Anterior intramuscular transposition of the ulnar nerve for cubital tunnel syndrome
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Keywords:
Cubital tunnel
Ulnar Neuropathy
Little finger
Entrapment neuropathy of the ulnar nerve at the elbow (cubital tunnel syndrome) has been recognized for over 100 years. Conservative treatment may not relieve symptoms associated with this neuropathy. Several techniques have been described for the surgical treatment of cubital tunnel syndrome. This article, describes the anterior intramuscular interposition of the ulnar nerve for the surgical treatment of cubital tunnel syndrome.
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To evaluate the ultrasonographic findings obtained following various degrees of elbow flexion in patients with cubital tunnel syndrome (CuTS).Retrospective, cross-sectional study.General teaching hospital, rehabilitation unit.Electrophysiological and ultrasonographic assessments were performed on 11 elbows of healthy controls and 21 elbows of 17 patients with CuTS.Dynamic movement of the ulnar nerve during elbow motion was measured. To measure ulnar nerve dynamic movement during elbow motion, the distance from the medial epicondyle (ME) to the nearest surface of the ulnar nerve toward the ME was measured at the cubital tunnel inlet at elbow extension (0°), elbow flexion to 60°, and elbow flexion to 90°.The distance between the ME and ulnar nerve was lower in CuTS patients than in healthy patients at all elbow flexion angles. This difference was statistically significant at 0° and 60° elbow flexion (P < 0.05). When calculating the cutoff value, the distance between the ME and ulnar nerve at full elbow extension for CuTS diagnosis was 0.53 cm (sensitivity = 71.4%, specificity = 90.7%). The distance ratio between the ME and ulnar nerve for diagnosis of ulnar neuropathy at the elbow was 24.4% (sensitivity = 76.2%, specificity = 100%).Measurement of the distance between the ME and ulnar nerve in full elbow extension may facilitate the diagnosis of patients with CuTS. These findings may be important for CuTS diagnosis, as they were also observed in patients with mild-stage CuTS.
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Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome.It is the most common peripheral neuropathy of the ulnar nerve.The surgical treatment of the cubital tunnel syndrome is widely described in the literature, however the variations of the standard muscular anatomy in the medial humeral epicondyle region may create technical difficulties during surgical management.The epitrochleoanconeus muscle, which is an aberrant muscle of this region, is a rare cause of cubital tunnel syndrome.A case with ulnar nerve compression at the elbow caused by an uncommon etiological factor, hypertrophic epitrochleoanconeus muscle, and its surgical management is reported.
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To the Editor: We appreciate the kind words and insightful commentary from Professor Coraci and colleagues1 regarding our recent manuscript on the incidence of cubital tunnel syndrome (CTS) among US health plan enrollees.2 As noted, one of the limits of this study is the possible bias of misclassification since our data were drawn from a national database, which relies upon correct International Classification of Diseases–9th edition (ICD-9) coding of CTS. The code 354.2 indicates any type of ulnar neuropathy, which could include compression at Guyon's Canal or elsewhere, likely leading to an overestimation of the incidence of CTS. We proposed several ways to achieve a more accurate incidence of CTS through further clinical information or diagnostic studies, specifically, history, physical examination, and electromyelography (EMG). EMG of the ulnar nerve can be technically challenging, but is a useful modality for delineating etiologies of ulnar nerve neuropathy.3 However, further clinical and diagnostic tools to better discover the true incidence of CTS are still needed. Coraci et al1 nicely demonstrate the diagnostic utility of ultrasound (US) with an illustrative case of a patient with paresthesias of the fourth and fifth digit. US clearly demonstrated enlargement of the ulnar nerve at the elbow, along with significant dislocation upon flexion, delineating the anatomic cause of this otherwise nonspecific ulnar neuropathy. Their point is well taken, US represents a noninvasive, cost-effective, relatively sensitive way to help identify structural causes of ulnar neuropathy.4 Furthermore, US allows for dynamic evaluation of the ulnar nerve, and anatomic insights that can be used to assist with surgical planning. While US does require operator experience as well as image interpretation, both of which necessitate training, we agree with Professor Coraci; it is certainly a useful modality for helping diagnose CTS. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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Compression neuropathy of the ulnar nerve at the elbow is well-recognised as cubital tunnel syndrome (CuTS). Many causes of ulnar neuropathy at the elbow have been identified. A previously unreported finding of ulnar nerve compression in the cubital tunnel caused by a thrombosed proximal ulnar recurrent artery vena comitans is described.
