CUBITAL TUNNEL SYNDROME DUE TO AN INTRANEURAL GANGLION CYST OF THE ULNAR NERVE.

Cubital tunnel syndrome is the second most common neuropathy of the upper extremity. Cubital tunnel syndrome caused by intraneural ganglion cysts is rare in clinical practice. We present the case of a 71-year-old male patient with a 4-month history of cubital tunnel syndrome of the left elbow due to an intraneural ganglion cyst. After revision of the ulnar nerve and resection of the intraneural cyst nearly complete recovery was achieved within a 5 month follow-up but some sensory deficits of the fifth fingertip. We recommend preoperative ultrasound examination of the cubital tunnel even in cases with clear diagnosis. Ganglion cyst as a cause of cubital tunnel is rare but needs to be diagnosed and treated as soon as possible to prevent irreversible complications.

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.

Cubital tunnel syndrome of the ulnar nerve caused by an epineural ganglion cyst: a case report and review of the literature.

BACKGROUND: The ulnar nerve has a long and complex anatomical course, originating from the brachial neural plexus in the neck with nerve trunk formation at the posterior neck triangle, and on to the axilla. This intricate anatomical pathway renders the nerve susceptible to compression, direct injury, and traction throughout its course. Compression of the ulnar nerve is the second most common compression neuropathy of the median nerve adjacent to the wrist joint, after carpal tunnel syndrome. CASE PRESENTATION: A 45-year-old Sudanese housewife complained of progressive right forearm and hand muscle wasting, pain, and neuropathic symptoms. She was diagnosed with right-sided cubital tunnel syndrome. The diagnosis was derived intraoperatively from a nerve conduction study suggesting the level of conduction block and recommending decompression. Magnetic resonance imaging was not done preoperatively due to financial limitations. An epineural ganglion (15 × 20 mm2) compressing and flattening the ulnar nerve was diagnosed intraoperatively. Surgical decompression of the ulnar nerve and removal of the epineural ganglion achieved a remarkable postoperative result and pleasing outcome. CONCLUSION: Surgical management is the cornerstone of treatment for compressive neuropathy and ranges from simple nerve decompression to complex neurolysis procedures and nerve transposition to adjust the anatomical course of the nerve.

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.

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.

Neurolymphomatosis of the Ulnar Nerve Presenting as Cubital Tunnel Syndrome: A Case Report.

Lymphoma is a malignant tumour of the lymphatic system. Neurolymphomatosis occurs when lymphoma cells invade the peripheral nervous system (PNS). Neurolymphomatosis has been reported involving the sciatic nerve, nerve roots and within the axilla and the upper arm. It can cause nerve dysfunction depending on the involved nerve. Neurolymphomatosis involving the ulnar nerve is rare. We report a patient with neurolymphomatosis of the ulnar nerve around the elbow that presented with features of cubital tunnel syndrome. A high index of suspicion is necessary in patients with cubital tunnel syndrome that present with uncommon symptoms such as sudden onset, rapid progression and/or severe pain. Level of Evidence: Level V (Therapeutic).

Clinical efficacy of decompression and anterior transposition of the ulnar nerve in osteoarthritis-induced cubital tunnel syndrome and influencing factors.

We aimed to explore the clinical efficacy of decompression and anterior transposition of the ulnar nerve in osteoarthritis-induced cubital tunnel syndrome (CTS). 109 patients with moderate-to-severe CTS treated from July 2015 to March 2019 were selected. Upper-limb function was scored. After ultrasound examination, decompression and anterior transposition of the ulnar nerve were performed; then ulnar nerve motor nerve conduction velocity (MNCV) was assessed. Patients were followed up every 3 months for 18 months and their prognosis was assessed. Upper-limb function examination results were compared according to disease severity. Univariate and multivariate regression analyses were conducted, and a nomogram prediction model was established. After treatment, the number of patients with intrinsic contracture of the hand, Tinel sign (+), clipping paper test (+) and Froment's sign (+) significantly declined; hand grip strength, ulnar nerve MNCV, latency, amplitude, 2-point discrimination (2-PD) and Disabilities of the Arm, Shoulder and Hand (DASH) score were improved (p < 0.05). Age, gender, course of disease, long-term elbow bend work (LTEBW), ulnar nerve MNCV, 2-PD and DASH score were independent risk factors for poor prognosis (p < 0.05). The calibration curve confirmed that prognosis results after treatment were highly consistent with actual outcomes. Decompression and anterior transposition of the ulnar nerve exerted significant therapeutic effects on moderate-to-severe osteoarthritis-induced CTS. The nomogram prediction model established by age, gender, course of disease, LTEBW, ulnar nerve MNCV, 2-PD and DASH score can be used to effectively evaluate prognosis.

