The Management of Cubital Tunnel Syndrome

doi:10.1016/j.jhsa.2015.03.011

The Journal of Hand Surgery

Volume 40, Issue 9, September 2015, Pages 1897-1904

https://doi.org/10.1016/j.jhsa.2015.03.011 Get rights and content

Symptomatic cubital tunnel syndrome is a condition that frequently prompts patients to seek hand surgical care. Although cubital tunnel syndrome is readily diagnosed, achieving complete symptom resolution remains challenging. This article reviews related anatomy, clinical presentation, and current management options for cubital tunnel syndrome with an emphasis on contemporary outcomes research.

Section snippets

Anatomy

The arcuate Osborne’s ligament, which extends between the medial epicondyle and humeral head of the flexor carpi ulnaris to the olecranon and the ulnar head of the flexor carpi ulnaris muscle, forms the roof of the cubital tunnel; the medial collateral ligament, elbow joint capsule, and olecranon form the floor.⁶ Although the ulnar nerve can be compressed by the arcade of Struthers proximally, medial epicondyle, and deep flexor pronator aponeurosis distally,6, 7 the most common site of

Clinical Presentation and Diagnosis

Diagnosis of cubital tunnel syndrome is made through a combination of history, physical examination, and confirmatory nerve conduction testing. Paresthesia is anticipated in the little finger and ulnar half of the ring finger. Sensory disturbance on the dorsal ulnar hand confirms compression proximal to the Guyon canal based on the origin of the dorsal cutaneous branch of the ulnar nerve in the distal forearm.¹³ Weakness of the interossei, the adductor pollicis, and the ulnar lumbrical muscles,

Nonsurgical Treatment

A trial of nonsurgical management is recommended for all patients with mild and moderate cubital tunnel syndrome. In a review of over 50 published series, 58% of patients with mild cubital tunnel symptoms reported relief of paresthesia with nonsurgical management.¹⁶ Four commonly prescribed nonsurgical measures include discontinuing triceps strengthening exercises, avoiding applying direct pressure to the medial aspect of the elbow on firm surfaces, maintaining a resting elbow position of 45°

Operative Treatment

The 3 most commonly employed operative approaches to cubital tunnel syndrome are simple decompression, medial epicondylectomy, and anterior transposition (subcutaneous, intramuscular, and submuscular). Each of these procedures has been found to produce satisfactory clinical outcomes.

Revision Cubital Tunnel Surgery

Surgical treatment of cubital tunnel syndrome has been unable to duplicate the success rate of carpal tunnel release. A canine model demonstrated consistent intraneural changes within the subcutaneously transposed ulnar nerve and extraneural scarring around it, which may explain the imperfect outcomes in previously reported surgical series.⁴⁴ When cubital tunnel surgery fails, anterior submuscular transposition is the most commonly recommended technique for revision surgery.45, 46 Before

Posttraumatic Cubital Tunnel Syndrome

Posttraumatic cubital tunnel symptoms can result from elbow fractures and dislocations. Shin and Ring⁴⁹ suggested that posttraumatic cubital tunnel symptoms are less responsive to nonsurgical measures than are symptoms associated with nontraumatic nerve compression. In a series reporting on patients with posttraumatic versus nontraumatic cubital tunnel syndrome, there was a higher incidence of complete symptom resolution in the nontraumatic group.⁵⁰ In another case-control series, prior elbow

Ulnar Nerve Hypermobility

Ulnar nerve hypermobility has been noted in over one third of the adult population. The presence of nerve perching or subluxation has not been associated with a higher prevalence of cubital tunnel syndrome, however.¹⁴ Most surgeons recommend transposition or epicondylectomy when a hypermobile nerve is present Few studies have examined the outcome of decompression alone in cases in which there has been a hypermobile ulnar nerve. Nerve stability has not clearly influenced surgical outcomes in

