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Ulnar nerve entrapment at the elbow. A surgical series and a systematic review of the literature

Published:September 07, 2017DOI:https://doi.org/10.1016/j.jocn.2017.08.012

      Highlights

      • Anterior subcutaneous transposition (AST) is widely used for cubital tunnel syndrome.
      • In our surgical series, AST provides excellent results with long-term follow-up.
      • Its effectiveness is particulary noticeable in cases with severe neuropathy.
      • In a systematic review, AST has the lowest recurrence rate among various techniques.
      • Preoperative status is the main predictive factor for outcome after surgery.

      Abstract

      Chronic compression of the ulnar nerve at the elbow is the second most common entrapment neuropathy. Various surgical options have been described. Timing of surgery is also debated. In this study we report the long-term results of a consecutive surgical series of anterior subcutaneous transpositions and review the pertinent literature. Sixty consecutive patients underwent anterior subcutaneous transposition at our Institution to treat ulnar nerve compression at the elbow. McGowan scale was used in the neurological exam before surgery. Bishop rating system was used to assess outcome. Seventy-eight% of patients scored good-excellent. None of the patients worsened. No complications and no recurrences were reported. Young age and good pre-operative neurological status (McGowan grade 1) were predictive of favorable outcome both at univariate and at multivariate analysis. No differences in outcome were observed between patients with intermediate (McGowan grade 2) and severe (McGowan grade 3) neuropathy. Thirty-four studies assessing outcome of different surgical techniques were reviewed. Anterior subcutaneous transposition had the lowest recurrence rate with an excellent effectiveness and safety profile. The favorable predictive role for outcome of preoperative neurological status was confirmed. The good long-term clinical results of the present series and the results of literature analysis confirm the value of anterior subcutaneous transposition of the ulnar nerve at the elbow. This technique has a particular effectiveness in most severe compressions, where outcomes are comparable with intermediate neuropathy cases. Moreover, our results suggest an aggressive attitude towards ulnar nerve compression at the elbow, particularly in younger patients.

