Symptoms Of Cubital Tunnel Syndrome Research Articles

Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BackgroundDouble crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review.MethodsThe study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases.ResultsIn 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases.ConclusionTypical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Diagnosis of Ulnar Neuropathy at the Elbow Using Ultrasound — A Comparison to Electrophysiologic Studies

Given the relatively high false negative rate of electrodiagnostic studies (EDX) in patients with clinically diagnosed ulnar neuropathy at the elbow (UNE), we sought to determine whether an alternative objective test could more effectively detect UNE. Additionally, we proposed to determine the relationship between the cross-sectional area (CSA) of the ulnar nerve on ultrasound(US), EDX, and clinical symptoms. This was a retrospective study of patients presenting with symptomatic UNE. The performance characteristics of EDX versus ultrasound were calculated using the clinical diagnosis of UNE as the reference standard. Standard EDX studies and US of the ulnar nerve were analyzed. Maximal CSA of the ulnar nerve and EDX severity were analyzed for patients with each combination of US-positive/negative and EDX-positive/negative findings. Analysis was performed on 89 patients and 115 nerves with signs and symptoms of cubital tunnel syndrome. In total, 56 (49%) nerves were diagnosed as mild UNE, 32 (28%) nerves were diagnosed as moderate UNE, 17 (15%) nerves were diagnosed as severe UNE, and 10 (8%) nerves were negative for UNE by EDX. Maximal-maximal CSA was highly correlated with disease severity as determined by nerve conduction studies/electromyography. Compared with EDX+/US+, patients with EDX-/US+ showed higher rates of ulnar sensory loss and elbow tenderness with similar rates of positive Tinel and intrinsic muscle atrophy. In this sample of patients with clinically diagnosed UNE, 91.3% of the patients demonstrated positive EDX studies, whereas 94.8% had a positive US. Ultrasound is an alternative to EDX that could be incorporated clinically in the diagnosis and management of UNE. Ultrasound was able to consistently detect clinically positive cubital tunnel syndrome demonstrating its utility as a confirmatory or supplemental test to the clinical assessment if one is required. Ultrasound additionally may be able to better identify patients with early stages of UNE with negative EDX findings. Diagnostic IV.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Fascial Epicondylar Augmentation in Cases of Cubital Tunnel Syndrome With Ulnar Nerve Instability.

Cubital tunnel syndrome (CubTS) is one of the most common compression-traction neuropathy in the upper extremity. The gold standard is simple in situ decompression with revision of potential compression sites through skin incision as small as rationally possible. Properly conducted conservative treatment is more effective in CubTS as opposed to carpal tunnel syndrome. At the same time, optimal management of CubTS remains controversial. Nevertheless, there is a subclass of patients with symptoms of CubTS that have ulnar nerve instability (UNI) with subluxation of the nerve over the medial epicondyle where conservative treatment would not be successful. UNI can be diagnosed by ultrasound preoperatively, but there are situations where the ulnar nerve becomes unstable with elbow flexion already on the operating table. Currently the most popular surgical reconstruction for clinically relevant UNI is anterior transposition of the nerve. With the proposed technique the nerve stays in orthotopic position, and the segmental vascularity is preserved, innervation to the flexor carpi ulnaris muscle is not jeopardized and ulnar nerve glide-floss exercises are possible as opposed to the standard subcutaneous transposition technique. No subfascial transposition, slings or blocking flaps are used for nerve stabilization which we consider contradiction to the surgery of nerve release.

