Cubital Tunnel Syndrome

DESCRIPTION

The operation of the muscles and the feeling of our hands are provided by three different nerves. Respectively, these are radial, unlar and median nerves. There are some areas sensitive to pressure (compression) through the lines of each nevre. Ulnar mnerve is generally subject to the pressure (compression) increasing on the medial side of the elbow joint. The relevant findings are called cubital tunnel syndrome.

Cubital tunnel syndrome is commonly seen and the reason to occur (ethiology) is not known. Around the elbow joint, there are tunnel-like structures through which the unlar nevre passes (figure 1). The base of the tunnel is composed of the bones called humerus and ulna which are forming the elbow joint. The roof of the tunnel is composed of a sheth-like structure called Osborne’s Ligament (figure 2). This sheath is the extension of a muscle called Flexor Carpi Ulnaris. While the unlar nevre progresses through the arm, it passes through this tunnel of the elbow joint (figure 3). The increase of the pressure inside the tunnel or the pressure of some formations around the tunnel to the tunnel causes the compression and dysfunction of the ulnar nevre.

 

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(Figure 1)
(Figure 2)
(Figure 3)

 

Pressure making formation around the tunnel (academical information):

1-Struthers belt: A structure 8 cm to the elbow joint, can make pressure to the ulnar nerve.

2-Medial head of the muscle called triceps can make pressure to the ulnar nerve.

3-Medial intermuscularseptum: The ligament between two muscles enabling the movement on the elbow joint can make pressure to the ulnar nerve.

4-Medial epicondyle osteophytes: The osteophytes forming around the elbow joint can make pressure to the ulnar nerve.

5-Cubital tunnel (also known as FCU aponeurosis, OSBORNE’s ligament): Mentioned above.

6-Ankoneus epitroklearis: a small muscle observed arund the elbow joint. It is seen at 10% and can make pressure to the ulnar nerve.

7-Arcuate ligament: A kind of sheath (aponeurosis) around the muscle called flexorcarpiulnaris.

8-Deep flexor-pronatoraponeurosis: 4 cm away from the elbow joint.

During the surgery, the existence of all the aforementioned structures that can make pressure should be examined (figure 1, 2, 3).

 

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(Figure 1)
(Figure 2)
(Figure 3)

 

WHAT IS THE CAUSE?

Cubital tunnel syndrome is commonly seen. In most of the cases, the exact reason is not known. In such cases, the main pathology is the pressure or the compressure of the aforementioned anatomic structes on the nerve through the line it extends. This condition is called idiopathic cubital tunnel syndrome.

In some cases, the nerve is under the pressure or the compression of one or more than one of these anatomic structures through the line it extends; however this pressure is not too much to cause a cubital tunnel syndrome in a normal person. In these patients, there are some infrastructre disorders causing the nerve tissue to give early findings or extreme sensitivity. Diabetes or tryoid gland diseases are among the examples. Thus, cubital tunnel like findgs may the first findings of some endocrine diseases like diabetes. It is also been found out that obesity and alcohol use also cause the extreme sensitivity of the nerve tissue. No connection is detected between the tobacco use.

In some cases, it is seen that the thickness of the ligaments passing above the nerve is normal but the ulnar nerve is compressed due to the extreme crowd within the tunnel (volume decrease). Misunioned fractures regarding the elbow joint, osteoarthritis can be given as example. Likewise, in the rheumatoid arthritis disease, abnormal increase (tenosynovitis) is observed on the tissue surrounding the ulnar nerve in the tunnel; this condition causes the crowd in the tunnel and pressure of the ulnar nerve.

The hormonal changes occuring in the pregnancy and breast-feeding period, edema and volme increase may cause cubital tunnel syndrome. This condition is generally temporary.

HOW TO DIAGNOSE?

The diagnose of this disease is CLINICALLY establihed upon the detailed history and examination by your doctor. All the examination methods are performed to support the diagnosis and not to pass any additional pathologies.

The clinical findings observed in the cubital tunnel syndrome change in accordance with the stage of the disease. The amount and term of the pressure on the nerves and the infrastructure disorders of the nerve tissue have effect on the determination of the clinical table. In some cases, genetic tendency is also suspected to have effect on the occurence of the nerve findings due to the pressure (pressure neuropathy).

