Cubital Tunnel Syndrome - James T. Mazzara, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Dr. Mazzara, what I'd like to discuss over the next few minutes is a condition called cubital tunnel syndrome. Now what that means is that it's a condition of the elbow that we know as ulnar nerve compression here. We call it cubital tunnel syndrome. It goes by other names, but talk to us a little bit about what that condition is and what symptoms it causes.

Dr. Mazzara: Well, cubital tunnel is actually compression or irritation of the ulnar nerve at the elbow. It's a very precise area where the ulnar nerve courses right in the back of the inside of the elbow. Patients commonly refer to that as their funny bone so that when you hit that hard enough what you're really hitting is the ulnar nerve at the cubital tunnel, and what happens for a variety of reasons is that something is going to cause pressure or swelling around the nerve, and that pressure or swelling around the nerve will cause the nerve to malfunction. When a nerve malfunctions a couple of things will happen. One is either you'll experience numbness or tingling which is generally an early phase and a milder form of cubital tunnel. You can eventually get and develop weakness and the weakness is actually noticed by patients in loss of hand dexterity. So they might notice that as they do very simple tasks with their hand and their fingers, it's not as strong or they don't function as normally as they used to and so patients under those circumstances are sometimes found to have nerve injuries at the elbow. They can have nerve injuries elsewhere as well, but one of the potential causes for that is at the elbow.

Dr. Sechrest: Now what do you think causes that compression on the nerve? Is this always an injury? Is this something that can occur over a period of time? Why do we get compression in the cubital tunnel?

Dr. Mazzara: Well, any time you have any kind of swelling around the nerve you'll get pressure on the nerve and that pressure causes symptoms and different things like diabetes, inflammatory arthritis like a rheumatoid arthritis, thyroid dysfunction, as well as trauma so previous trauma and recent trauma can cause swelling and damage and pressure on the nerve. People who lean on the elbow, people who have trauma to the elbow for one reason or another, can cause a lot of bleeding, swelling, and scarring around the nerve itself. When that occurs, there's a little ligament at the elbow, there's a small curved tunnel and a small ligament over that curved tunnel called Osborne's ligament. Something ends up squeezing the nerve, so whether it's thickening or scarring in Osborne's ligament, swelling of the nerve, or even arthritis in the joint underneath, that pressure will cause a problem with the nerve and patients notice that, as I mentioned, with numbness, tingling, or eventually weakness.

Dr. Sechrest: You mentioned trauma, and one of the things that I think we ought to bring for patients is sometimes children who've had elbow fractures and then that elbow fracture has healed in an abnormal position will actually cause a little more angle in the elbow and over a period of time that may lead to problems just because that elbow is no longer normal. So it may be 20 years after the original trauma.

Dr. Mazzara: That's very true. That's actually called a ‘tardy on the nerve palsy' and over a period of time people will develop problems as they get a little bit older, but that's really related to previous scar around the nerve and sometimes extra tension on the nerve. The nerve has a normal excursion. The nerve needs to be able to slide back and forth through the tunnel, just like with any physiologic structure, it has to have normal environment. When that environment around the nerve has been changed for one reason or another you get symptoms as a result of that.

Dr. Sechrest: Now, we all see patients who come into the office who are complaining of, "My hand's falling asleep"; they wake up at night with it falling asleep. They really come in and say, "No, it's my whole hand." They can't really distinguish. How do I, as a patient, begin to do a little bit of self diagnosis and begin to explore what is causing this and distinguish this from other nerve compression problems in the hand for us?

Dr. Mazzara: Well, first of all, when you have a compressed nerve the symptoms are sometimes vague and nondescript and it can be associated with an aching in the arm. If you have numbness or tingling what you really want to notice is, is that numbness and tingling in all of your fingers or does it just feel like it's in all of your fingers. Typically, all of the fingers aren't affected. If you have numbness and tingling in the thumb, index, middle finger, and maybe part of the ring finger, that's typically going to be carpal tunnel syndrome. Numbness and tingling over the little finger, if it's in the arm, it's going to cubital tunnel. So, when your little finger is involved it's cubital tunnel, when it's the other fingers it actually carpal tunnel. You also have to be concerned about assigning the diagnosis of cubital tunnel or carpal tunnel when you have numbness in your fingers, because the same nerves that get compressed at your elbow and your wrist come out of your neck; and so, the nerve be compressed in the cervical spine and through either a herniated disc or a bone spur, and there's a condition called the double crush phenomenon where patients will have pressure on the nerve in two locations. So pressure on the nerve in the neck predisposes somebody to get carpal tunnel or cubital tunnel at the elbow with less pressure on the nerve at the elbow.