Ulnar Groove Plasty Guided by a 3D Printing Technique for Moderate to Severe Cubital Tunnel Syndrome Caused by Elbow Osteoarthritis.

BACKGROUND The purpose of this study was to explore the feasibility of ulnar groove plasty guided by a three-dimensional (3D) printing technique for treatment of moderate to severe cubital tunnel syndrome (CuTS) caused by elbow osteoarthritis. MATERIAL AND METHODS Patients with moderate to severe CuTS secondary to osteoarthritis of the elbow were enrolled in our hospital from April 2015 to March 2018. Based on a previously proposed "elbow canal index", a 1: 1 model of the elbow joint was printed using CT image data collected preoperatively. After computer-aided measurement, the standard for enlargement of the ulnar nerve groove was calculated and a personalized "trial model" was created by 3D reconstruction. After intraoperative exposure of the ulnar nerve sulcus, the proliferative osteoid was burred with a grinding drill, and the cubital enlargement was verified by the trial model. The ulnar nerve was decompressed and reincorporated into the enlarged cubital canal, and the Osborne ligament was zig-zag elongated and reconstructed. RESULTS None of the patients reported experiencing medial elbow instability, medial elbow pain, ulnar nerve subluxation, flexor-pronator weakness, or incision infection. There was significant improvement of the motor nerve conduction velocity, sensory nerve conduction velocity, two-point discrimination of the little finger, grip strength, pinch strength of the thumb and index finger, VAS score, and DASH score in this study (P<0.001). CONCLUSIONS Ulnar groove plasty guided by a 3D printing technique may be another effective treatment of moderate to severe CuTS caused by elbow osteoarthritis.

Ulnar nerve decompression and transposition with versus without supercharged end-to-side motor nerve transfer for advanced cubital tunnel syndrome: a randomized comparison study.

OBJECTIVE: The objective of this prospective randomized study was to compare ulnar nerve decompression and anterior subfascial transposition with versus without supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for advanced cubital tunnel syndrome, to describe performing the nerve transfer through a small incision, and to investigate predictive factors for poor recovery following the procedure. METHODS: Between January 2013 and October 2016, 93 patients were randomly allocated to a study group (n = 45) and a control group (n = 48). Patients in the study group were treated with supercharged motor nerve transfer via a 5-cm incision following decompression and anterior subfascial transposition. Patients in the control group were treated with decompression and anterior subfascial transposition alone. Postoperative pinch strength and compound muscle action potential amplitude (CMAPa) were assessed. Function of the limb was assessed based on the Gabel/Amadio scale. Between-group data were compared, and significance was set at p < 0.05. Potential risk factors were collected from demographic data and disease severity indicators. RESULTS: At the final follow-up at 2 years, the results of the study group were superior to those of the control group with regard to postoperative pinch strength (75.13% ± 7.65% vs 62.11% ± 6.97%, p < 0.05); CMAPa of the first dorsal interossei (17.17 ± 5.84 mV vs 12.20 ± 4.09 mV, p < 0.01); CMAPa of abductor digiti minimi (11.57 ± 4.04 mV vs 8.43 ± 6.11 mV, p < 0.01); and excellent to good results (0.67 for the study group vs 0.35 for the control group, p < 0.05). Multivariate analysis showed that the advanced age (OR 2.98, 95% CI 2.25-4.10; p = 0.003) in the study group was related to unsatisfactory outcome in the patients. CONCLUSIONS: In the treatment of advanced cubital tunnel syndrome, additional supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer may produce a better function of the hand. The authors also found that cases in the elderly were related to unsatisfactory postoperative results for these patients and that they could be informed of the possibility of worsening surgery results.

