What are the treatment options for ulnar nerve compression or neuropathy?

Treatment Options for Ulnar Nerve Compression or Neuropathy

The first-line treatment for mild to moderate ulnar nerve compression should be conservative management, including patient education on avoiding prolonged elbow flexion and maintaining neutral forearm position, while surgical intervention should be reserved for cases that fail conservative treatment or show progressive neurological deficits. 1

Conservative Treatment Options

Patient Education and Activity Modification

• Avoid positions that place pressure on the ulnar groove
• Limit arm abduction to 90° when supine
• Avoid elbow flexion greater than 90°
• Maintain neutral forearm position
• Avoid prolonged movements or positions that aggravate symptoms

Splinting and Physical Therapy

• Night splinting to maintain neutral elbow position
• Nerve gliding exercises
• Heat application as adjunctive therapy

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)
  • Avoid tricyclic antidepressant dosages higher than 100 mg/day due to cardiac risk
• Topical agents: lidocaine patches or creams

Surgical Treatment Options

Surgical intervention should be considered for:

• 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

Surgical Techniques

1. Simple decompression: Moderate-quality evidence shows this is equally effective as transposition procedures with fewer wound infections 2

2. Decompression with transposition:

   • Subcutaneous transposition
   • Submuscular transposition
   • Both are effective but associated with more wound infections than simple decompression 2

3. Medial epicondylectomy: Comparable outcomes to anterior transposition 2

4. Endoscopic decompression: Similar clinical improvement to open decompression but higher risk of hematoma 2

Treatment Algorithm Based on Severity

Mild to Moderate Cases

1. Start with patient education and activity modification
2. Add night splinting and nerve gliding exercises if needed
3. Consider pharmacological management for pain control
4. Monitor for 3 months for improvement

Severe Cases or Failed Conservative Management

1. Surgical consultation
2. Simple decompression as first-line surgical approach (fewer complications)
3. Consider transposition procedures for specific cases (recurrent symptoms, subluxation)

Risk Factors to Consider

• Body habitus
• Pre-existing neurologic symptoms
• Diabetes mellitus (optimize glucose control)
• Peripheral vascular disease
• Alcohol dependency
• Arthritis

Perioperative Considerations for Prevention

• Avoid improper use of automated blood pressure cuffs on the arm 3
• Avoid shoulder braces in steep head-down position 3
• Use padded armboards to decrease risk of upper extremity neuropathy 3
• Use specific padding at the elbow to decrease risk of ulnar neuropathy 3
• Perform early postoperative physical assessment to detect neuropathies 3

Follow-up and Monitoring

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

Long-term outcomes after surgical treatment remain favorable even after 20+ years of follow-up, suggesting that appropriate surgical intervention provides durable results 4.