What is the treatment for cubital tunnel syndrome?

Treatment of Cubital Tunnel Syndrome

The treatment of cubital tunnel syndrome should begin with conservative management for mild to moderate cases, progressing to surgical intervention when conservative measures fail or in cases with advanced symptoms such as muscle weakness, atrophy, or fixed sensory changes. 1

Initial Assessment and Diagnosis

• Typical symptoms include:

  • Numbness and tingling in the ring and small fingers (earliest sign)
  • Paresthesia along the ulnar nerve distribution
  • Hand weakness and clumsiness
  • Muscle atrophy (in advanced cases)
  • Pain and tenderness at the medial elbow

• Diagnostic tests:

  • Physical examination: Tinel's sign, flexion-compression test, palpation for nerve thickening
  • Nerve conduction studies to confirm diagnosis
  • Ultrasound or MRI to visualize morphological changes in the nerve 1, 2

Treatment Algorithm

1. Conservative Management (First-Line for Mild to Moderate Cases)

• Activity modification: Avoid repetitive elbow flexion and external pressure on the nerve
• Night splinting to prevent elbow flexion during sleep
• Elbow padding during daytime activities
• Night-gliding exercises 2

2. Surgical Management

Indicated when:

• Conservative treatment fails
• Patient presents with motor weakness
• Muscle atrophy is present
• Fixed sensory changes are evident 1

Surgical Options:

1. Simple In Situ Decompression (Treatment of Choice)

   • Can be performed open or endoscopically under local anesthesia
   • Must extend 5-6 cm distal to the medial epicondyle
   • Recommended for primary cubital tunnel syndrome and most post-traumatic cases 1

2. Anterior Transposition

   • Subcutaneous transposition: Indicated for painful ulnar nerve luxation or when the nerve "snaps" over the medial epicondyle
   • Submuscular transposition: Preferred in cases with significant scarring, providing a healthy vascular bed and soft tissue protection
   • Intramuscular transposition: Less commonly used 1, 3

3. Medial Epicondylectomy

   • Less commonly performed, especially in Germany 1

Special Considerations

• In cases of severe bone or tissue changes at the elbow (especially with cubitus valgus), anterior transposition is indicated 1
• For persistent or recurrent cubital tunnel syndrome, submuscular transposition with musculofascial lengthening has shown good results 4

Potential Complications

• Risks of transposition include compromised blood flow to the nerve and kinking due to insufficient mobilization
• Revision surgery may be necessary if complications occur 1
• Advanced disease can lead to irreversible muscle atrophy and hand contractures if left untreated 3

Treatment Outcomes

• Simple decompression is effective for most primary cases of cubital tunnel syndrome
• Comparative studies show short-term advantages to specific techniques, but overall results between different surgical approaches are generally equivocal
• The choice of surgical treatment should be based on the specific clinical situation and etiology of nerve compression 3

When properly diagnosed and treated, most patients with cubital tunnel syndrome can expect good outcomes with significant symptom relief and prevention of further nerve damage.