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Ulnar neuropathy at the elbow (UNE) is the second most frequent peripheral nerve entrapment neuropathy in the upper extremity. The diagnosis is determined through a combination of history, physical examination, and electrodiagnostic testing. However, the use of high-resolution sonography is increasing, with sonographic measurements of ulnar nerve dimension established as a reliable diagnostic criterion for UNE. Sonographic imaging can describe anatomical features beyond ulnar nerve size, and therefore additional observations could potentially be used in UNE diagnosis and treatment follow-up. This review was a scoping of the literature on different sonographic measurements and assessments that have been reported to evaluate the ulnar nerve and cubital tunnel. This should provide a guide to scanning protocols for sonographers.
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Abstract Background Various surgical options are used for the treatment of ulnar nerve entrapment at the elbow. In this study, anterior trans-muscular transposition of the ulnar nerve was used for the treatment of cubital tunnel syndrome. Objectives To evaluate the surgical results of anterior trans-muscular transposition technique for the treatment of cubital tunnel syndrome with particular emphasis on clinical outcome. Methods Forty patients with cubital tunnel syndrome were operated using anterior trans-muscular transposition technique. Patients were classified into post-operative clinical outcome grades according to the Wilson & Krout criteria, and they were followed up by visual analog scale (VAS), the Disability of Arm Shoulder and Hand (DASH) questionnaire, electrophysiological study, and post-operative clinical evaluation. Results Forty patients with cubital tunnel syndrome who underwent anterior trans-muscular transposition of the ulnar nerve show a significant clinical improvement at 24 months post-surgery regarding visual analog scale (VAS), the Disability of Arm Shoulder and Hand (DASH) questionnaire, electrophysiological study, and the Wilson & Krout grading as 87.5% of the patients recorded excellent and good outcome. Conclusion Anterior transmuscular transposition of the ulnar nerve is a safe and effective treatment for ulnar nerve entrapment at the elbow.
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Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity and the most common point of compression for the ulnar nerve. We present a case of ulnar nerve compression neuropathy at the elbow secondary to an abnormal subluxating medial head of triceps. A 37-year-old right hand dominant male presented with a history of bilateral medial elbow pain and ulnar distribution hand numbness. During his left cubital tunnel release surgery, the abnormal anatomy was noted. Initial subfascial anterior transposition was insufficient and had to be revised to a subcutaneous transposition intraoperatively. Failure to recognize the contribution of triceps abnormalities can lead to incomplete resolution following surgery. Surgeons should be wary of uncommon findings and adjust their approach appropriately.
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Background
Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper limb following carpal tunnel syndrome and is the most common site for entrapment for the ulnar nerveObjectives
Our aim is to evaluate the role of ultrasonography (US) as a diagnostic tool for Cubital tunnel syndrome (CuTS) in comparison with nerve conduction study (NCS). Methods: twenty elbows with CuTS and twenty asymptomatic controls were assessed by NCS and underwent ultrasonography of elbows. Data from patients and controls were compared to determine the diagnostic relations in patients with CuTS and the grade of severityResults
There was a high degree of correlation between NCS of the ulnar nerve, clinical parameters and variable US measurements. The CSA of the ulnar nerve was the most sensitive parameter and a cut-off point of 9.5 mm2 behind medial epicondyle was found to be 100% sensitive and 80% specific. The ulnar nerve ratios (UNR) had a diagnostic accuracy of 95% with 85% specificity.Conclusion
Ultrasonographic measurements of the ulnar nerve CSA and UNR have a comparable diagnostic value as a non-invasive and an alternative modality for the evaluation of CuTSReferences
[1] Simon N, Ralph J, Poncelet A, Engstrom J, Chin C, Kliot M. A comparison of ultrasonographic and electrophysiologic inchingin ulnar neuropathy at the elbow. Clin Neurophysiol. 2015;126(2):391-398. [2] Omejec G, Podnar S. Normative values for short-segment nerve conduction studies and ultrasonography of the ulnar nerve at the elbow. Muscle nerve. 2015;51(3):370-377. [3] Yoon J, Walker F, Cartwright M. Ultrasonographic swelling ratio in the diagnosis of ulnar neuropathy at the elbow. Muscle nerve. 2008;38(4):1231-1235. [4] Bayrak A, Bayrak I, Turker H, Elmali M, Nural M. Ultrasonography in patients with ulnar neuropathy at the elbow: Comparison of cross-sectional area and swelling ratio with electrophysiological severity. Muscle nerve. 2010;41(5):661-666.Disclosure of Interests
None declaredCubital tunnel
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Cubital tunnel
Entrapment Neuropathy
Ulnar Neuropathy
Conservative Management
Elbow pain
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