The tissue changes observed in the chronic nerve pressure progress as in the following stages (academic information):

1-Disturbance of the blood-nerve barrier: The contamination of the liquid in the blood to the nerve tissue in an uncontrolled way.

2-Endoneural edema: Accumulation of the liquid in the nerve tissue and its pressure.

3-Perineural thicknening: the thickhening of the sheath covering the nerve as a result of the pressure.

4-Increased endoneural pressure: Interruption of the intra-nerve blood stream (changes in the microneural circulation).

5-Dynamic ischemia: Complete stop of the blood stream in some position of the elbow joint.

6-Locaized demyelination: Innutrition of the exterior sheath of the nerve due to the interruption of the blood stream. It can be considered as stripping of the exterior plastic of an electric cable and reveal of the copper wires (figure 12).

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(Figure 12)

7-Diffuse demyelination: Complete elimination of the plastic surrounding the copper wires through the cable.

8-Axonal degeneration: Death of the real nerve cables providing the conduction within the sheath (rupture of the copper wires)

The clinical findings observed in the cubital tunnel syndrome may change in accordance with the pathological stage of the disease.

The clinical findings of the cubital tunnel syndrome can be summarized as follows:

Pain: Pain and sensitivity on the fore arm can be observed. The pressure by the finger upon the beding of the elbow may cause to the pain.

Sensation disorder findings: Electrification and prickling feeling extending to the fourth and fifth finger through the line the nerve passes. This finding is called as tunnel syndrome.

Moreover, prickling and numbness increasing especially during the nights can be observed on the same fingers. The reason for this is to sleep as our elbow joint bent. The bent elbow joint causes to the increase of the findings and pressure on the ulnar nerve. Sensation disorder findings always occur before and more severe than the loss of strenght (motor) findings.

Many devices and methods have been defined for sensation evaluation. Most commonly Semmes-WeinsteinMonoflamentleri is used. These are nylons in different diameters. The nylon is tounched to the skin and pressure is applied until it is bent. The thinnest nylon that is felt by the patient is the pressure thereshold. Different results of the same test performed in different times in a normal person makes the test suspicious.

Two point discrimintation: One single feeling of the different wire tips touched to the fingers of the patient. Two point discrimination test is only disturbed in the advanced stages of the disease.

Motor examination findingsMotor examination findings are observed in the advanced stages of the disease with the decrease in the strenght of the muscles affected. The motor examination findings can be summarized as follows (academic information):

In accordance with the interior anatomy of the ulnar nerve, the nerve limbs and the the limbs exteding to the intrinsic muscles are close the the exterio side of the nerve. So, first these limbs are effected by the pressure occurence.

1- After the decrease in the strenght of the intrinsic muscles, fine movements gets less strenghtful. In the advanced stages, strophy gets more clear in the muscles (figure 4).

Figure 4. Atrophy in the intrinsic muscles.

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(Figure 5)

5-Wartenberg bulgusu: Küçük parmağın kapanamaması (Figure 6).

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(Figure 6)

6- Froment bulgusu: Kas gücü kaybına bağlı olarak yan kavramada başparmağın lateral kenarı yerine parmak ucu kullanılır (Figure 5).

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(Figure 5)

In the diagnosing stage, detailed medical history of the patient is highly important. Even rarely, cubital tunnel syndrome may be the first finding of some endocrine and rheumatismal  diseases. In this case, the required laboratory tests should be made. Chest x-ray may be required for the smokers. The first findings may be cubital tunnel like ulnar nerve findings of the lung tumors in the apex. Direct radiography may be required in some arthritis like diseases regarding the elbow joint. In order to verify the diagnosis, generally a test called electromyography is performed. In this test, the speed and health of the nerve conduction and other probable nerve compressions can be observed. Compression may be observed on more than one area through the same nerve line (doublecrush, Lancet 1973). For example, ulnar nerve can be compressed on both the wrist and the neck. The test can be performed by a neurologist or physical therapist. In the patients diagnosed with doublecrush, the second area is general the cervical vertebra. In these cases, MRI (magnetic resonance examination) of the cervical vertebra should be taken. The compression on the cervical vertebra is generally called as cervical discal hernia.

WHAT IS THE TREATMENT?

