Symptoms After Ulnar Nerve Decompression

Patients suffering from cubital tunnel syndrome may seek relief from painful, disabling symptoms through surgery. But imagine their surprise and disappointment when they have a successful outcome and then the symptoms come back. Are these symptoms the same old (persistent) unchanged symptoms or are they a true recurrence of the previous problem?

That is the question addressed by two hand surgeons from Kaiser Permanente in Los Angeles California and the University of Washington (Seattle). Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow.

The symptoms are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel will cause an electric shock sensation down to the little finger. This is called Tinel's sign. Grip strength may be affected to the point that the person can no longer lift objects or even hold a cup of coffee. This syndrome can be very disabling.

Treatment usually begins with conservative (nonoperative) care. First, it is important to stop doing whatever is causing the pain in the first place. Taking frequent breaks during activities and even modifying job activities is important. Antiinflammatory medications, physical therapy, and splinting are helpful. The therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on the elbow.

If the symptoms do not go away with changes in activity and nonsurgical treatments, surgery to stop damage to the ulnar nerve may be recommended. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. The hope is to reduce pain and other symptoms, possibly to even eliminate all symptoms. But a full recovery is rare. And even those patients who experience a good result at first often experience a return of their former symptoms.

So, again the question becomes -- were those symptoms there all along and the patient didn't realize it? Or are these symptoms a recurrence (the problem got better at first and then worse later)? As the authors of this article point out, the answer to this question is unknown. Certainly it is possible that the patient was so hopeful for improvement that they felt a change in their symptoms even when there was no change in the nerve physiology or function.

And it is possible that another problem is present (e.g., painful neuroma over the nerve) that could be adding to the persistent symptoms. But studies show that removing the neuroma or performing a second surgery to take pressure off the nerve doesn't seem to help. If anything, patients report worse results after revision surgery.

In fact, it is more often the case that the symptoms of pain or numbness, weakness, and muscle atrophy (wasting) are permanent. It's possible the first surgery was unlikely to change anything. The authors suggest that there could have been symptoms of nerve dysfunction for a long time before the patients ever noticed them. By the time the problem became obvious, damage to the nerve was permanent.

There are some risk factors to suggest patients who might not be good candidates for surgery to treat cubital tunnel syndrome. These include depression or other mood disorders and/or problems with coping. Dissatisfaction with the results and disability are linked with these psychologic problems and may be the real key to poor outcomes.

There is also the possibility that poor results occur because of the surgery itself. There are different ways to surgically treat cubital tunnel syndrome. Studies are needed to show which technique is the best with the fewest complications. Until the procedure is perfected, the authors suggest that patients should be told what to expect realistically.

Failure to get the desired results may require a second procedure to look for (and remove) any neuromas and to further decompress the nerve (beyond what was done in the first surgery). Follow-up rehab with the hand therapist is essential to ensure full, smooth nerve gliding and prevent scar adhesions from forming.

References: Amirhesam Ehsan, MD, and Douglas P. Hanel, MD. Recurrent or Persistent Cubital Tunnel Syndrome. In The Journal of Hand Surgery. September 2012. Vol. 37A. No. 9. Pp. 1910-1912.