Volumetric assessment of ulnar nerves in cubital tunnel syndrome with 3D modeling of the MRI and its relationship with electrodiagnostic findings.

BACKGROUND: Thickened nerve cross-sectional areas (CSA) have been investigated in compressive neuropathy, but the longitudinal extent of nerve swelling has yet to be evaluated. We did a volumetric assessment of the ulnar nerve in cubital tunnel syndrome (CuTS) with three-dimensional (3D) magnetic resonance imaging (MRI) modeling and investigated this relationship with clinical and electrodiagnostic parameters. METHODS: We compared 40 CuTS patient elbow MRIs to 46 patient elbow MRIs with lateral elbow epicondylitis as controls. The ulnar nerve was modeled with Mimics software and was assessed qualitatively and quantitatively. The CSA and ulnar nerve volumes were recorded, and the area under the receiver operating characteristic (ROC) curve was calculated for diagnostic performance. We analyzed clinical and electrodiagnostic parameters to investigate their relationship with the 3D ulnar nerve parameters. RESULTS: For the diagnosis of CuTS, the area under the curve value was 0.915 for the largest CSA and 0.910 for the volume in the ROC curve. The optimal cut-off was 14.53 mm2 and 529 mm3 respectively. When electrodiagnostic parameters were investigated, the 3D ulnar nerve volume was significantly inversely associated with motor conduction velocity, although there was no association between the largest CSA and any of the electrodiagnostic parameters. CONCLUSIONS: The 3D ulnar nerve volume, which is an integration or multilevel measurement of CSAs, showed diagnostic usefulness similar to CSA, but it correlated better with conduction velocity, indicating demyelination or early-to-moderate nerve damage in CuTS.

Evaluation of Different Surgical Techniques for Revision Cubital Tunnel Release: A Meta-Analysis of Patient-Reported Symptoms.

PURPOSE: Controversy exists regarding the best option for revision surgery in refractory cubital tunnel syndrome (CuTS). The purpose of this systematic review was to evaluate the effectiveness of revision surgery and determine the optimal surgical approach for patients requiring revision surgery for CuTS. METHODS: A literature search was conducted. Characteristics of the included studies were summarized descriptively. The risk ratio between patient-reported preoperative and postoperative outcomes relating to pain, motor, and sensory deficits was calculated. A meta-regression analysis was performed to evaluate the postoperative symptom improvements based on the type of secondary surgery. Random-effects meta-analysis and descriptive statistics were used when appropriate. RESULTS: A total of 471 patients were evaluated in 20 studies. In total, 254 (53.9%) male and 217 (46.1%) female patients, with an average age of 49.2 ± 14.1 years, were included in this study. Pain was the most common symptom (n = 346, 81.6%), followed by sensory and motor dysfunction in 342 (80.6%) and 223 (52.6%) patients, respectively. Meta-analysis comparing preoperative and postoperative symptoms between patients who had submuscular transposition (SMT), subcutaneous transposition (SCT), and neurolysis showed that a significant subgroup difference exists between the types of revision surgery in sensory and motor improvements. Meta-regression showed that SMT was associated with better outcomes compared with SCT in motor and sensory improvements. CONCLUSIONS: Revision surgery for CuTS can be useful for addressing recurrent and persistent symptoms. Compared with neurolysis and SCT, SMT seems to be the superior option for revision surgery, demonstrating substantial improvement in all symptom domains. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anconeus epitrochlearis muscle (epitrochlearisanconeus muscle; Musculus epitrochleoanconeus) with cubital tunnel syndrome - a rare but relevant clinical entity.