Dr. Sechrest: Yes, it's interesting, because I think sometimes patients think somehow the human body is different than things that are normally associated with, but really our nervous system is like any other wiring harness to some degree, and a lot of times it's a concept of trying to figure where that wiring harness is getting interrupted and it can be in multiple places. So, although we give these names to things, we'll really trying to figure out where is the nerve being compressed and what are we going to do about it.
Dr. Mazzara: Absolutely.

Dr. Sechrest: Now, tell me a little bit about the symptoms. You mentioned the numbness. What other symptoms is a patient who's having compression at the cubital tunnel likely going to feel?

Dr. Mazzara: Well, if it's early on and they don't have advanced nerve injury, they may have some aching in the arm. It may bother them sometimes when they sleep and they have to straighten the elbow when they sleep. It is sometimes not very specific. It doesn't always go down to the hand however, so patients who have a compression neuropathy in the elbow or even in the wrist may have symptoms that sometimes go up as far as the shoulder or neck. So it's not isolated to the elbow itself. When you have pressure on the nerve at the elbow, your numbness and tingling will typically be on the outside of the 5th finger, top or bottom of the 5th finger, but you may also develop weakness over a period of time and that weakness involves sometimes an inability to get all of the fingers together. That is an indication of more advanced disease, so if you have intrinsic wasting, or wasting of the little muscles in the hand, you may end up seeing a little atrophy or indentation on this side of your hand and you may also have some weakness in getting those fingers together. In addition, you may also have some weakness in trying to keep the fingers straight. When you have ulnar nerve related weakness, you may get what's called pseudoclawing of the fingers where these fingers are not able to be maintained in a straight position because of the weakness of these small muscles and they extend like that a little bit. More advanced cases of ulnar nerve injury may also be associated with some weakness or atrophy between the thumb and the index finger, and this atrophy may result in some weakness in pinch, so that's where the dexterity issue becomes an issue for patients because patients who cannot pick up something with the index finger and the thumb may say, "Well, Jim, I'm getting a little clumsy, and either I'm getting old or I have arthritis or there's something else going on." Sometimes it's loss of dexterity from nerve injury at the elbow.

Dr. Sechrest: Now, when that patient presents to your office, what do you do to try to make this diagnosis? How do you try to narrow down what's causing their problem?

Dr. Mazzara: Well, you always have to start at the cervical spine. Evaluate the neck. You take a great history. You get all the details you can. Since we know medications can cause nerve related symptoms, you want to ask patients what medications they're on. We need to examine their cervical spine, check their reflexes, and then check their motor and sensory exam, which means we may go to the point of using a sensory tester in the hand. More often than not what I'll do is take a little wisp of paper from the exam table, and just kind of stroke the tip of the finger to see if their sensation is the same in the little finger as it is in the index, and how is it on the left hand compared to the right. Then we want to arrange their neck and just make sure that we're not missing anything elsewhere, and then we put a little pressure on the nerve at the elbow. We probably go to this last here. We want to make sure that we have not missed anything else, and then we examine the elbow itself. We examine the elbow for a range-of-motion, for appearance, for swelling, and then we tap on the nerve at the elbow, at the cubital tunnel here, and then might hold the elbow in a little degree of flexion and put a little pressure right over the ulnar nerve and then time that. That's a test that if the patient develops the onset of numbness or tingling within sometimes a minute or two, they may have some swelling or irritation at the ulnar nerve at the elbow. A normal nerve will not necessarily become numb and tingly over a short period of time over a few seconds. A more inflamed, compressed nerve certainly will.

Dr. Sechrest: Yeah, it's interesting. Patients will a lot of times present when these symptoms are coming and going. They're not there all the time and sometimes it's very difficult to sort of make that decision of what's going on because you can't see anything at the time. Imaging studies. Is there any role for any type of imaging whether it's x-ray, MRI scan, anything to help make this diagnosis?

