The cubital tunnel syndrome caused by intraneural ganglion cyst of the ulnar nerve at the elbow: a case report

Background

Cubital tunnel syndrome is common nerve compression syndrome among peripheral nerve compression diseases. However, the syndrome caused by intraneural ganglion cysts has been rarely reported. Medical approaches, like ultrasound-guided aspiration and open surgical treatment remain to be discussed.

Case presentation

A 57-year-old woman presented with occasional pain, numbness and paralysis in her left hand and a palpable, painless mass in the ulnar side of her left elbow. Ultrasound-guided aspiration of the mass was performed to decompress the ulnar nerve. The patient experienced an evident release of pain in her hand, but symptoms of numbness and paralysis recurred 3 months later which greatly bothered the patient’s daily life. After evaluation, we had to perform an open surgery to excise the cyst. External neurolysis and anterior subcutaneous transposition were done. The patient was followed up for 2 years, and she made a complete recovery with no functional limitation.

Conclusions

The symptoms caused by intraneural ganglion cyst can be alleviated by accurate puncture. But puncture may be not complete and symptoms could recur. Complete external neurolysis can be counted as a complete and reliable treatment. Therefore, early diagnosis, careful preoperative imaging assessment and full decompression can be expected to receive a good rehabilitation.

     

The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans

The posterior branch of the medial antebrachial cutaneous nerve courses in proximity to the cubital tunnel and is particularly prone to injury during ulnar nerve release at the elbow. Inadvertent injury to medial antebrachial cutaneous nerve branches during surgery can result in the formation of painful neuromas that can be misdiagnosed as recurrent disease. It is important to understand the relevant anatomy of the medial antebrachial cutaneous nerve branches during cubital tunnel surgery to avoid significant postoperative morbidity. This prospective observational anatomic study examined the position of the posterior branch of the medial antebrachial cutaneous nerve in relationship to a standard approach to the cubital tunnel in a randomly selected group of 97 patients undergoing primary surgery over a 3-year period. Medial antebrachial cutaneous nerve branches were noted to cross at or proximal to the medial humeral epicondyle 61 percent of the time at an average proximal distance of 1.8 cm. Medial antebrachial cutaneous nerve branches were noted to cross distal to the medial humeral epicondyle 100 percent of the time at an average distal distance of 3.1 cm. Understanding the general position of crossing medial antebrachial cutaneous nerve branches during ulnar nerve release at the elbow may help to prevent iatrogenic injury to this cutaneous nerve.     

The lateral root of the ulnar nerve

In 158 brachial plexuses the origin of the fibers of the ulnar nerve-whether only from the medial or also from the lateral fascicle-was investigated. A lateral root was found in 56%. This lateral root may either be accompanied by fibers of the median nerve (type 1) or may run separately (type 2). Where this root crosses the medial root of the median nerve, either a small minority of fibers of the latter nerve may run behind the ulnar fibers (type a), or all median fibers are in front of them (type b). Considering the relation 56:44% between ulnar nerves with and without a lateral root both possibilities have to be considered as normal variations, none as a variety. In analogy to the term 'median loop' the term 'ulnaris loop' is suggested for specimens with a lateral root.     

The management of cubital tunnel syndrome: a meta-analysis of clinical studies

Despite extensive clinical experience in treating cubital tunnel syndrome, optimal surgical management remains controversial. A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. Patients were staged preoperatively into minimum, moderate, and severe groups on the basis of clinical presentation. Treatment modalities included nonoperative management, surgical decompression, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition. Statistical analysis using a standard SAS database with analysis of variance and chi-square tests was used to assess the efficacy of each therapeutic modality. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result. This article reveals statistically significant differences in outcomes among therapeutic modalities, which may assist in treatment planning; it introduces standardized methods to aid in determining, analyzing, and communicating treatment outcomes.     

A surgical approach to the motor branch of the ulnar nerve

Isolated injury to the motor branch of the ulnar nerve is a relatively rare injury, often initially misdiagnosed. If repair is attempted through the original laceration without complete motor branch exposure, results can be less than satisfactory. A recent case illustrates this injury and provides us with an opportunity to review the surgical anatomy of the motor branch of the ulnar nerve. The surgical approach to the motor branch has been detailed and specifically emphasizes complete motor branch exposure from the main ulnar nerve trunk to the most distal motor branch entry into the adductor pollicis muscle. This approach permits definition of the exact level of the nerve injury, preservation of any intact proximal fine motor branches, and facilitates the mechanics of nerve repair.     

Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics

This study evaluated the effectiveness of identifying surgically correctable ulnar nerve compression at the elbow based on provocative clinical testing alone in patients with cubital tunnel syndrome after failure of conservative treatment. Twenty-four patients were included in the study (mean age, 60 years). Three patients underwent bilateral procedures. Patients complaining of symptoms in the distribution of the ulnar nerve were tested by elicitation of Tinel's sign and combined flexion and pressure testing at the elbow and wrist. Two-point discrimination was determined. After a failed 6-week trial of conservative therapy patients underwent anterior submuscular transposition of the ulnar nerve with carpal tunnel release. Postoperatively, the change in two-point discrimination as measured at 6 months was significantly improved, with a mean improvement per digital nerve of 2.52 mm (p<0.001). Mean time to relief was 7.2 weeks. Complications included one hematoma and one seroma. A total of 26 of the 27 limbs chosen for surgical treatment by provocative clinical testing alone experienced relief of symptoms with anterior submuscular transposition of the ulnar nerve and carpal tunnel release. This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing.