 0/31 intramuscular 2/3 0/3 0/3 1/3 4/6 2/6 0/6 0/6 Nine patients lost to follow up. Total of 72 cases evaluated in 71 patients. Neurol Med Chir (Tokyo) 45, May, 2005 242 S. Asamoto et al. caused by mobilizing nerves or perineural vessels preoperative conditions, but such conditions are due to severe perioperative neurological findings. difficult to obtain.10,16,18,23,42) Variousoutcomesof different surgical treatments for this neuropathy Discussion have been described, so it is difficult to assess which surgical procedure is the best for this Operative procedures can be divided into two disease.1,2,4–6,8,26,38,42) groups: decompression (including medial epicon- Microsurgical technique allows the perineural dylectomy) with transposition, and decompression vessels to be preserved in decompression and, to a without transposition. Decompression without lesser degree, in anterior transposition procedures, transposition is also referred to as decompression so the use of the surgical microscope seems to be in situ or ``simple decompression.'' Transposing the important. In this study, microsurgical treatment nerve has two main advantages. The first is that tended to improve clinical outcome in patients with the nerve removed from an unsuitable bed and UNE. These results should be reconfirmed in a repositioned to one that is less scarred.3–5) This is prospective controlled study with randomized use of necessary for many types of lesions, that are prox- microsurgical technique. No other examination of imal to or within the epicondylar groove.1,18,19,21) The various surgical procedures with or without the second advantage is that by transposing the nerve operating microscope in the treatment of this into a new pathway volar to the axis of elbow neuropathy is available. motion, the nerve is effectively lengthened, which Both simple decompression and surgical manipu- decreases tension with elbow flexion. There are lation to improve the articular mobile region are three methods for transposition: subcutaneous clearlyrequiredinsomepatientswithUNE, transposition, intramuscular transposition, and although we experienced no such case in our series. submuscular transposition.4,5,22,28,30,37)
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