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Cubital Tunnel Syndrome (Ulnar nerve entrapment at the elbow)

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The Problem
Carpal Tunnel Syndrome is a problem brought on by a pinched nerve at the wrist sometimes resulting in numbness, tingling, and pain in the arm, hand, and fingers. The tunnel is a space through the wrist bones where nine tendons and the median nerve pass from the forearm to the hand. Tendons bend the fingers. The median nerve is big, about the size of a pen or pencil. This nerve contains thousands of small individual nerve fibers. Some of these make the muscles to the thumb work: lift the thumb up and out from your hand and allow the thumb to turn and pinch the other fingertips. The rest of the nerve fibers bring feeling from the tip of the thumb, index, middle, and part of the ring fingers.

Pressure on this nerve usually comes from thickened lining of the tendons, which is called tenosynovitis. Repetitive hand activity can increase pressure in the tunnel. Tissue growths (tumors), bone dislocations, fractures, and arthritis can narrow the tunnel but are more rare. Body swelling from fluid retention of pregnancy or heart failure can cause the symptoms of carpal tunnel syndrome. When the fluid retention improves, the symptoms usually go away. Other medical conditions (such as diabetes, rheumatoid arthritis, and hypothyroidism) also can increase pressure in the carpal tunnel.

When the pressure builds up, the blood flow in the nerve decreases. When the nerve does not get enough oxygen, you develop the numbness and tingling feelings in your fingers. With the wrist bent down which often happens when you are asleep, the nerve gets pressed harder against the ligament. This further decreases the blood flow to the nerve and awakens you with the feeling that your hand is "asleep." A splint places the wrist in a straight or neutral position which often takes pressure off the nerve. This is especially useful at night. When you reach the stage where the splinting no longer is helpful, then another form of treatment becomes necessary.

Medical treatment may be combined with splinting. You may already be on medicine that lessens the swelling in these tissues. This includes some medicines used to treat different forms of arthritis, diabetes, or thyroid problems. Changing the activities that you do with your hand every day, such as taking time off work or changing your hobbies may help. For example, doing less sewing or knitting or playing less tennis or golf, may decrease the swelling in this tunnel. When medicines, changing activities, or splints prove to be ineffective in relieving your symptoms you may need surgery. Without surgery and continued pressure on the nerve, you may completely loose all the feeling in the thumb, index, middle, and part of the ring finger. Without feeling heat, cold, or pain the fingers are more likely to be injured. Additionally, the thumb will lose the ability to lift out from the palm of the hand, because some thumb muscles become paralyzed. Prolonged damage may become permanent.

Diagnosis
Detailed information on how the hands have been used and information about prior injuries and symptoms are important. Dr. Bermant may send you for X-rays or scans to evaluate the bones for arthritis or fractures. You also may have laboratory tests performed to evaluate possible other conditions. Nerve conduction testing and electromyogram (EMG) may evaluate the extent of damage and whether the neck, shoulder, or elbow are involved.

The Operation
The operation consists of cutting the ligament that forms the roof of the tunnel. Releasing the ligament relieves the pressure on the nerve. Additional procedures may be necessary. Sometimes Dr. Bermant needs to remove swollen tissue or other structures in the tunnel that are pressing on the nerve. Examples include a cyst from the joint or a fatty tumor. When the nerve has been compressed for a long time, scar tissue builds inside the nerve. When this has happened, usually the fingers remain numb all the time and you lose delicate sensation. The muscles that lift the thumb out from the hand may also have become partly paralyzed. With excessive scar tissue, an internal neurolysis is added to the operation of ligament release. In this procedure, using magnification, the outer wrapping of the nerve is opened and the scar tissue is removed from within the nerve.

Recovery Phase
The recovery process occurs generally in two stages. The operation releases pressure on the nerve and blood flow improves in the nerve immediately. By the time the sutures are removed, the numbness and tingling may either be gone or greatly diminished from your hand and the nighttime awakening no longer occurs. Nerves that scar or degenerate do not recover this quickly. Actual degeneration of nerve fibers may result in muscle wasting or inability to discriminate fine points with the ends of the fingers. The nerve fibers must regenerate from the site of the nerve injury, the wrist, to the muscles or fingertips. Thus, over a period of 6 months to a year, there will be continued improvement in muscle strength and ability to discriminate with the tips of the fingers. There is no way to hurry this neural regeneration process. The regrowth may be associated with pain, similar to that experienced when your leg and foot "come back to life" after falling asleep. Such pain may last more than six weeks and require additional pain medication, massage, and prolonged postoperative care.

This information can be reviewed by you with Doctor Bermant and any information not understood discussed with him. We hope that this information makes you better aware of the operation, the potential benefits, risks, and complications, and help you in the recovery period following surgery.

version 4/24/96

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