BACKGROUND: Compression of the ulnar nerve at the elbow within the cubital tunnel is related to the anatomical structures and is generally believed to be caused by Osborne's ligament (also known as the cubital retinaculum). However, in rare cases an anatomical variation of the developmental peculiarity of a remaining anconeus epitrochlearis muscle may be responsible for the disease. METHODS: We present a series of five cases in which an anconeus epitrochlearis muscle was found as the cause of illness. RESULTS: All patients presented with typical symptoms of numbness and tingling in the hand and ulnar fingers, and recurring pain as well as weakness of the ulnar innervated muscles. With neurophysiologically confirmed diminished nerve conduction velocity and unsuccessful conservative treatment, surgical decompression revealed an anconeus epitrochlearis muscle as the reason of compression. Full symptom relief was achieved immediately after the procedure in all cases. CONCLUSIONS: This article strives to call attention to this entity when diagnosing ulnar nerve compression. Myectomy and medial epicondylectomy is the preferred treatment option in such cases.

Compression Neuropathies: Revisions and Managing Expectations.

Most compression neuropathies can be reliably treated with surgical decompression; however, in approximately 25% of the cases, this release fails, requiring revision surgery. Defining the correct diagnosis after a failed nerve decompression (ie, persistent, recurrent, or new symptoms) is of the utmost importance and guides toward the optimal treatment. This article describes the clinical categorization of secondary carpal tunnel syndrome and cubital tunnel syndrome, intraoperative principles of revision surgery and treatment options that are currently available.

Mechanomyography as a Surgical Adjunct for Treatment of Chronic Entrapment Neuropathy: A Case Series.

BACKGROUND: Chronic entrapment neuropathy results in a clinical syndrome ranging from mild pain to debilitating atrophy. There remains a lack of objective metrics that quantify nerve dysfunction and guide surgical decision-making. Mechanomyography (MMG) reflects mechanical motor activity after stimulation of neuromuscular tissue and may indicate underlying nerve dysfunction. OBJECTIVE: To evaluate the role of MMG as a surgical adjunct in treating chronic entrapment neuropathies. METHODS: Patients 18 years or older with cubital tunnel syndrome (n = 8) and common peroneal neuropathy (n = 15) were enrolled. Surgical decompression of entrapped nerves was performed with intraoperative MMG of the hypothenar and tibialis anterior muscles. MMG stimulus thresholds (MMG-st) were correlated with compound muscle action potential (CMAP), motor nerve conduction velocity, baseline functional status, and clinical outcomes. RESULTS: After nerve decompression, MMG-st significantly reduced, the mean reduction of 0.5 mA (95% CI: 0.3-0.7, P < .001). On bivariate analysis, MMG-st exhibited significant negative correlation with common peroneal nerve CMAP ( P < .05), but no association with ulnar nerve CMAP and motor nerve conduction velocity. On preoperative electrodiagnosis, 60% of nerves had axonal loss and 40% had conduction block. The MMG-st was higher in the nerves with axonal loss as compared with the nerves with conduction block. MMG-st was negatively correlated with preoperative hand strength (grip/pinch) and foot-dorsiflexion/toe-extension strength ( P < .05). At the final visit, MMG-st significantly correlated with pain, PROMIS-10 physical function, and Oswestry Disability Index ( P < .05). CONCLUSION: MMG-st may serve as a surgical adjunct indicating axonal integrity in chronic entrapment neuropathies which may aid in clinical decision-making and prognostication of functional outcomes.

Computerized adaptive testing for the patient evaluation measure (PEM) in patients undergoing cubital tunnel syndrome surgery.

In outcome measures, item response theory (IRT) validation can deliver interval-scaled high-quality measurement that can be harnessed using computerized adaptive tests (CATs) to pose fewer questions to patients. We aimed to develop a CAT by developing an IRT model for the Patient Evaluation Measure (PEM) for patients undergoing cubital tunnel syndrome (CuTS) surgery. Nine hundred and seventy-nine completed PEM responses of patients with CuTS in the United Kingdom Hand Registry were used to develop and calibrate the CAT. Its performance was then evaluated in a simulated cohort of 1000 patients. The CAT reduced the original PEM length from ten to a median of two questions (range two to four), while preserving a high level of precision (median standard error of measurement of 0.27). The mean error between the CAT score and full-length score was 0.08%. A Bland-Altman analysis showed good agreement with no signs of bias. The CAT version of the PEM can substantially reduce patient burden while enhancing construct validity by harnessing IRT for patients undergoing CuTS surgery.

