Management of Recalcitrant Cubital Tunnel Syndrome

Abstract

Cubital tunnel syndrome is a common upper extremity compressive neuropathy. Recalcitrant cubital tunnel syndrome poses diagnostic and treatment challenges. Potential etiologies of persistent or recurrent symptoms after surgical treatment include an inaccurate preoperative diagnosis, incomplete nerve decompression, iatrogenic injury, postsurgical perineural adhesions, irreversible nerve pathology, or conditions associated with secondary nerve compression. Confirmation of recalcitrant ulnar nerve pathology relies on a thorough history to consider symptoms and chronology, careful examination to quantify nerve function and to assess for focal nerve provocation, and objective testing to highlight a possible nerve lesion such as ultrasonography and electrodiagnostic testing. Conservative treatment may provide symptomatic relief; however, surgical management such as revision neuroplasty, neurolysis, nerve reconstruction, and/or anterior transposition may be indicated. Optimizing the biology of the local nerve environment is critical. No surgical treatment procedure has shown superiority over another; however, individualized treatment is emphasized to improve symptoms and maximize nerve recovery potential.

Cubital Tunnel Syndrome: Review of Diagnosis and Management

“…Originating from the medial cord of the brachial plexus (C7-T1), the ulnar nerve passes posterior to the pectoralis major muscle and medial to the brachial artery while descending within the anterior compartment of the upper arm 5 . Near the distal third of the upper arm, its course changes to the posterior compartment of the arm as it traverses the medial intermuscular septum 6 .…”

“…Following the cubital tunnel, the ulnar nerve travels to the anterior compartment of the forearm a few centimetres distal to the medial epicondyle 6 . It continues deep to the superficial flexorpronator aponeurosis (arcuate ligament) and the deep fascia of the humeral and ulnar heads of the flexor carpi ulnaris 5 . The two muscular heads of the flexor carpi ulnaris as well as the deep fascia of the flexor digitorum superficialis can be sources of external compression of the ulnar nerve 3 , 13 .…”

“…The proximal branching pattern of the ulnar nerve is variable. However, the first branch is often an articular branch for the ulnohumeral joint 5 , 6 . Following this, there are motor branches to the ulnar and humeral muscular head of the flexor carpi ulnaris, then branches to the ulnar half (4th and 5th digits) of the flexor digitorum profundus.…”

“…Other sources of external compression can include tumours 18 and ganglion 19 . Sources of internal compression include: the arcuate ligament, flexor carpi ulnaris, flexor digitorum superficialis, arcade of Struthers, cubital tunnel, anconeus epitrochlearis, and potentially the medial intermuscular septum following anterior transposition of the ulnar nerve 3 , 5 , 6 , 7 , 8 , 11 , 12 . Lastly, fractures, dislocations, ectopic bone, bone spurs, osteophytes, and other bony deformities such as cubitus varus and valgus can all lead to irritation of the ulnar nerve at the elbow.…”

“…The cubital tunnel is comprised of the medial epicondyle, the proximal olecranon, the medial collateral ligament, and Osborne's ligament. Its roof is formed by Osborne's ligament and its floor is formed by the posterior and oblique bands of the ulnar collateral ligament [5]. Osborne's ligament, otherwise known as the cubital tunnel retinaculum, is the most common site for ulnar nerve compression [3,11].…”