Dr. Mazzara: If you think it's exclusively located at the elbow, I'll do an x-ray of the elbow to make sure we're not missing some arthritis. On the other hand, if you think it's at the neck or a potential for there to be nerve compression at the neck, you need to do an x-ray of the cervical spine. I'll occasionally do an MRI of the cervical spine if I think there is the slightest possibility of somebody having a nerve compressed elsewhere. In addition to that, I don't think an MRI of the elbow is necessary, but I will always do a nerve conduction test. So EMG, nerve conduction study, will tell me fairly precisely where the nerve is compressed including whether or not it's compressed in the neck and how severely it's compressed and whether or not there's any nerve damage; and if so, how much is there. Is it mild compression of the nerve or is it more advanced compression of the nerve where some of the fibers or filaments of the nerve, some of the individual nerve fibers themselves have started to die. That's a more significant finding because that really indicates that any treatment you have has to be directed to a more advanced degree of nerve damage and the outcome of that may be different than if it's very mild nerve damage.

Dr. Sechrest: Well, let's talk a little bit about treatment, and let's start with what are our options for conservative treatment? Medications? Physical therapy? What works?

Dr. Mazzara: Well, what I've found is that the use of anti-inflammatories can be very helpful. I commonly ask patients to try to avoid putting pressure on the elbow, so leaning with the arm down is generally not a good idea if you have ulnar neuropathy. Physical therapy, I've not really found to be very helpful. I don't use injections in this area. I don't find that to be very helpful at all. Sometimes at night, I'll ask patients to wear a little padded elbow brace at night – a little gentle reminder that they shouldn't be bending their elbow when they sleep, but that's very hard for patients to do.

Dr. Sechrest: Yeah, I find that patients really resist those splints. It will work if you can sleep with your arm out straight, but you can't sleep.

Dr. Mazzara: Right.

Dr. Sechrest: So, you've sort of created another problem for them for the most part. When should a person be concerned and begin considering whether or not this needs surgery to decompress that nerve?

Dr. Mazzara: Well, that really requires that we break down patients into separate categories. So, if there's mild, moderate, and more advanced degrees of nerve damage, patients who have milder forms of nerve compression at the elbow may get better with activity modification and anti-inflammatories and a little bit of time. Those people generally don't need surgery. If they get better over a short period of time, they don't even need to have a nerve conduction test. Patients who may have seen continuing symptoms even with modified activity and anti-inflammatories and maybe that splint that we referred to generally are going to need a nerve conduction test, and if they have some evidence of pressure on the nerve, they become a candidate for a decompression of that nerve. People who have more advanced degrees of nerve damage, who have suggestion that there is some death of the individual nerve fibers, potentially permanent damage of those nerve fibers at the ulnar nerve at the elbow, really need to think seriously about having that nerve treated surgically, because they're just not going to get better with bracing and time and anti-inflammatories; and to not treat those people surgically, or at least offer them surgery, really means that they have permanent damage which, guaranteed, will get worse. If you take that last group of patients with advanced nerve damage, the best you can tell those people sometimes is that, "We can decompress your nerve. If everything goes well it won't get worse." We can't really promise them they're going to get better though.

Dr. Sechrest: Right. Now, in terms of the actual operation. I know there's many different ways described in our surgical literature, and people use different techniques to decompress the ulnar nerve. What's your approach to surgery on the ulnar nerve?

Dr. Mazzara: Well, studies look at the different techniques that we offer patients, and every once in a while some study will come out and say this technique is better than that technique. Recently, there was a study that was reviewed in our orthopaedic journal that says they're all pretty comparable, and of the three major treatment options my own preference is to do a decompression, or what's called the medial epicondylectomy; and what that does is you actually go into the area where the nerve is at the elbow through a small incision, and for very mild forms or moderate degrees of cubital tunnel, just decompressing the nerve, releasing it, and removing a little bump on the bone called the medial epicondyle and mobilizing that nerve forward can be very, very effective. In those patients, one of the downsides of that is that the nerve is then on the inside of the elbow, it's under the skin, but can be a source of irritation for some patients. There's another technique called subcutaneous decompression, which I don't normally do because I find that those people have a potential increased rate of recurrence; and the procedure that I prefer to do is called a submuscular transposition of the ulnar nerve which actually allows me to take the ulnar and put it under the muscle where I think it has the best chance at healing, at recovering, and has the lowest chance of being a source of irritation for patients because it's protected by muscle and tendon. When we look at patients who need revisions of cubital tunnel surgery previously performed, almost everybody agrees that those people end up needing a submuscular transposition of the nerve because where the nerve seems to do the best. Well, my own philosophy is if the nerve does well there for a revision, it should do well there for a first time around that I think many of those patients seem to do very well.