Cubital tunnel perfusion in different postures-An anatomical investigation.

INTRODUCTION/AIMS: For cubital tunnel syndrome, the avoidance of predisposing arm positions and the use of elbow splints are common conservative treatment options. The rationale is to prevent excessive stretching and compression of the nerve in the cubital tunnel, as this mechanical stress impedes intraneural perfusion. Data regarding those upper extremity postures to avoid, or whether elbow flexion alone is detrimental, are inconsistent. This study aimed to assess perfusion and size changes of the cubital tunnel during different postures in an experimental cadaver setup. METHODS: Axillary arteries in 30 upper extremities of fresh cadavers were injected with ultrasound contrast agent. High-resolution ultrasound of the cubital tunnel was performed during five different arm postures that gradually increased tension on the ulnar nerve and caused cubital tunnel narrowing. Contrast enhancement within the tunnel was measured to quantify perfusion. Cubital tunnel cross-sectional area was measured to detect compression. RESULTS: Increasing tension significantly reduced perfusion. When isolated, neither shoulder elevation, elbow flexion, pronation, nor extension of wrist and fingers impaired perfusion. However, combining two or more of these postures led to significant decreases. Significant narrowing of the cubital tunnel was seen in full elbow flexion and shoulder elevation. DISCUSSION: Combinations of some upper extremity joint positions reduce nerve perfusion, but isolated elbow flexion does not have a significant impact. We hypothesize that elbow splints alone may not influence cubital tunnel perfusion but may only prevent direct compression of the ulnar nerve. Advising patients about upper extremity postures that should be avoided may be more effective.

Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand.

A 59-year-old woman was referred with weakness, paraesthesia, numbness and clawing of the little and ring fingers for the last 2 years. MRI of the cervical spine was normal and nerve conduction velocity revealed abnormality of the ulnar nerve. Ultrasound and MRI showed medial osteophytes and effusion of the elbow joint with stretched and thinned ulnar nerve in the cubital tunnel. The patient underwent release and anterior transposition of the ulnar nerve with significant relief of symptoms.

Management of Recalcitrant Cubital Tunnel Syndrome.

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.

Osseous morphology of the medial epicondyle: an anatomoradiological study with potential clinical implications.

PURPOSE: The cubital tunnel is limited anteriorly by the medial epicondyle (ME), laterally by the medial collateral ligament, and superiorly by Osborne's fascia and the cubital tunnel retinaculum. Previous studies were mostly dedicated to the roof of the cubital tunnel, in the way that the study of the groove for ulnar nerve and ME anatomy is relatively scarce in the literature. We sought to describe the radiological anatomy of the groove for ulnar nerve and ME in healthy volunteers with multiplanar computed tomography (CT). METHODS: We analyzed 3D CT images of 30 healthy volunteers (mean age 39 years, range 18-66 years). Nine variables were measured from the right elbow, including sizes, areas and angles in two different planes (coronal and axial). RESULTS: Mean ME width and length were 17.3 ± 3.5 mm and 31.7 ± 4.5 mm, respectively. According to categorical correlation studies, ME width (X) was deemed the most representative morphological characteristic because of the positive correlation to five other different anatomical measurements. A three-tiered anatomical classification was proposed based on data distribution. CONCLUSION: Large individual variation is found in the shape of ME, both in coronal and axial planes. The knowledge of individual osseous morphology is of great value potentially contributing to the surgical decision-making in patients affected by cubital tunnel syndrome.

Ulnar neuropathy at the elbow.

