Page 36 - Read Online

Topic: Peripheral Nerve Repair and Regeneration

Recalcitrant cubital tunnel syndrome

Adolfo Vigasio, Ignazio Marcoccio, Eleonora Morandini

Hand Surgery and Orthopaedic Microsurgery Unit, Istituto Clinico Città di Brescia‑Gruppo San Donato, 25123 Brescia, Italy.
Address for correspondence: Dr. Ignazio Marcoccio, Hand Surgery and Orthopaedic Microsurgery Unit, Istituto Clinico Città di
Brescia-Gruppo San Donato, 25123 Brescia, Italy. E-mail: info@ignaziomarcoccio.it

ABSTRACT
Ulnar nerve neuropathy at the elbow represents the second most frequent compression neuropathy
of the upper extremity. Of the five different anatomical areas responsible for ulnar nerve compression
at the elbow region, the epitrochlear-olecranon channel and Osborne’s arcade are the most common.
An additional cause of nerve damage is a dynamic process in which the ulnar nerve dislocates
anteriorly at the epitrochlear-olecranon level during elbow flexion, partially or completely, causing
nerve friction and constriction leading to chronic neuropathic pain. Failure after primary surgery is
generally secondary to procedural errors or technical omissions, frequently represented by incomplete
nerve decompression, failure to recognize nerve instability after nerve decompression, loosening of
the nerve anchor after superficial nerve transposition with consequent spontaneous nerve relocation
in the epitrochlear-olecranon channel, perineural fibrosis and neurodesis, which creates new nerve
compression. In association with the clinical evaluation, electromyography studies, magnetic resonance
imaging and ultrasound are useful tools that may aid in the decision-making process when considering
revision surgery. Superficial anterior transposition is the most commonly employed technique but also
has a high failure rate, as opposed to anterior deep transposition that is the method of choice for many
surgeons despite being more technically demanding. The results of revision surgery following recalcitrant
ulnar nerve compression at the elbow are inferior to those obtained after primary surgery. Nonetheless,
the clinical advantages remain relevant provided that the revision surgery is performed by an expert
surgeon. To avoid misinterpretation, the patient is completely informed of the quality of results.

Key words:
Cubital tunnel syndrome, failed nerve decompression, nerve transposition, recalcitrant nerve
compression, ulnar nerve

INTRODUCTION known as Osborne’s arcade, and (5) the vertical fibrous
septum that originates from the ulna and separates
Ulnar nerve neuropathy at the elbow represents the second the ulnar nerve and the ulnar part of the FCU from
most frequent compression neuropathy of the upper the pronator‑flexor muscles innervated by the median
[1]
[3]
extremity. The ulnar nerve may be compressed at the nerve [Figure 1a and b]. The epitrochlear‑olecranon
[2]
elbow region in the following five different anatomical areas, channel and Osborne’s arcade or ligament are the most
listed from proximal to distal: (1) arcade of Struthers, (2) the frequent areas of compression. An additional cause of
proximal epitrochlear region, (3) the epitrochlear‑olecranon nerve damage at the epitrochlear‑olecranon level is
channel, (4) the fibrous arch between the humeral and nerve instability. This is a dynamic process in which the
ulnar portions of the flexor carpi ulnaris (FCU), better ulnar nerve dislocates anteriorly during elbow flexion,
reaching the epicondylar crest (subluxation) or passing
Access this article online over it completely (luxation). Ligamentous laxity or
Quick Response Code: the absence of stabilization mechanisms [4,5] causes a
Website: continuous snapping of the nerve over the epitrochlea,
www.parjournal.net
and in the case of complete anterior dislocation, the
nerve kinks at the Osborne arcade, causing nerve friction
[6]
DOI: and constriction leading to chronic neuropathic pain.
10.4103/2347-9264.160881 Various surgical procedures have been described for the
treatment of cubital tunnel syndrome, including in situ

176 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015