Dr. Sechrest: How do you make the decision whether you proceed on initially with a submuscular transposition or whether you do the medial epicondylectomy?

Dr. Mazzara: I think for very mild to moderate forms of cubital tunnel in somebody who I don't think is at risk for having irritation of the nerve, I'll recommend and offer a decompression of the medial epicondylectomy. You just remove a little portion of the medial epicondyle, it's not the whole portion of the bone, because that would destabilize the joint, but there's a technique for doing that allows us to take some tension off the nerve and free it up. For patients who I think are going back to more physical kinds of tasks, who may have more advanced degrees of nerve injury, I think those are people who would end up doing better with a submuscular transposition. Now there are different versions of the submuscular transposition. The one I do puts nerve in the front of the elbow where it's under no tension whatsoever and we do a lengthening of the tendon. So what we'll actually do is we'll move the muscle and tendon down, but we cut the tendon in such a way where we can actually reattach it, but it's longer, so there's less tension and there's no chance for that nerve to be under any pressure at that point.

Dr. Sechrest: Now, let's talk a little bit about the recovery time for these two procedures. What is a patient expecting? I'm assuming that this is still being done as an outpatient procedure?

Dr. Mazzara: It is.

Dr. Sechrest: These patients are not staying in the hospital.

Dr. Mazzara: It's an outpatient procedure. The patients are generally given a bulky dressing for a week or so, sometimes a little bit less for the medial epicondylectomy and the debridement. Those people can get moving fairly quickly. When we do the submuscular transposition I might put them in a padded dressing for about a week or so, but then they start moving fairly quickly after that. I generally don't let them do any heavy work for sometimes 4-6 weeks, but they can do lighter activities much sooner than that.

Dr. Sechrest: Are they going to need any sort of physical therapy after this or do these people recover on their own?

Dr. Mazzara: Sometimes they need physical therapy. They go back. They work with the therapist to get their motion back, and the motion comes back very, very quickly. The strength takes a little bit longer because the tendons that are attached up here tend to take a little bit of time to recover.

Dr. Sechrest: Now what about nerve damage? What are we talking about when we're monitoring these patients after surgery? How long do you think it's going to take for us to see any change in that nerve? If the nerve is going to get better, how long is that going to take? And when do we finally give up and say, "you know, we've stopped the process, but we don't think you're going to get any better"?

Dr. Mazzara: It depends on the degree of nerve damage. Many patients will come back after surgery and all of their preoperative symptoms are gone, and they're gone because the nerve was not permanently damaged. So taking the pressure off the nerve, decompressing that nerve, or translocating that nerve makes all the difference in the world. Those people come back and their elbow hurts from having the surgery, but their fingers and hand feel normal. When they have more advanced degrees of nerve damage, some of those people may come back after surgery and say, "Well, the aching in the arm is gone, but my fingers are still numb and my hand is still weak." That nerve will take a year, maybe two, to fully recover depending on the degree of nerve damage.

Dr. Sechrest: So you're telling people at this point, "Don't give up hope yet" and "It could take a while".

Dr. Mazzara: Yes. It can take quite a while depending on the degree or nerve injury.

Dr. Sechrest: It's interesting. I think that sometimes what I'll tell patients is that I think we've got pretty good evidence that nerves grow at about 2 millimeters a day, if they're starting to grow back.

Dr. Mazzara: Yes.

Dr. Sechrest: So, if you cut a nerve and repair it, you're expecting it to sort of 2 millimeters a day, and it takes a while, probably 6-8 weeks for that process to start, before it starts.

Dr. Mazzara: Exactly.

Dr. Sechrest: So sometimes I'll sort of do this process where I'll measure and say, "Well, this is sort of what I would expect, and it can be anywhere around that, but this is the way I'm gauging what I'm telling you."

Dr. Mazzara: I would agree. I would tend to be a little bit more conservative. I tell them a millimeter a day. That gives me a little bit of time to allow those patients to expect recovery, and I think that a millimeter to two a day is not unrealistic, but it's not immediate. Okay. The nerve has the potential to regenerate but it never quite gets back to perfection. It can get better, but to promise a patient who has got really advanced nerve damage a normal outcome, is not always a realistic thing. People will recover tremendously following this kind of surgery, but not always to perfection.

Dr. Sechrest: Yes. Well, I think the best advice we can give patients is have patience.

Dr. Mazzara: And don't wait so long.

Dr. Sechrest: And don't wait so long before they have surgery.