Pediatric Cubital Tunnel Syndrome

Cubital tunnel syndrome is rare in pediatric and adolescent patients, although it is more frequently encountered in dominant arms of young throwing athletes. In a retrospective investigation in children and adolescents, nonsurgical management completely relieved symptoms in only 44% of 39 patients.⁵¹ Twenty-three percent of simple decompression procedures required revision.⁵¹ The authors suggested that nonsurgical management remains a reasonable initial step even if it is frequently

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Cited by (71)

Anterior transposition and positioning via helix sling method in cubital tunnel syndrome: An open-label, retrospective trial of maximum 5-year follow-up
2024, Heliyon
Ulnar nerve transposition is used for cubital tunnel syndrome (CuTS) with nerve instability. The aim is to report a modified technique for ulnar nerve transposition using medial intermuscular septum and Osborne's ligament as a double-strand helix sling to recreate a sliding channel for the ulnar nerve and the functional outcomes at follow-ups.
Twenty-five patients with persistent CuTS underwent nerve release and subcutaneous transposition from January 2017 to January 2022 in our institute. Among them, 9 patients were excluded due to incomplete medical records, lack of follow-up history, or bilateral limb numbness. The medial intermuscular septum with one end attached was excised to rebuild a tension-free double-strand helix sling by anchoring at the residue of Osborne's ligament. The modified Mc-Gowan classification was applied to evaluate the disease severity preoperatively. The quick disability of arm and shoulder and hand (quickDASH) questionnaire and visual analogue scale (VAS) scores were used to evaluate pre- and postoperative symptoms. Ultrasound imaging was utilized for nerve structure evaluation before surgery and at follow-ups.
Sixteen out of twenty-five patients received follow-ups postoperatively (ranging from 9 to 69 months, 36 months in average). No findings indicated subluxation of ulnar nerve or recompression by ultrasound imaging examination. According to quickDASH and VAS scores and physical examination, 14 out of 16 patients showed postoperative improvement in symptoms and function at final follow-ups.
In this modified technique, the medial intermuscular septum and Osborne's ligament can create tension-free helix sling for stable and smooth sliding and preventing subluxation after nerve transposition, which is highly effective and safe for CuTS treatment.
Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy
2023, Journal of Hand Surgery Global Online
Citation Excerpt :
Furthermore, a prospective randomized study reported superior outcomes and patient satisfaction following medial epicondylectomy compared with transposition.100 Current indications for medial epicondylectomy include patients with hypermobile nerves, pre-existing vascular disease where transposition could potentially worsen ischemia, and thin patients.1,76 A 13% revision rate has been reported in the literature with younger age, associated workers’ compensation claims, mild disease, and preoperative narcotic use being identified as risk factors for reoperation.101
Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient’s history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.
Wound Dehiscence Following Cubital Tunnel Surgery
2023, Journal of Hand Surgery
Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described.
Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence.
The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2–57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12–32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence.
Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention.
Therapeutic IV.
A complete analysis of the surgical treatment for cubital tunnel syndrome: an umbrella review
2023, Journal of Shoulder and Elbow Surgery
Numerous original studies have been presented regarding various surgical treatments for cubital tunnel syndrome (CubTS). The results of these analyses regarding the different surgical treatments for CubTS frequently differ and, in some cases, contradict each other, creating confusion. Therefore, our umbrella review aimed to summarize the evidence from meta-analyses and systematic reviews regarding the surgical treatments of CubTS, and along with the new, more detailed outcomes, provide an evidence-based tool for surgeons performing these procedures.
To perform this umbrella review, a systematic search was conducted for meta-analyses investigating CubTS in PubMed, Scopus, Embase, Web of Science, Google Scholar, Cochrane Library, BIOSIS, and EBSCO medical databases.
