What is the treatment for ulnar nerve compression?

Treatment for Ulnar Nerve Compression

Conservative management should be tried first for mild to moderate cases of ulnar neuropathy, with surgical intervention reserved for severe or progressive cases that fail to respond to non-surgical approaches after approximately 3 months. 1

Diagnosis Considerations

• Distinguish ulnar neuropathy from other causes such as cervical radiculopathy, thoracic outlet syndrome, vitamin B12 deficiency, hypothyroidism, and alcohol toxicity
• MRI is the reference standard for imaging ulnar nerve entrapment
• Ultrasound assessment has high accuracy rates for evaluating nerve entrapment and can demonstrate nerve dislocation

Conservative Management

Patient Education and Activity Modification

• Avoid prolonged elbow flexion and direct pressure on the nerve
• Maintain optimal postural alignment at rest and during activities
• Reduce activities that cause symptoms

Splinting

• Night splinting to prevent elbow flexion shows 89% improvement rate in symptoms 2
• Splinting is preferred over injections as it shows a higher rate of improvement 2

Pharmacological Management

• First-line medications:
  • Calcium channel α2-δ ligands: gabapentin (900-3600 mg/day) or pregabalin (300-600 mg/day)
  • Tricyclic antidepressants: nortriptyline or desipramine (start at 10 mg/day, titrate up to 75 mg/day)
  • SNRIs: duloxetine (60-120 mg/day) or venlafaxine (150-225 mg/day) 1
  • Avoid tricyclic antidepressant doses higher than 100 mg/day due to cardiac risk

Local Injections

• Steroid/lidocaine injections show improvement in 54% of cases 2
• Can be used as a bridge to surgery or for patients who refuse surgical intervention

Topical Treatments

• Lidocaine patches or creams may provide relief for neuropathic pain
• Topical amitriptyline-ketamine combinations may be beneficial

Surgical Management

Indications for Surgery

• Severe symptoms unresponsive to conservative measures
• Progressive neurological deficits
• Failed conservative treatment after approximately 3 months
• Significant functional limitation
• Habitual ulnar nerve subluxation/dislocation at the elbow 1

Surgical Options

1. Simple (in situ) decompression
2. Decompression with medial epicondylectomy
3. Anterior subcutaneous transposition
4. Anterior submuscular transposition 3

Submuscular transposition has a high degree of success and is generally accepted as the preferred procedure when prior surgery has been unsuccessful 4. It's also preferred as the primary procedure for most chronic neuropathies requiring surgery.

Follow-up and Monitoring

• Regular reassessment of pain and function
• Monitor for medication side effects, especially with tricyclic antidepressants (anticholinergic effects, cardiac toxicity)
• Adjust treatment based on response
• Consider referral to physical therapy if symptoms persist

Special Considerations

• For patients with diabetes, optimizing glucose control is crucial to prevent progression of neuropathy 1
• Elderly patients and those with thick adipose tissue in their arms may benefit more from subcutaneous transposition if surgery is needed 4
• Be vigilant for ulnar nerve compression in bedridden patients, as it can occur during prolonged bed rest 5

Treatment Algorithm

1. Start with conservative management (splinting, activity modification, medications)
2. If no improvement after 6-8 weeks, consider steroid/lidocaine injection
3. If symptoms persist after 3 months of conservative treatment or if neurological deficits progress, refer for surgical evaluation
4. For surgical cases, select procedure based on severity and specific anatomical considerations, with submuscular transposition often preferred for chronic cases