Dr. Mazzara: Yeah, yeah.

Dr. Sechrest: Just out of curiosity, do you ever do a repeat nerve conduction velocity to try to see if, and show the patient, that actually the nerve is repairing itself? Is that any use to you?

Dr. Mazzara: I generally don't do that to demonstrate to the patient that the nerve is recovering unless there's another issue at hand that I'm concerned about injury to nerve itself. If I'm concerned about injury to the nerve itself, or scar tissue in the nerve itself, I might do that. If I'm considering a second exploration of the nerve, because the patient for a period of time is not seeing any improvement, then we may go and do a nerve test to see if there's any change from the previous change from the previous EMG nerve conduction test. So going in and sometimes decompressing the nerve itself can be beneficial for those patients, but in many cases, that's not going to be a lot of help.

Dr. Sechrest: Well, let's talk about some of the things that can go wrong with an operation like this. I think we mentioned the fact that even if the surgery is done pristinely, you still may not get better. You may still feel that it's successful that we've stopped the process, but I'm assuming this like other types of surgery, has potential complications. What do you worry about an orthopaedic surgeon?

Dr. Mazzara: Well, you're operating on the nerve, and you're always worried about nerve injury. So the things we worry about are nerve damage, and that's an issue for concern in any instance where you're doing any kind of nerve decompression; and even though we know where the nerve is, and we're extremely careful, any kind of nerve that is injured, or under tension in the first place, is very sensitive and very prone to manipulation, so it's much more likely to become injured if there's a little bit of extra tension on it. Bleeding. Bleeding is always a concern. Sometimes bleeding will occur in the area and, in particular, if somebody's doing submuscular transposition there might be a little bit more bleeding following that surgery. Some patients will have bleeding that actually goes down the arm, they look like they're quite bruised. That generally recovers very, very quickly and is not a long-term concern for the majority of those patients. Infection. Risk of any surgery. I guess the biggest concern is outcome. You have to have realistic expectations. If your nerve is very badly damaged, you can't expect perfection. If it's mild and you're getting to it early on in the process, you can expect a much better result. And then there's always the risk of recurrence. Recurrent nerve compression, irritation of the nerve. When you look at the studies that seem to analyze the rate of recurrence, one of the studies that was published in 2003 would indicate that the lowest rate for recurrence is with the submuscular transposition, with the lengthening of the tendon, and, in fact, that's the procedure I do in the majority of the patients that I see.

Dr. Sechrest: Any other complications that we should discuss that are potential problems with this operation?

Dr. Mazzara: One thing that we see in some patients is sometimes an injury to the branch of medial antebrachial cutaneous nerve. In English what that really means is that there's a very, very tiny branch, sensory branch, of a nerve over here on the inside of the elbow, and in some patients that branch of the nerve is either directly in the way of the transposition of the big ulnar nerve. In most patients we can preserve that, protect it, and move it out of the way. In some patients, we may have to sacrifice a small branch. Some people may have a little area of numbness on the inside of the elbow. Nobody really complains about that. It doesn't really bother patients, but it's something that I counsel patients on preoperatively so if they come back and their hand feels better and there's a little numb area on the inside of their elbow or forearm, they're not overly concerned about that and we know that happens, but it's not a big issue.

Dr. Sechrest: Well, thanks for an interesting discussion about a very common problem in the elbow. Any last minute advice you would have to patients who may looking for a physician to take care of this? They suspect they have a problem in the elbow with their cubital tunnel. What should they be looking for in a surgeon?

Dr. Mazzara: Well, I think you need to see somebody who has a lot of experience and special interest in treating this condition. I would tell you that not every orthopaedic surgeon will treat cubital tunnel syndrome surgically. Not everybody has got a vast background and experience in treating this particular condition, and you really have to understand that if a nerve is under pressure and it's injured, the longer you wait, the more likely that nerve is to develop permanent damage potentially leading to a less optimal outcome when you eventually decide to have treatment. So if you have nerve injury in the arm and elbow, you really don't want to wait until it's permanently damaged because the results may not be as good as you would like.

Dr. Sechrest: So this is not a condition that you want to sort of say, "It'll go away and I'll just live with it for a while"?

Dr. Mazzara: I think when your fingers are numb and tingly and your hand is weak that's a reason to be concerned and get an evaluation.

Dr. Sechrest: I think that sounds like good advice. Thank you very much.

Dr. Mazzara: Thank you.

Dr. Sechrest: Thank you very much. Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.