      Keywords

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      References

        • Mondelli M.
        • Giannini F.
        • Ballerini M.
        • Ginanneschi F.
        • Martorelli E.
        Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy).
        J Neurol Sci. 2005; 234: 5-10
        • Di Rocco F.
        • Doglietto F.
        • Tufo T.
        • Ciampini A.
        • Lauretti L.
        • Fernandez E.
        Posttraumatic immobilization in flexion of a congenital valgus elbow and cubital tunnel syndrome-case report.
        Surg Neurol. 2009; 71: 709-712
        • Fernandez E.
        • Pallini R.
        • Lauretti L.
        • Scogna A.
        • La Marca F.
        Neurosurgery of the peripheral nervous system: cubital tunnel syndrome.
        Surg Neurol. 1998; 50: 83-85
        • Won H.S.
        • Han S.H.
        • Oh C.S.
        • Chung I.H.
        • Kim S.M.
        • Lim S.Y.
        Topographic relationship between the medial intermuscular septum and the ulnar nerve in the upper arm.
        J Neurosurg. 2011; 114: 1534-1537
        • Macchi V.
        • Tiengo C.
        • Porzionato A.
        • Stecco C.
        • Sarasin G.
        • Tubbs S.
        • et al.
        The cubital tunnel: a radiologic and histotopographic study.
        J Anat. 2014; 225: 262-269
        • Mahan M.A.
        • Gasco J.
        • Mokhtee D.B.
        • Brown J.M.
        Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited.
        J Neurosurg. 2015; 123: 1216-1222
        • Mahan M.A.
        • Vaz K.M.
        • Weingarten D.
        • Brown J.M.
        • Shah S.B.
        Altered ulnar nerve kinematic behavior in a cadaver model of entrapment.
        Neurosurgery. 2015; 76: 747-755
        • Bartels R.H.M.
        • Menovsky T.
        • Van Overbeeke J.J.
        • Verhagen W.I.M.
        Surgical management of ulnar nerve compression at the elbow: an analysis of the literature.
        J Neurosurg. 1998; 89: 722-727
        • Zlowodzki M.
        • Chan S.
        • Bhandari M.
        • Kalliainen L.
        • Schubert W.
        Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials.
        J Bone Joint Surg Am. 2007; 89: 2591-2598
        • Caliandro P.
        • La Torre G.
        • Padua R.
        • Giannini F.
        • Padua L.
        Treatment for ulnar neuropathy at the elbow.
        Cochrane Database Syst Rev. 2016; 11: CD006839
        • Schmidt S.
        • Kleist Welch-Guerra W.
        • Matthes M.
        • Baldauf J.
        • Schminke U.
        • Schroeder H.W.
        Endoscopic vs open decompression of the ulnar nerve in cubital tunnel syndrome: a prospective randomized double-blind study.
        Neurosurgery. 2015; 77: 960-971
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6: e1000097
        • Wilson D.H.
        • Krout R.
        Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompression without transposition. Technical note.
        J Neurosurg. 1973; 38: 780-785
        • Geutjens G.G.
        • Langstaff R.J.
        • Smith N.J.
        • Jefferson D.
        • Howell C.J.
        • Barton N.J.
        Medial epicondylectomy or ulnar-nerve transposition for ulnar neuropathy at the elbow?.
        J Bone Joint Surg Br. 1996; 78: 777-779
        • Amako M.
        • Nemoto K.
        • Kawaguchi M.
        • Kato N.
        • Arino H.
        • Fujikawa K.
        Comparison between partial and minimal medial epicondylectomy combined with decompression for the treatment of cubital tunnel.
        J Hand Surg Am. 2000; 25: 1043-1050
        • Muermans S.
        • De Smet L.
        Partial medial epicondylectomy for cubital tunnel syndrome: outcome and complications.
        J Shoulder Elbow Surg. 2002; 11: 248-252
        • Dellon A.L.
        • Coert J.H.
        Results of the musculofascial lengthening technique for submuscular transposition of the ulnar nerve at the elbow.
        J Bone Joint Surg Am. 2003; 85-A: 1314-1320
        • Taha A.
        • Galarza M.
        • Zuccarello M.
        • Taha J.
        Outcomes of cubital tunnel surgery among patients with absent sensory nerve conduction.
        Neurosurgery. 2004; 54: 891-895
        • Asamoto S.
        • Böker D.K.
        • Jödicke A.
        Surgical treatment for ulnar nerve entrapment at the elbow.
        Neurol Med Chir (Tokyo). 2005; 45: 240-244
        • Bartels R.H.
        • Verhagen W.
        • van der Wilt G.J.
        • Meulstee J.
        • van Rossum L.G.
        • Grotenhuis J.A.
        Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: part 1.
        Neurosurgery. 2005; 56: 522-530
        • Davis G.A.
        • Bulluss K.J.
        Submuscular transposition of the ulnar nerve: review of safety, efficacy and correlation with neurophysiological outcome.
        J Clin Neurosci. 2005; 12: 524-528
        • Gervasio O.
        • Gambardella G.
        • Zaccone C.
        • Branca D.
        Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study.
        Neurosurgery. 2005; 56: 108-117
        • Matsuzaki H.
        • Yoshizu T.
        • Maki Y.
        • Tsubokawa N.
        • Yamamoto Y.
        • Toishi S.
        Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome.
        J Hand Surg Am. 2004; 29: 373-378
        • Nabhan A.
        • Ahlhelm F.
        • Kelm J.
        • Reith W.
        • Schwerdtfeger K.
        • Steudel W.I.
        Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome.
        J Hand Surg Br. 2005; 30: 521-524
        • Baek G.H.
        • Kwon B.C.
        • Chung M.S.
        Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome.