Analyse des facteurs anatomiques associés au syndrome du tunnel ulnaire

BackgroundPrevious studies demonstrated that soft tissues, such as retinaculum, fibrous band, and anconeus, cause ulnar nerve compression, whereas other studies showed that the bony structures strain the ulnar nerve that runs directly behind the medial epicondyle constituting the boundary of the cubital tunnel during elbow flexion. However, no studies have reported the association of the shape of the bony structure with cubital tunnel syndrome symptoms. Are computed tomography (CT) and magnetic resonance imaging (MRI)-measured parameters of the bony cubital tunnel related to idiopathic cubital tunnel syndrome symptoms? HypothesisWe hypothesized that CT and MRI-measured parameters of the bony cubital tunnel were related to idiopathic cubital tunnel syndrome symptoms. We aimed to investigate the relationship between the radiographic parameters based on CT and MRI and idiopathic cubital tunnel syndrome symptoms. Patients and methodsWe analyzed 224 elbows (77 affected elbows of patients with idiopathic cubital tunnel syndrome, 77 unaffected elbows of patients with cubital tunnel syndrome, 70 elbows of patients without cubital tunnel syndrome symptoms) using CT and MRI. Cubital tunnel cross-sectional area, cubital tunnel volume, and ulnar nerve cross-sectional area were measured in the three groups at flexion and extension. A new cubital tunnel center with a new boundary was proposed that could play a role in ulnar nerve compression symptoms. ResultsThe cross-sectional areas and volumes of the cubital tunnel measured in the elbow flexion state were the smallest among the group with the affected elbows in patients. There was no difference between unaffected elbows and the non-patient group. The cross-sectional area of the ulnar nerve highly correlated with cubital tunnel symptoms in the flexion state. DiscussionThe shape of the cubital tunnel is an important factor in cubital tunnel syndrome, and normal variations in the volume and cross-sectional area of the cubital tunnel and ulnar nerve could influence the occurrence of idiopathic cubital tunnel syndrome. Level of evidenceIII, Therapeutic study.

Analysis of the Anatomical Factors Associated with Cubital Tunnel Syndrome

BackgroundPrevious studies demonstrated that soft tissues, such as retinaculum, fibrous band, and anconeus, cause ulnar nerve compression, whereas other studies showed that the bony structures strain the ulnar nerve that runs directly behind the medial epicondyle constituting the boundary of the cubital tunnel during elbow flexion. However, no studies have reported the association of the shape of the bony structure with cubital tunnel syndrome symptoms. Are computed tomography (CT) and magnetic resonance imaging (MRI)-measured parameters of the bony cubital tunnel related to idiopathic cubital tunnel syndrome symptoms? HypothesisWe hypothesized that CT and MRI-measured parameters of the bony cubital tunnel were related to idiopathic cubital tunnel syndrome symptoms. We aimed to investigate the relationship between the radiographic parameters based on CT and MRI and idiopathic cubital tunnel syndrome symptoms. Patients and methodsWe analyzed 224 elbows (77 affected elbows of patients with idiopathic cubital tunnel syndrome, 77 unaffected elbows of patients with cubital tunnel syndrome, 70 elbows of patients without cubital tunnel syndrome symptoms) using CT and MRI. Cubital tunnel cross-sectional area, cubital tunnel volume, and ulnar nerve cross-sectional area were measured in the three groups at flexion and extension. A new cubital tunnel center with a new boundary was proposed that could play a role in ulnar nerve compression symptoms. ResultsThe cross-sectional areas and volumes of the cubital tunnel measured in the elbow flexion state were the smallest among the group with the affected elbows in patients. There was no difference between unaffected elbows and the non-patient group. The cross-sectional area of the ulnar nerve highly correlated with cubital tunnel symptoms in the flexion state. DiscussionThe shape of the cubital tunnel is an important factor in cubital tunnel syndrome, and normal variations in the volume and cross-sectional area of the cubital tunnel and ulnar nerve could influence the occurrence of idiopathic cubital tunnel syndrome. Level of evidenceIII, Therapeutic study.

Analysis the cause of failure in primary surgery of cubital tunnel syndrome and clinical evaluation of revision cubital tunnel surgery

Objective To explore the reasons for the failure of primary cubital tunnel syndrome (CuTS) surgery, summarize the technical details of cubital tunnel revision and evaluate the clinical efficacy. Methods From January 2015 to December 2016, 20 patients with persistent or new symptoms of CuTS after primary operation were treated with revision. The technical details of revision of cubital tunnel were summarized and the clinical efficacy was evaluated by observing the compression of ulnar nerve during operation and following up the improvement of clinical symptoms. Results The incomplete release of common compression points of ulnar nerve in elbow and improper preparation of fascial tissue flaps for anterior ulnar nerve were the main reasons for the failure of operation. After at least 12 months of follow-up, the strength of hand intrinsic muscles, skin sensation and pain symptoms of ulnar nerve innervation were significantly improved. Conclusion For the cases of CuTS with severe symptoms or new symptoms after primary operation, the main reason for failure is improper handling of details. The clinical efficacy of revision of CuTS is satisfactory, but it is worse than that of successful primary surgery. Key words: Cubital tunnel syndrome; Treatment failure; Revision; Neuropathic pain; Medial antebrachial cutaneous nerve

Anconeus Epitrochlearis Muscle Associated With Cubital Tunnel Syndrome: A Case Series.