At the elbow, the ulnar nerve (UN) may be the site of a static compression (by the cubital tunnel retinaculum and Osborne's ligament between the two heads of the flexor carpi ulnaris), or a dynamic compression, especially when the nerve is unstable (subluxation/dislocation outside the ulnar groove). The clinical basis for the diagnosis of ulnar neuropathy involves looking for subjective and objective signs of sensory and/or motor deficit in the ulnar nerve's territory in the hand, a pseudo-Tinel's sign, and doing manipulations to provoke UN irritation. The diagnosis is confirmed by electromyography and ultrasonography. In the early stages, patient education and elimination of flexion postures or repeated elbow flexion motions can provide relief. If this fails or signs of sensory and/or motor deficit are present, surgical treatment is proposed. If the nerve is stable, in-situ nerve decompression is typically done as the first-line treatment. If the nerve is unstable, anterior nerve transposition - generally subcutaneous - or more rarely, a medial epicondylectomy can be done. If surgical treatment fails, the patient's history is reviewed, and diagnostic tests can be repeated. Except in cases of a fibrotic scar, the main causes of failure are neuroma of a branch of the medial cutaneous nerve of the forearm, instability of the nerve and persistence of a compression point. In the latter two cases, surgical revision is justified and anterior nerve transposition or epicondylectomy can be proposed.

Analysis of the Anatomical Factors Associated with Cubital Tunnel Syndrome.

BACKGROUND: Previous studies demonstrated that soft tissues, such as retinaculum, fibrous band, and anconeus, cause ulnar nerve compression, whereas other studies showed that the bony structures strain the ulnar nerve that runs directly behind the medial epicondyle constituting the boundary of the cubital tunnel during elbow flexion. However, no studies have reported the association of the shape of the bony structure with cubital tunnel syndrome symptoms. Are computed tomography (CT) and magnetic resonance imaging (MRI)-measured parameters of the bony cubital tunnel related to idiopathic cubital tunnel syndrome symptoms? HYPOTHESIS: We hypothesized that CT and MRI-measured parameters of the bony cubital tunnel were related to idiopathic cubital tunnel syndrome symptoms. We aimed to investigate the relationship between the radiographic parameters based on CT and MRI and idiopathic cubital tunnel syndrome symptoms. PATIENTS AND METHODS: We analyzed 224 elbows (77 affected elbows of patients with idiopathic cubital tunnel syndrome, 77 unaffected elbows of patients with cubital tunnel syndrome, 70 elbows of patients without cubital tunnel syndrome symptoms) using CT and MRI. Cubital tunnel cross-sectional area, cubital tunnel volume, and ulnar nerve cross-sectional area were measured in the three groups at flexion and extension. A new cubital tunnel center with a new boundary was proposed that could play a role in ulnar nerve compression symptoms. RESULTS: The cross-sectional areas and volumes of the cubital tunnel measured in the elbow flexion state were the smallest among the group with the affected elbows in patients. There was no difference between unaffected elbows and the non-patient group. The cross-sectional area of the ulnar nerve highly correlated with cubital tunnel symptoms in the flexion state. DISCUSSION: The shape of the cubital tunnel is an important factor in cubital tunnel syndrome, and normal variations in the volume and cross-sectional area of the cubital tunnel and ulnar nerve could influence the occurrence of idiopathic cubital tunnel syndrome. LEVEL OF EVIDENCE: III, Therapeutic study.

Ulnar Nerve Entrapment at Elbow in an Adult Patient with Macrodactyly.

We describe a case of an adult patient presenting with cubital tunnel syndrome in the setting of previously undiagnosed macrodactyly. Early diagnosis and management of macrodactyly is important to help prevent symptoms associated with compromised peripheral nerves and reduce the likelihood of the permanent motor and sensory sequelae of prolonged nerve compression.

The utility of ultrasound examination in cubital tunnel syndrome caused by heterotopic ossification.

This case presents the utility of ultrasound examination in diagnostics, providing accurate therapy and follow-up of entrapment syndrome of the ulnar nerve, caused by heterotopic ossification. The heterotopic ossifications were in this case presumably linked to a long-term working with a vibration sander.