Intraoperative electrical stimulation promotes the short-term recovery of patients with cubital tunnel syndrome after surgery.

BACKGROUND: This study was designed to investigate whether intraoperative electrical nerve stimulation has effects on the short-term recovery of cubital tunnel syndrome patients after ulnar nerve release. METHODS: Patients diagnosed as cubital tunnel syndrome were selected. At the same time, they received conventional surgery treatment. The patients were divided by a randomized digits table into two groups. The control group underwent conventional surgery, and the electrical stimulation (ES) group underwent intraoperative electrical stimulation. All the patients were tested for sensory and motor functions, grip strength, key pinch strength, motor conductivity velocity (MCV), and maximum compound muscle action potential (CMAP) before operation and 1 month and 6 months after operation. RESULTS: In patients treated with intraoperative ES, the sensory and motor functions and the strength of muscle were significantly improved after 1-month and 6-month follow-up than the control group. After the follow-up, the patients in the ES group had significantly higher grip strength and key pinch strength than the control group. After the follow-up, the patients in the ES group had significantly higher MCV and CMAP than the control group. CONCLUSION: Intraoperative electrical stimulation of nerve muscle can significantly promote the short-term recovery of nerve and muscle functions after the surgery in cubital tunnel syndrome patients.

What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

BACKGROUND: It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. QUESTIONS/PURPOSES: (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? METHODS: We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. RESULTS: The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). CONCLUSION: The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDSs) are often used to confirm diagnosis. However, negative EDSs can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDSs, who are treated surgically. METHODS: Patients who had EDSs before ulnar nerve surgery were identified by means of database search. Chart review was performed on 867 cases to identify those with negative EDSs. Twenty-five ulnar nerve operations in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical examination findings, and outcome measures (ie, Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Ulnar Nerve Evaluation). RESULTS: At a mean follow-up period of 20.7 ± 14.9 months, 15 of 25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 patients who had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative Disabilities of the Arm, Shoulder and Hand score was 40.0 [interquartile range (IQR), 23.9 to 58.0], which significantly decreased to a median of 6.8 (IQR, 0 to 22.7) at final follow-up ( P < 0.01). The median postoperative Patient-Rated Ulnar Nerve Evaluation score was 9.5 (IQR, 1.5 to 19.5). CONCLUSIONS: Patients with CuTS and normal EDSs treated surgically can be expected to have favorable outcomes with respect to symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, the authors continue to offer surgical intervention for these patients when nonoperative treatment has failed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. METHODS: A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. RESULTS: A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. CONCLUSIONS: The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. CLINICAL RELEVANCE: Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Factors Associated With Severity of Cubital Tunnel Syndrome at Presentation.

BACKGROUND: The outcomes of cubital tunnel syndrome surgery are affected by preoperative disease severity. The aim of this study was to identify factors associated with clinical and electrodiagnostic severity of cubital tunnel syndrome at presentation. METHODS: We retrospectively identified 213 patients with electrodiagnostically confirmed cubital tunnel syndrome who underwent cubital tunnel surgery from July 2008 to June 2013. Our primary response variable was clinical cubital tunnel syndrome severity assessed by the McGowan grade. Our secondary response variables were sensory nerve action potential (SNAP) recordability, presence of fibrillations, and motor nerve conduction velocities (CVs) in the abductor digiti minimi (ADM) and first dorsal interosseous (FDI). Bivariate analysis was used to screen for factors associated with disease severity; significant variables were selected for multivariable regression analysis. RESULTS: Older age was associated with higher McGowan grade and diabetes mellitus was associated with unrecordable SNAPs on bivariate analysis. No other variables met inclusion criteria for multivariable regression analysis for McGowan grade or unrecordable SNAPs. Multivariable regression analysis showed older age and higher Distressed Communities Index (DCI) to be associated with decreased motor nerve CVs in ADM. Multivariable regression analysis showed higher body mass index (BMI) and higher DCI to be associated with decreased motor nerve CVs in FDI. No variable was associated with the presence of fibrillations. CONCLUSIONS: A subset of patients with cubital tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier surgery. Older patients, with higher BMI, with diabetes mellitus, and with economic distress are at higher risk for presentation with more severe disease.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Prospective outcome analysis of ulnar tunnel syndrome: Comparing traumatic versus non-traumatic etiologies.