Background: Cubital tunnel syndrome is a common compressive neuropathy of the upper extremity. The anconeus epitrochlearis muscle is an unusual but occasional contributor. We review our experience with this anomalous muscle in elbows with cubital tunnel syndrome. Methods: We retrospectively reviewed charts of 13 patients noted to have an anconeus epitrochlearis muscle associated with cubital tunnel syndrome. Results: Ten patients had unilateral ulnar neuropathy supported by nerve conduction studies. Three had bilateral cubital tunnel syndrome symptoms with 1 of those having normal nerve conduction studies for both elbows. Eight elbows were treated with myotomy of the anconeus epitrochlearis muscle and submuscular transposition of the ulnar nerve. The other 8 elbows were treated with myotomy of the anconeus epitrochlearis muscle and in situ decompression of the ulnar nerve only. All but 1 patient had either clinical resolution or improvement of symptoms at follow-up ranging from 2 weeks to 1 year after surgery. The 1 patient who had persistent symptoms had received myotomy and in situ decompression of the ulnar nerve only. Conclusions: An anomalous anconeus epitrochlearis occasionally results in compression of the ulnar nerve but is usually an incidental finding. Its contribution to compression neuropathy can be tested intraoperatively by passively ranging the elbow while observing the change in vector and tension of its muscle fibers over the ulnar nerve. Regardless of findings, we recommend myotomy of the muscle and in situ decompression of the ulnar nerve. Submuscular transposition of the ulnar nerve may be necessary if there is subluxation.

Clinical Outcome for Failed Radial Head Arthroplasty Treated with Explantation

Purpose: Failure after radial head arthroplasty is uncommon, but clinically significant. Treatment for failure may involve implant removal. We describe fourteen patients who underwent implant removal after failed radial head arthroplasty. Methods: A retrospective review was performed to determine the cause of failure and clinical data were prospectively collected. Results: At mean follow up of 38 months the mean VAS for pain score was 3.0 and the mean DASH score was 40.5. The mean MEPS was 69. All patients demonstrated improved elbow range of motion. Mean elbow flexion at final follow up was 124° to an average extension deficit of 25°. Fifty percent of patients exhibited clinical symptoms of cubital tunnel syndrome. Three patients required additional surgery after implant removal. Conclusions: Implant removal for failed radial head arthroplasty improves range of motion and demonstrates acceptable outcomes at intermediate-term follow up. However, 50% of patients developed cubital tunnel syndrome and 21% required revision surgery.

Characteristic and treatment of acute aggravating cubital tunnel syndrome

To investigate the causes and the characteristics of acute aggravating cubital tunnel syndrome. The enrolling criteria of subjects were as follows: (1) Patients with manifestation of cubital tunnel syndrome for more than 6 months; (2) acute exacerbation of the disease for no more than 4 weeks. The clinical data from March 2011 to December 2014 was collected and analyzed retrospectively. Twelve cases aged 52 to 65 met the enrolling criteria and were included in this study, and among them 10 patients were male, 2 were female; 5 cases were on the left and the other 7 on the right. All of them had some degree of cubital tunnel syndrome symptoms before the onset of acute exacerbation. When nerve decompression and anterior transposition of the ulnar nerve was performed, the elbow joint cysts which squeezed the ulnar nerve were found. The cysts were then resected. In all 12 cases, the compression symptoms of ulnar nerve were relieved after surgery. The mean follow up period was 13 months, ranging from 6 to 45 months. According to Gu Yudong functional evaluation criteria for cubital tunnel syndrome, 2 of the patients can be judged as "Excellent", 8 "good" and 2 "acceptable" at the follow-up. Cyst compression may induce the acute exacerbation of ulnar nerve symptom in patients with cubital tunnel syndrome. Early diagnosis and treatment is critical for these patients.