In the early stages of the diseases, the precautions are taken to prevent the increase of the pressure around the ulnar nerve. The elbow splint to be used during the nights enables the elbow joint to be open and prevents the increase of the pressure by preventing the bending of the elbow. The patients diagnosed with medical diseases (diabetes, rheumatism  etc.) should be first treated by the specialist. Vitamin B componds and NSAI medication administrations are the other parts of the treatment. With all these administrations, the surgery can be prevented or delayed in half of the patients. These precautions are generally sufficient in the early stages.

For the patients with unsuccessful results, surgery is the only option. During the surgery, the existence of all the aforementioned anatomic structures that might make pressure on the nerve tissue should be examined and released by carefully preserving (figure 7, 8, 9). After this step, there are three option for the surgeon.

 

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(Figure 7)
(Figure 8)
(Figure 9)

 

1-Sinir olduğu yerde bırakılabilir (in-situ dekompresyon) (Figure 10).

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(Figure 10)

 

2-The nerve can be transferred to the fore side of the elbow. Since this intervention will shorten the distance that the nerve passes through, it will decrease the stretch on the nerve tissue (figure 11). After the transfer to the fore side, the nerve can either be preserved by keeping under the fat tissue (subcutaneous transposition) or embedded inside the muscle tissue (submuscular transposition).

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(Figure 11)

3-The bone surrounding the nerve tissue can be removed and the nerve can be released (medialepi condylectomy).

There are several medical issues describing the advantages and disadvantages of the three methods. As a personal algorithm, I prefer in-situ decompression in the early stage cases and subcutaneous transposition in the advance stage cases. In the conditions when the anatomy of the elbow changes in advanced stages (after fracture, elbow stiffness etc.) I prefer submusculartransposition (figure 15 and 16). I do not prefer medialepicondylectomy as I do not consider it as a surgical intervention against the pathology.

 

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(Figure 15)
(Figure 16)

 

WHAT IS THE PROGRESS OF THE SURGICAL TREATMENT, WHAT IS AHEAD OF US?

Orthopedician or Hand Surgeon examination is very important. The surgery is mostly performed with daycase hospitalization. There is no need for general anesthesia. Applying local (axillary block or RIVA) is generally sufficient. It is very important for you to mention about your special conditions (chronic diseases, regularly taken medication) during your consultation with the hand surgeon. Cold application and keeping the hand above the heart level in the postop early period (the first 3 days) will relieve the pain and throbbing. The bandage is generally opened within 5th-7th days  and the wound is controlled. If there is no complication, you can take shower. Physical therapy and rehabilitation is rarely nweed at the end of this period. Even though the process changes in accordance with the surgery periormed and the condition  of your wrist, it is expected to get back to normal life within 6 weeks.

PROBABLE COMPLICATIONS

The most important complication is the non-recovery of the complaints or even rarely worsening of the patients after the surgery. It is very important that the surgery is performed under microscope. In case the nerve gets damaged, a long and troubled period starts.

During the surgery, the existence of all the aforementioned anatomic structures that might make pressure on the nerve tissue should be examined and released by carefully preserving. Another probable complication is the insufficient opening of the ligament. In this case, the surgery should be repeated (figure 13 and 12). The other copmplications are limitation of finger movements due to the tissue adhesion in the surgical wound area, chronic pain (RSD) and receiving late or never receiving the expected results.

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(Figure 13)
(Figure 14)

 

IMPORTANT NOTICE

Even rarely observed, the elimination of the below given diseases is highly important for each patient having numbness, prickling, sensation disorder and loss of strength. Thoracic outlet syndrome is observed approximately in 30% and carptal tunnel syndrome is observed in 40% of the patients diagnosed with cubital tunnel.

1-Diabetes

2-Thyrodi gland function disorders

3-Alcohol abuse

4-Genetic motor-sensation neuropathies:

a)Charcot-Marie Tooth

b)HNPP (hereditaryneuropathywithliabilitytopressurepalsies)

5- Upper motor neuron diseases

6-Peripheral neuropathy (Guillain-Barre disease)

7-Cervical discal diseases (cervical discal hernia)

8- Thoracic outlet syndrome

9-Amilotrophic lateral sclerosis (ALS): It should be taken into consideration if the loos of strength (motor findings) is more advanced than sensorial findings.