What is the recommended treatment for cubital tunnel syndrome?

Management of Cubital Tunnel Syndrome

For patients with cubital tunnel syndrome, conservative management should be the first-line treatment for mild to moderate cases, with surgical intervention reserved for cases that fail conservative therapy or present with advanced symptoms such as muscle atrophy or persistent sensory changes.

Diagnosis

• Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression syndrome after carpal tunnel syndrome 1, 2
• Clinical presentation typically includes numbness, tingling, or pain in the ring and small fingers and dorsoulnar hand 2
• Diagnosis is primarily clinical, based on physical examination findings:
  • Positive Tinel's sign at the cubital tunnel
  • Pain with elbow flexion-compression test
  • Palpable ulnar nerve thickening or tenderness 2
• Nerve conduction studies can confirm the diagnosis and assess severity 1
• Ultrasound and MRI may be useful to show morphological changes in the nerve 1

Conservative Management

For mild to moderate CuTS, conservative treatment should be attempted first:

• Patient education and activity modification to avoid repetitive elbow flexion and external pressure on the elbow 3
• Night splinting to prevent elbow flexion during sleep 3
  • Splints should maintain the elbow in 30-45° of flexion to minimize pressure on the ulnar nerve
• Nerve gliding exercises to improve nerve mobility and reduce adhesions 4
• Avoidance of leaning on the elbow or direct pressure on the cubital tunnel 3
• Conservative treatment should typically be trialed for 3 months before considering surgical options 3

Surgical Management

Surgical intervention is indicated when:

• Conservative treatment fails after 3 months
• Patient presents with muscle atrophy
• Fixed sensory changes
• Progressive motor weakness 1

Surgical options include:

1. Simple in situ decompression (open or endoscopic):

   • Treatment of choice for primary cubital tunnel syndrome
   • Decompression should extend at least 5-6 cm distal to the medial epicondyle
   • Can be performed under local anesthesia
   • Preferred for uncomplicated cases 1

2. Anterior transposition of the ulnar nerve:

   • Indicated when the nerve luxation is painful or when the nerve "snaps" over the medial epicondyle
   • Also indicated in cases with severe bone or tissue changes at the elbow, especially with cubitus valgus 1
   • Three types:
     • Subcutaneous (most common)
     • Intramuscular
     • Submuscular (preferred in cases with significant scarring) 1, 5

3. Medial epicondylectomy:

   • Less commonly performed, especially in Germany 1
   • Removes the bony prominence that may compress the nerve during elbow flexion

Treatment Algorithm

1. Mild to Moderate CuTS (no muscle atrophy or fixed sensory changes):

   • Begin with 3 months of conservative management:
     • Patient education and activity modification
     • Night splinting
     • Nerve gliding exercises
     • Avoidance of direct pressure on the elbow 3

2. If symptoms persist after conservative management:

   • Proceed to surgical intervention:
     • Simple in situ decompression for most primary cases 1
     • Consider anterior transposition if nerve instability or severe elbow deformity is present 1

3. Severe CuTS (muscle atrophy, fixed sensory changes, or progressive weakness):

   • Proceed directly to surgical intervention 1
   • Simple decompression for primary cases
   • Consider anterior transposition for complex cases with elbow deformity or nerve instability 1

Post-Treatment Monitoring

• Follow-up to assess symptom improvement and functional recovery
• Monitor for potential complications after surgery:
  • Recurrent compression (may require revision surgery)
  • Compromise in blood flow to the nerve
  • Kinking of the nerve due to insufficient mobilization during transposition 1

Prognosis

• Early intervention generally leads to better outcomes 2
• If left untreated, chronic ulnar nerve compression can lead to irreversible damage and permanent functional impairment 2, 5
• Patients with mild symptoms and shorter duration typically have better outcomes than those with advanced disease 2