Anconeus Epitrochlearis as a Source of Medial Elbow Pain in Baseball Pitchers

Medial elbow pain is reported in 18% to 69% of baseball players aged of 9 and 19 years. This is due to the large valgus stresses focused on the medial side of the elbow during overhead activities. In overhead throwers and pitchers, pain can be attributed to valgus extension overload with resultant posteromedial impingement, overuse of the flexor-pronator musculature resulting in medial epicondylitis, or occasional muscle tears or ruptures. The anconeus epitrochlearis is a known cause of cubital tunnel syndrome and has been postulated as a source of medial elbow pain in overhead athletes. This article describes the cases of 3 right-handed baseball pitchers with persistent right-sided medial elbow pain during throwing despite a prolonged period of rest, physical therapy, and nonsteroidal anti-inflammatory drugs. Two patients had symptoms of cubital tunnel syndrome as diagnosed by electromyogram and nerve conduction studies and the presence of the anconeus epitrochlearis muscle per magnetic resonance imaging. All patients underwent isolated release of the anconeus muscle without ulnar nerve transposition and returned to their previous levels of activity. The diagnosis and treatment of pitchers who present with medial-sided elbow pain can be complex. The differential should include an enlarged or inflamed anconeus epitrochlearis muscle as a possible cause. Conservative management should be the first modality. However, surgical excision with isolated release of the muscle can be successful in returning patients with persistent pain despite a trial of conservative management to their previous levels of function.

Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome

Shoulder internal rotation enhances symptom provocation attributed to cubital tunnel syndrome. We present a modified elbow flexion test--the shoulder internal rotation elbow flexion test--for diagnosing cubital tunnel syndrome. Fifty-five ulnar nerves in cubital tunnel syndrome patients and 123 ulnar nerves in controls were examined with 5 seconds each of elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests before and after treatment (surgery in 18; conservative in others). For the shoulder internal rotation elbow flexion test position, 90° abduction, maximum internal rotation, and 10° flexion of the shoulder were combined with the elbow flexion test position. The test was considered positive if any symptom for cubital tunnel syndrome developed <5 seconds. Influence of the shoulder internal rotation elbow flexion test was evaluated by nerve conduction studies in 10 cubital tunnel syndrome nerves and 7 control nerves. The sensitivities/specificities of the 5-second elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests were 25%/100%, 58%/100%, and 87%/98%, respectively. Sensitivity differences between the shoulder internal rotation elbow flexion test and the other two tests were significant. Shoulder internal rotation elbow flexion test results and cubital tunnel syndrome symptoms were significantly correlated. Influence of the shoulder internal rotation elbow flexion test on the ulnar nerve was seen in 8 of 10 cubital tunnel syndrome nerves but not in controls. The 5-second shoulder internal rotation elbow flexion test is specific, easy and quick provocative test for diagnosing cubital tunnel syndrome.

Endoscopy-Assisted Cubital Tunnel Release Under Carbon Dioxide Insufflation and Anterior Transposition

The optimal treatment for cubital tunnel syndrome is widely debated. The purpose of this study is to describe the technique of an endoscopic-assisted ulnar nerve decompression using carbon dioxide insufflation in association with subcutaneous anterior transposition and to assess the success or failure of the method of treatment. In all, 8 male and 4 female patients with an average age of 42 years (range, 25-56) who presented signs, symptoms, and abnormal neurophysiological studies of cubital tunnel syndrome were recruited in the retrospective study. Between August 2008 and June 2009, they were operated on using a 0-degree lens endoscope. Preoperatively, they were classified according to the Dellon scale, and the Bishop rating system was used to evaluate the postoperative outcomes. Preoperatively, 5 patients were rated as mild, another 5 as moderate, and the remaining 2 as severe. The average length of the incision was 15 ± 3 mm, the mean length of the ulnar nerve decompression was 18 ± 2 cm, and the whole duration of surgery (skin to skin) lasted 30 ± 5 minutes. The endoscopic-assisted cubital tunnel release under carbon dioxide insufflation and subcutaneous anterior transposition surgeries in all patients were performed with no difficulty. All the patients had improvement in symptoms of cubital tunnel syndrome and 10 of 12 patients scored excellent according to the modified Bishop Rating System at a minimum of 1 year after surgery. Endoscopy-assisted cubital tunnel release under carbon dioxide insufflation demonstrated similar results compared with conventional open surgeries, besides, it may avoid problems such as long incision, painful scarring, and have additional advantages of providing an extended endoscopic view, which is safe and mini-invasive with favorable results in a 12-month follow-up.