Detailed comparison of surgical outcomes, such as clinical improvement, complications, or reoperation rates, of different treatment methods for CubTS was performed. New risk ratios in all categories were established based on all of the primary studies available in the literature.
The goal of the present umbrella review was to gather and summarize all data about the surgical treatments for CubTS in the available literature and provide new outcomes and an evidence-based tool for surgeons performing these procedures. Each comparison of the surgical techniques has been discussed, and the present study’s results were compared with the outcomes of the previous studies.
Magnetoneurography as a novel functional imaging technique for the ulnar nerve at the elbow
2022, Clinical Neurophysiology
To visualize the neural activity of the ulnar nerve at the elbow using magnetoneurography (MNG).
Subjects were asymptomatic volunteers (eight men and one woman; age, 26–53 years) and a male patient with cubital tunnel syndrome (age, 54 years). The ulnar nerve was electrically stimulated at the left wrist and evoked magnetic fields were recorded by a 132-channel biomagnetometer system with a superconducting quantum interference device at the elbow. Evoked potentials were also recorded and their correspondence to the evoked magnetic fields was evaluated in healthy participants.
Evoked magnetic fields were successfully recorded by MNG, and computationally reconstructed currents were able to visualize the neural activity of the ulnar nerve at the elbow. In the affected arm of the patient, reconstructed intra-axonal and inflow currents attenuated and decelerated around the elbow. Latencies of reconstructed currents and evoked potentials were correspondent within an error of 0.4 ms in asymptomatic participants.
Neural activity in the ulnar nerve can be visualized by MNG, which may be a novel functional imaging technique for ulnar neuropathy at the elbow, including cubital tunnel syndrome.
MNG permits visualization of evoked currents in the ulnar nerve at the cubital tunnel.
Angiosomes of the Ulnar Nerve at the Elbow: A Cadaver Trial Using Contrast-Enhanced Ultrasound
2021, Ultrasound in Medicine and Biology
Three major arteries supplying the ulnar nerve in the cubital tunnel are commonly known. However, their vascular territories (angiosomes) have not been described yet. Contrast-enhanced ultrasound was used to identify the angiosomes of posterior ulnar recurrent artery, inferior ulnar collateral artery and superior ulnar collateral artery in 20 fresh, non-frozen human body donors. The arteries were cannulated, and physiologic blood flow was simulated. Contrast agent was applied in each vessel in a randomized sequence, and the length of the contrast-enhancing ulnar nerve segment was measured by a radiologist blinded to the sequence. The angiosome of the posterior ulnar recurrent artery overlaps both other angiosomes. It fully covers the cubital tunnel in 63.6% of specimens. In addition, collateral flow via nerve and muscle branches of the arterial anastomotic network around the elbow (rete articulare cubiti) partly maintains the intra-neural blood flow in the absence of a vascular pedicle. The posterior ulnar recurrent artery is the dominant nutrient vessel of the ulnar nerve in the cubital tunnel. A potential watershed zone exists proximal to the Osborne ligament. Knowledge of these angiosomes may advance surgery of the ulnar nerve in the cubital tunnel.

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Current conceptsThe Management of Cubital Tunnel Syndrome

Section snippets

Anatomy

Clinical Presentation and Diagnosis

Nonsurgical Treatment

Operative Treatment

Revision Cubital Tunnel Surgery

Posttraumatic Cubital Tunnel Syndrome

Ulnar Nerve Hypermobility

Pediatric Cubital Tunnel Syndrome

J Neurol Sci

J Hand Surg Am

Ann Chir Main Memb Super

J Hand Surg Am

J Hand Surg Am

J Hand Surg Br

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Shoulder Elbow Surg

J Hand Surg Am

J Hand Surg Eur Vol

J Hand Surg Am

Orthop Clin North Am

J Hand Surg Am

J Hand Surg Am

Cubital tunnel syndrome—a review and management guidelines

Cent Eur Neurosurg

Surgical management of ulnar nerve compression at the elbow: an analysis of the literature

J Neurosurg

Entrapment neuropathy of the ulnar nerve

J Am Acad Orthop Surg

Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow: an experimental study in human cadavera

J Bone Joint Surg Am

Current concepts
The Management of Cubital Tunnel Syndrome