Cubital Tunnel Syndrome: A neuropathy of the ulnar nerve causing symptoms of numbness and shooting pain in the medial aspect of the forearm, also including the medial half of the fourth digit and the fifth digit, usually caused due compression or irritation of the nerve.
Ulnar Nerve anatomy: C8 and T1 nerve roots join and give rise to the medial cord in the brachial plexus. Ulnar nerve originates as a branch of medial cord. The ulnar nerve then travels down the arm along with the brachial artery towards the elbow joint, at which point it enters the posterior compartment of the forearm via the cubital tunnel. Cubital tunnel is the region where the ulnar nerve is most likely to be damaged due to its location and anatomy. At this point, the ulnar nerve travels between the olecranon and the medial epicondyle.
Multiple causes can result in ulnar nerve compression and damage at the cubital tunnel and cause symptoms such as tingling in the medial aspect of the forearm along with the little finger and medial aspect of the ring finger.
A study of 117 patients identified that direct pressure on the nerve because of habits while sitting, or secondary to occupational activities is a significant cause of the nerve damage as the nerve passes posterior to the medial epicondyle.
Ulnar nerve neuropathy is the second most common neuropathy of the arm. A study of 91 patients identified that close to 60% of these patients had anatomical changes in the cubital tunnel that caused the ulnar nerve neuropathy, of which nearly 20% of patients had a subluxation of the ulnar nerve. Other causes identified in this study were osteophytes in almost 7% of patients and luxation of the ulnar nerve in nearly 10% of patients. Post-traumatic lesions also can cause symptoms in about 3.3% of patients.
The presenting patient complaint is typically one of "pins and needles" in forearm/hand. On further questioning of the precise nature of the patient's complaint, the tingling sensation usually presents in the little finger and a half of the ring finger. These symptoms may be present transiently initially then gradually get worse.
There may be a weakness of the interosseous muscles on examination. The extent of muscle damage and sensory changes will depend on the damage caused to the nerve. In advanced disease, there may be a weakness of the handgrip.
Diagnosis can be made clinically, and nerve conduction studies are often used to confirm the diagnosis. In some patients, however, nerve conductions may be normal in the early stages of symptoms; therefore, interpretation of nerve conduction studies should always be in a clinical context.
X-ray of the elbow joint can be done to exclude bony pathologies such as osteophytes and minor fractures which may cause compression of the nerve.
Both ultrasonic scanning (USS) and magnetic resonance imaging (MRI) have sensitivity and specificity over 80% in diagnosis. MRI and USS are also helpful to identify other causes of compression, which may not be picked up on plain radiograph films such as soft tissue swelling and lesions such as neuroma, ganglions, aneurysms, etc.
Pathological findings should undergo careful evaluation when deciding on treatment options. Patients can often benefit from non-surgical interventions; therefore clinician should evaluate and determine an end goal with the patient for treatment before deciding on the route of treatment.
Surgical treatment: Patient's with severe symptoms might not improve with conservative management. After trying the non-surgical management, some patients may not recover and will require surgical intervention to improve their symptoms. Surgical management involves decompression of the nerve in the cubital tunnel. Some surgeons release the pressure in the cubital tunnel region while others prefer free mobilization of the ulnar nerve.
Various methods of surgical treatment have been discussed and performed. Some studies have suggested medial epicondylectomy as a method to decompress and release pressure from the ulnar nerve.
About half the patients achieve an improvement in their symptoms with conservative management.
Patient education about their symptoms and causes is of great importance, which is vital if the aim is to manage the patient with conservative means as a slow improvement of symptoms can put people off from conservative management.
If using non-steroidal anti-inflammatory medications, then education about the use of NSAIDs and gastric protection is a necessary discussion to have with patients. Gastric protection is obtainable by using proton pump inhibitors (PPIs). It is also suggested to take NSAIDs with or after food.
A multi-disciplinary team including a nurse, physical therapist, and clinician input can enhance recovery. Physiotherapy can provide significant help if muscle weakness is present. Discussion with the pharmacist can help patients to understand the use and side-effects of analgesic medications. The surgeon should discuss the surgical approach and the potential risks/benefits of the procedure. The nurse should assist in follow up care and monitoring for complications.
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