A Fusiform Epineural Ganglion Encompassing the Ulnar Nerve in the Cubital Tunnel

Cubital tunnel syndrome, caused by a ganglion, is rare and most ganglion cysts originate from the medial aspect of the ulnohumeral joint. We present an extremely rare case of a fusiform epineural ganglion, encompassing the ulnar nerve in the cubital tunnel. A 48-yearold man complained of a 6-month history of typical cubital tunnel syndrome symptoms. Electrophysiological studies were compatible with the compressive neuropathy of the ulnar nerve. A fusiform epineural ganglion cyst (1.4 cm in diameter and 7.2 cm in length), which encompasses the ulnar nerve in the cubital tunnel, was found with no connection to the elbow joint. The ganglion cyst was excised and the ulnar nerve anterior transmuscular transposition was performed. Six months postoperatively, the patient was free of pain, tingling sensations, and numbness. In addition, his grip and pinch strength improved, the muscle wasting showed recovery, and an electrophysiological study demonstrated some improvement.

Subcutaneous Anterior Transposition Versus Decompression and Medial Epicondylectomy for the Treatment of Cubital Tunnel Syndrome

A review of the literature often fails to uncover the best procedure for the treatment of cubital tunnel syndrome. This article compares 2 frequently used methods (subcutaneous anterior transposition vs decompression and medial epicondylectomy) for their effectiveness in relieving both subjective and objective symptoms of cubital tunnel syndrome. Between August 1991 and October 1993, nineteen patients underwent surgical decompression by a single surgeon for ulnar neuropathy at the elbow. Factors evaluated included upper extremity range of motion, elbow valgus stress, grip strength, pinch, 2-point discrimination, and pre- and postoperative nerve conduction. A standardized questionnaire was administered to assess subjective relief of symptoms.In the transposition group, grip strength averaged 71.2% of normal and pinch strength 86.6% of normal, and 2-point discrimination averaged 8.0 mm. The derived subjective assessment score was 23.2 of a possible 40. The average ulnar motor conduction velocity across the elbow was 50.1 m/sec preoperatively and 56.3 m/sec postoperatively. In the medial epicondylectomy group, grip strength averaged 79.5% of normal and pinch strength 81.7% of normal, and 2-point discrimination averaged 8.0 mm. The average ulnar motor conduction velocity across the elbow was 45.7 m/sec preoperatively and 55.7 m/sec postoperatively. No statistically significant difference existed between the 2 groups for the aforementioned indexes. These results do not indicate a difference between the outcomes of the patients undergoing either of the procedures. Because epicondylectomy is less technically demanding, with less soft tissue dissection of the nerve, it may be preferred over ulnar transposition.

Endoscopically assisted release of the ulnar nerve for cubital tunnel syndrome

Recently, the simple decompression of the ulnar nerve has been advocated as the best surgical approach for the treatment of the cubital tunnel syndrome. Encouraged by the positive results observed with the use of the endoscopic approach for the treatment of the carpal tunnel syndrome, there have been reports about the use of endoscopes for decompression of the ulnar nerve at the level of the elbow since 1999. The objective of this study was to demonstrate the surgical results obtained with a simple and replicable technique employed for endoscopic release of the ulnar nerve in cases of cubital tunnel syndrome. It was retrospectively studied thirteen patients who presented signs and symptoms of cubital tunnel syndrome and who were operated on by an endoscopically assisted technique, from 2007 to 2009. The approach included the use of a 0 degrees lens neuroendoscope usually employed for ventricular endoscopy. Preoperative clinical and electrophysiological data were collected and compared to those observed 6 months after the surgery. The Dellon's scale was used for rating the severity of the lesions, and the postoperative outcome was assessed based on the Bishop rating system. All procedures were completed successfully via the endoscopically assisted approach, and no surgery had to be converted to an open operation. Postoperatively, 76.9% of the cases were completely free of signs and symptoms (8 and 9 points on the Bishop scale), 15.3% presented with light complaints (7 points), and only one subject (7.6%) reached 5 points on the outcome scale. Complete normalization of the electrophysiological studies was also observed in seven patients, most of whom were classified preoperatively as Dellon's grades I and II, but three of whom were classified as grade III. Normalization of the sensory conduction studies was observed in ten cases, normalization of the motor conduction studies in six subjects, and in four patients, there was improvement in electromyographic parameters. The endoscopically assisted approach for decompression of the ulnar nerve at the level of the elbow is a minimally invasive technique that demonstrated surgical results similar to those reported via the open approach. It may have additional advantages such as the reduction of soft tissue manipulation, faster mobilization of the arm, and quicker return of the patients to their daily activities.