BACKGROUND: Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies. METHODS: Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength. RESULTS: 21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles. CONCLUSIONS: Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.

Treatment of Peripheral Nerve Compression Syndromes of the Upper Extremities: a Systematic Review. / Die Therapie peripherer Nervenkompressionssyndrome der oberen Extremität ­ eine systematische Übersichtsarbeit.

BACKGROUND: Nerve compression syndromes are referred to as chronic irritation or pressure palsies of peripheral nerves in areas of preformed anatomical constriction. Carpal tunnel syndrome is the most common nerve compression syndrome, followed by cubital tunnel syndrome. In addition, less frequent nerve compression syndromes of the upper extremities that affect the median, ulnar or radial nerves have been described. This review provides an overview of current treatment options for nerve compression syndromes of the upper extremities. STUDY DESIGN: Systematic overview. METHODS: Based on established national (AWMF) and international guidelines as well as the Cochrane Library, we performed a systematic literature search on PubMed (NLM), focusing on randomised controlled trials. RESULTS: Over the research period (2012 - 2020), there were 43 randomised trials that investigated surgical carpal tunnel release methods, 68 that compared different conservative therapies and 12 that compared surgical versus conservative treatments. Furthermore, eight studies analysed surgical techniques and four analysed conservative techniques for cubital tunnel syndrome. No randomised trials were conducted on the less common peripheral nerve compression syndromes, but case reports and observational studies were conducted. CONCLUSION: For carpal and cubital tunnel syndromes, there are evidence-based diagnostic methods as well as therapeutic recommendations based on randomised and controlled trials. When diagnosis is made after clinical examination and supported by radiological and electrophysiological evaluation, surgical treatment is considered superior to conservative treatment. In particular, excellent long-term results can be achieved by surgery for carpal and cubital tunnel syndromes. More controlled studies are needed to establish evidence-based therapeutic recommendations for the less common nerve compression syndromes, which are somewhat controversially and inconsistently defined.

Quality of life and satisfaction in patients surgically treated for cubital tunnel syndrome.

OBJECTIVE: Cubital tunnel syndrome (CuTS) results from compression of the ulnar nerve at the elbow, resulting in pain, weakness, and numbness of the hand and forearm. This work describes the Quality of Life (QoL) and satisfaction after CuTS surgery and identifies the factors associated with those outcomes. METHODS: This cross-sectional study included patients surgically treated for CuTS from January 2011 to September 2021 at the Neurosurgery Clinic of the Clinic Center in Serbia. The questionnaires applied were the Short Form 36 (SF-36), EuroQol instrument (EQ-5D-5 L), Bishop's score and Patient-Rated Ulnar Nerve Evaluation (PRUNE). RESULTS: Sixty-two patients met the inclusion criteria. Bishop's score: The median score was 10 (7.75-11), 54.8% of the cases presented excellent results. PRUNE: The median score for symptoms was 19 (6-38.5); for functional, was 14 (0.75-38); and the total was 18.25 (5.87-34.12). SF-36: The subscale with the best result was social functioning (84.68 ± 22.79). The scale with the worst value was emotional well-being (49.35 ± 7.87). EQ-5D-5L: Over 50% patients did not present problems with mobility, self-care, activity, and anxiety. The average EQ-VAS was 72.77 ± 18.70; and 0.72 ± 0.21 of the EQ-index, revealing a good QoL. Models for QoL and satisfaction: Ten models showed statistical significance. The variables with major involvement were body mass index and time evolution of the symptoms. CONCLUSION: Surgical decompression has proved to diminish the symptoms, improving QoL and satisfaction. Many fixed and changeable factors can affect the satisfaction levels after surgery.