        J Shoulder Elbow Surg. 2006; 15: 609-613
        • Biggs M.
        • Curtis J.A.
        Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition.
        Neurosurgery. 2006; 58: 296-304
        • Efstathopoulos D.G.
        • Themistocleous G.S.
        • Papagelopoulos P.J.
        • Chloros G.D.
        • Gerostathopoulos N.E.
        • Soucacos P.N.
        Outcome of partial medial epicondylectomy for cubital tunnel syndrome.
        Clin Orthop Relat Res. 2006; 444: 134-139
        • Charles Y.P.
        • Coulet B.
        • Rouzaud J.C.
        • Daures J.P.
        • Chammas M.
        Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome.
        J Hand Surg Am. 2009; 34: 866-874
        • Keiner D.
        • Gaab M.R.
        • Schroeder H.W.
        • Oertel J.
        Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome–a prospective study.
        Acta Neurochir (Wien). 2009; 151: 311-315
        • Hamidreza A.
        • Saeid A.
        • Mohammadreza D.
        • Zohreh Z.
        • Mehdi S.
        Anterior subcutaneous transposition of ulnar nerve with fascial flap and complete excision of medial intermuscular septum in cubital tunnel syndrome: a prospective patient cohort.
        Clin Neurol Neurosurg. 2011; 113: 631-634
        • Schnabl S.M.
        • Kisslinger F.
        • Schramm A.
        • Dragu A.
        • Kneser U.
        • Unglaub F.
        • et al.
        Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome.
        Arch Orthop Trauma Surg. 2011; 131: 1027-1033
        • Cirpar M.
        • Turker M.
        • Ozuak C.S.
        Distal medial epicondylectomy. A modification of partial medial epicondylectomy for cubital tunnel syndrome: preliminary results.
        Arch Orthop Trauma Surg. 2012; 132: 1569-1575
        • Kim K.W.
        • Lee H.J.
        • Rhee S.H.
        • Baek G.H.
        Minimal epicondylectomy improves neurologic deficits in moderate to severe cubital tunnel syndrome.
        Clin Orthop Relat Res. 2012; 470: 1405-1413
        • Zarezadeh A.
        • Shemshaki H.
        • Nourbakhsh M.
        • Etemadifar M.R.
        • Moeini M.
        • Mazoochian F.
        Comparison of anterior subcutaneous and submuscular transposition of ulnar nerve in treatment of cubital tunnel syndrome: A prospective randomized trial.
        J Res Med Sci. 2012; 17: 745-749
        • Bacle G.
        • Marteau E.
        • Freslon M.
        • Desmoineaux P.
        • Saint-Cast Y.
        • Lancigu R.
        • et al.
        Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months.
        Orthop Traumatol Surg Res. 2014; 100: S205-S208
        • Dützmann S.
        • Martin K.D.
        • Sobottka S.
        • Marquardt G.
        • Schackert G.
        • Seifert V.
        • et al.
        Open vs retractor-endoscopic in situ decompression of the ulnar nerve in cubital tunnel syndrome: a retrospective cohort study.
        Neurosurgery. 2013; 72: 605-616
        • Song J.W.
        • Waljee J.F.
        • Burns P.B.
        • Chung K.C.
        • Gaston R.G.
        • Haase S.C.
        • et al.
        An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group.
        Neurosurgery. 2013; 72: 971-981
        • Watanabe M.
        • Arita S.
        • Hashizume H.
        • Honda M.
        • Nishida K.
        • Ozaki T.
        Multiple regression analysis for grading and prognosis of cubital tunnel syndrome: assessment of Akahori's classification.
        Acta Med Okayama. 2013; 67: 35-44
        • Zimmerman R.M.
        • Jupiter J.B.
        • González del Pino J.
        Minimum 6-year follow-up after ulnar nerve decompression and submuscular transposition for primary entrapment.
        J Hand Surg Am. 2013; 38: 2398-2404
        • Han H.H.
        • Kang H.W.
        • Lee J.Y.
        • Jung S.N.
        Fascia wrapping technique: a modified method for the treatment of cubital tunnel syndrome.
        Sci World J. 2014; 2014: 482702
        • Kamat A.S.
        • Jay S.M.
        • Correia J.A.
        • Woon K.
        Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis.
        Acta Neurochir. 2014; 156: 153-157
        • Harder K.
        • Lukschu S.
        • Dunda S.E.
        • Krapohl B.D.
        Results after simple decompression of the ulnar nerve in cubital tunnel syndrome.
        GMS Interdiscip Plast Reconstr Surg DGPW. 2015; 4: Doc19
        • Kang H.J.
        • Koh I.H.
        • Chun Y.M.
        • Oh W.T.
        • Chung K.H.
        • Choi Y.R.
        Ulnar nerve stability-based surgery for cubital tunnel syndrome via a small incision: a comparison with classic anterior nerve transposition.
        J Orthop Surg Res. 2015; 10: 121
        • Lancigu R.
        • Saint Cast Y.
        • Raimbeau G.
        • Rabarin F.
        Dellon's anterior submuscular transposition of the ulnar nerve: retrospective study of 82 operated patients with 11.5 years' follow-up.
        Chir Main. 2015; 34: 234-239
        • Gaspar M.P.
        • Jacoby S.M.
        • Osterman A.L.
        • Kane P.M.
        Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome.
        J Shoulder Elbow Surg. 2016; 25: 681-687
        • Caputo A.E.
        • Watson H.K.
        Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome.
        J Hand Surg Am. 2000; 25: 544-551
        • Li M.X.
        • He K.
        • Hu Z.L.
        • Chen S.H.
        • Lv Y.C.
        • Liu Z.H.
        • et al.
        Applied anatomical study of the vascularized ulnar nerve and its blood supply for cubital tunnel syndrome at the elbow region.
        Neural Regen Res. 2015; 10: 141-145