Endoscopically Assisted Ulnar Neurolysis for Cubital Tunnel Syndrome

Controversy remains regarding the surgical treatment of cubital tunnel syndrome. Similar outcomes with ulnar nerve transposition, both subcutaneous and submuscular, and simple decompression have recently been reported. We describe an endoscopically assisted cubital tunnel release through a 2-cm incision using readily available standard equipment. Seventeen of 21 procedures successfully alleviated symptoms of cubital tunnel syndrome in these patients. Four patients who developed ulnar nerve subluxation intraoperatively who were treated with medial epicondylectomy failed to experience relief of symptoms and were successfully treated with anterior submuscular transposition. Patients with more profound motor weakness and/or electrodiagnostic studies had less complete relief of symptoms.

ELBOW GANGLION ARISING FROM MEDIAL EPICONDYLE PSEUDARTHROSIS

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.

Intraoperative Measurement of Pressure Adjacent to the Ulnar Nerve in Patients with Cubital Tunnel Syndrome

As hand therapists, we commonly treat cubital tunnel syndrome in patients both conservatively and postoperatively. It is interesting to learn that questions still arise regarding the cause of this nerve entrapment. Is it due to compression of the cubital tunnel wall, stretching of the nerve itself, or a combination of these factors? Previous studies have examined interstitial pressure within the cubital tunnel and have shown increased pressure with increased elbow flexion. However, these studies have all been performed in the cadaver lab. In this present study from Japan, pressure around the ulnar nerve was measured during surgery and a link was found to the duration of the disease and the severity of the neuropathy. Method: The study looked at eight patients undergoing decompression of the cubital tunnel. All of the patients complained of pain, numbness and parathesias of the ulnar hand, and loss of strength. The patients also demonstrated a positive Tinel's sign at the elbow, atrophy of the intrinsic muscles, decreased motor nerve conduction velocity, and symptom reproduction with elbow flexion. All eight patients demonstrated severe symptoms of cubital tunnel syndrome warranting surgical decompression. The Akahori classification system was used to grade the severity of the cubital tunnel syndrome. The surgical technique used is described. Pressures in each elbow were recorded at three locations: 1 cm, 2 cm, and 3 cm distal to the proximal edge of the cubital tunnel retinaculum. Measurements at each location were performed with the elbow flexed to 130° and in full extension. The measurements were taken three times and an average of the three was recorded. Statistical Analysis: The Student's t-test was used to evaluate the difference in pressures between elbow flexion and elbow extension and the differences in pressure between elbow flexion and the stages of ulnar nerve palsy. The Pearson's correlation analysis was used to study the relationship between age and pressure, motor nerve conduction velocity and pressure, and disease duration and pressure. Results: The statistical analysis indicates a statistically significant difference in the measurement of extraneural pressure with elbow flexion over elbow extension and increased pressure more proximally to the cubital tunnel than distally. Results of the statistical analysis also show a positive correlation between extraneural pressure with elbow flexion and the severity of the disease at each location in the cubital tunnel. The pressures also correlated positively with motor nerve conduction velocity. Conclusions: Previous studies on pressure around the ulnar nerve in cubital tunnel have been performed in the cadaver lab. This study measures pressure around the ulnar nerve during surgery and finds correlations with the amount of pressure and the severity of the nerve entrapment. A transducer-tipped fiberoptic probe is used to for intraoperative pressure measurement. This device was created for intracranial pressure monitoring. It is simple to use and has a rapid response to pressure changes. Reviewer's Commentary: This study makes no statement regarding the causative factors leading to cubital tunnel syndrome. However, the authors suggest that external compression plays a significant role in the development of ulnar nerve entrapment. They conclude that simple decompression of the ulnar nerve is insufficient and selected anterior transposition of the ulnar nerve as the surgical technique in all eight patients.

Cubital Tunnel Syndrome

The symptoms of cubital tunnel syndrome in 118 patients were mainly those of muscular atrophy, but they also included sensory disturbances in the ring and little fingers and pain in the ulnar side of the forearm. The syndrome occurs equally in men and women, with no particular age preference in adults. Seven tests are useful in diagnosing the condition. Treatment consists of excising the band, which constricts the ulnar nerve at the elbow. Sensory recovery is usually complete, but muscular atrophy may not recover in older patients. In my series of 561 nerve decompressions, ulnar nerve decompression was carried out eight times more often at the elbow than at the wrist.