A 60-Year-Old Woman with Symptoms of Combined Carpal Tunnel Syndrome and Cubital Tunnel Syndrome Due to an Elastofibroma Causing Compression of the Median and Ulnar Nerves.

BACKGROUND Cubital tunnel syndrome results from pressure or stretching of the ulnar nerve, and carpal tunnel syndrome involves the median nerve. Elastofibroma is a rare, benign, slow-growing soft-tissue tumor that commonly occurs as a bilateral infrascapular tumor in elderly women. This report is of a 60-year-old woman who presented with combined carpal tunnel syndrome and cubital tunnel syndrome due to an elastofibroma causing compression of the median and ulnar nerves. CASE REPORT We report the case of a 66-year-old woman with left-hand numbness, tingling along the fingers, sleep disturbance, and weakness in pinching or holding objects for an extended period. The clinical examination and nerve conduction studies established the diagnosis of combined carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTs) complicated by intrinsic muscle wasting. The patient underwent left carpal and cubital tunnels release surgery and end-to-side anterior interosseous nerve transfer to the motor component of the ulnar nerve. Pathologic evaluation of the entire specimen showed collagen bundles alternating with refractive cylinders stained with Verfoeff-van Gieson elastic stain. CONCLUSIONS This report is of a rare case of a histologically-confirmed single, peripheral, benign elastofibroma involving compression of the ulnar and median nerves. This case highlights the importance of histopathology in diagnosing rare soft-tissue tumors arising at an uncommon site and presenting with rare symptoms.

Some Misconceptions in the Treatment of Cubital Tunnel Syndrome, Radial Tunnel Syndrome, and Median Nerve Compression in the Forearm.

This article discusses ulnar, median, and radial nerve compression in the proximal forearm and elbow and some possible common misconceptions. In particular, the ligament of Struthers extremely rarely causes ulnar neuropathy. Lacertus syndrome and flexor superficialis-pronator syndrome can be diagnosed separately. Surgical release can be through a small incision. Acronyms for compression to radial nerve in proximal forearm can be simplified to radial tunnel syndrome, which includes a mild type (classical radial tunnel syndrome) and a severe type (posterior interosseous nerve (PIN) compression).

Submuscular transposition of the ulnar nerve for persistent or recurrent cubital tunnel syndrome: Results of a prospective case series.

BACKGROUND: Submuscular transposition (SMT) of the ulnar nerve is frequently performed as secondary procedure in patients with persistent or recurrent cubital tunnel syndrome (CuTS) despite previous surgery. Good results have been reported for this surgical strategy, but mainly in small retrospective case series. The goal of the present study is therefore to analyze the results prospectively using a patient-reported outcome measure (PROM): patient-rated ulnar nerve evaluation (PRUNE). METHODS: SMT of the ulnar nerve was performed in 30 consecutive patients who were referred because of persistent or recurrent CuTS despite previous surgery. Objective outcome was measured in the outpatient clinic using the Likert scale. The PRUNE questionnaire was obtained pre-operatively, 6 weeks, 3 months, 6 months, and 12 months after the surgery. Simultaneously, 20 patients with primary surgery for CuTS, that underwent simple decompression, were followed. RESULTS: Good outcome (Likert 1 or 2) was obtained in 67% after SMT for persistent/recurrent CuTS and 85% after decompression as primary surgical treatment. PRUNE scores were significantly decreased in both groups at all follow-up moments after surgery compared with pre-operative for the total questionnaire and subscales "pain," "sensory/motor symptoms," and "specific activities." In both groups, PRUNE score remained stable until 12 months of follow-up. CONCLUSION: This prospective study confirms previous results from retrospective studies showing that SMT is an effective surgical option for persistent or recurrent CuTS. Prospective (randomized controlled) trials are needed to compare the effectiveness of SMT to the surgical alternative of subcutaneous transposition of the ulnar nerve.