The Relationship between Early Improvement of Subjective Symptom and Surgical Outcomes in Moderate to Severe Cubital Tunnel Syndrome

Jung Yun Bae; Sang Ho Kwak; Seok Hyeon Kim; Won Chul Shin; Seung-Jun Lee; Kuen-Tak Suh

doi:10.4055/jkoa.2017.52.2.161

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Bae, Kwak, Kim, Shin, Lee, and Suh: The Relationship between Early Improvement of Subjective Symptom and Surgical Outcomes in Moderate to Severe Cubital Tunnel Syndrome

Original Article

J Korean Orthop Assoc 2017;52(2):161-169.

Published online: 1 December 2017

DOI: https://doi.org/10.4055/jkoa.2017.52.2.161

The Relationship between Early Improvement of Subjective Symptom and Surgical Outcomes in Moderate to Severe Cubital Tunnel Syndrome

Jung Yun Bae, M.D., Sang Ho Kwak, M.D., Seok Hyeon Kim, M.D., Won Chul Shin, M.D., Seung-Jun Lee, M.D., Kuen-Tak Suh, Ph.D.

Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Korea

Correspondence to: Sang Ho Kwak, M.D. Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea TEL: +82-55-360-2503 FAX: +82-55-360-2155 E-mail: shkwak2013@gmail.com

Received 4 May 2016 Revised 29 July 2016 Accepted 30 September 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Moderate to severe cubital tunnel syndrome usually requires surgical treatment. Most surgical outcomes are evaluated 6 months after the procedure; however, subjective symptoms begin to show improvement much earlier. In this study, we explored whether patients who experience early improvement of subjective symptoms have different clinical characteristics and surgical outcomes than those without early improvement.

Materials and Methods

Between January 2012 and February 2015, 36 surgical cases of moderate- to severe-stage cubital tunnel syndrome (modified McGowan grade IIA, IIB, or III) were included. Nineteen patients (15 males and 4 females with a mean age of 54.3±12.0 years) reported subjective symptom improvements within 14 days postoperatively. Seventeen patients (15 males and 2 females with a mean age of 53.4±11.9 years) did not report any early symptom improvements. Clinical characteristics—hand dominance, sex, smoking history, type of surgery, age, symptom duration, elbow range of motion, grip strength, key pinch strength, 2 point discrimination, pain, quick disabilities of the arm, shoulder and hand (DASH) score, and modified McGowan grade—were analyzed retrospectively using a Mann-Whitney test or chi square test. Surgical outcomes were measured at postoperative 3 and 12 months using repeated-measures ANOVA, and Wilson and Krout criteria were analyzed using a chi-square test.

Results

There was a difference in key pinch strength (p＜0.001) between the groups. At postoperative 12 months, Wilson and Krout criteria (p=0.029) were associated with early improvement of subjective symptoms. The subjects’ quick DASH scores and grip strengths improved over time, but no difference was observed between the groups.

Conclusion

After surgical treatments of moderate to severe cubital tunnel syndrome, patients who presented early improvement of subjective symptoms, compared with those who did not, had significantly higher preoperative key pinch strength and better surgical outcomes at postoperative 12 months.

Keywords: cubital tunnel syndrome, elbow, symptom evaluation, outcomes assessment

REFERENCES

1. Mowlavi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg. 2000; 106:327–34.

2. Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatr. 2006; 77:263–5.

3. Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am. 1989; 14:688–700.

4. Goldberg BJ, Light TR, Blair SJ. Ulnar neuropathy at the elbow: results of medial epicondylectomy. J Hand Surg Am. 1989; 14:182–8.

5. Svernlöv B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur Vol. 2009; 34:201–7.

6. Catalano LW 3rd, Barron OA. Anterior subcutaneous transposition of the ulnar nerve. Hand Clin. 2007; 23:339–44.

7. Dellon AL. Techniques for successful management of ulnar nerve entrapment at the elbow. Neurosurg Clin N Am. 1991; 2:57–73.

8. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989; 14:972–9.

9. Kim KW, Lee HJ, Rhee SH, Baek GH. Minimal epicondylecto-my improves neurologic deficits in moderate to severe cubital tunnel syndrome. Clin Orthop Relat Res. 2012; 470:1405–13.

10. Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Br. 2005; 30:521–4.

11. Mitsionis GI, Manoudis GN, Paschos NK, Korompilias AV, Beris AE. Comparative study of surgical treatment of ulnar nerve compression at the elbow. J Shoulder Elbow Surg. 2010; 19:513–9.

12. Macadam SA, Bezuhly M, Lefaivre KA. Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature. J Hand Surg Am. 2009; 34:1482–91.e5.

13. Lascar T, Laulan J. Cubital tunnel syndrome: a retrospective review of 53 anterior subcutaneous transpositions. J Hand Surg Br. 2000; 25:453–6.

14. Hoffmann R, Siemionow M. The endoscopic management of cubital tunnel syndrome. J Hand Surg Br. 2006; 31:23–9.

15. Kawanishi Y, Miyake J, Omori S, Murase T, Shimada K. The association between cubital tunnel morphology and ulnar neuropathy in patients with elbow osteoarthritis. J Shoulder Elbow Surg. 2014; 23:938–45.

16. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994; 19:817–20.

17. Oh SJ. Clinical electromyography: nerve conduction studies. 2003. 3rd ed. Philadelphia: Lippincott Williams & Wilkins;p. 105.

18. Mathiowetz V, Rennells C, Donahoe L. Effect of elbow position on grip and key pinch strength. J Hand Surg Am. 1985; 10:694–7.

19. Wilson DH, Krout R. Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompression without transposition. Technical note. J Neurosurg. 1973; 38:780–5.

20. Köse KC, Bilgin S, Cebesoy O, et al. Clinical results versus subjective improvement with anterior transposition in cubital tunnel syndrome. Adv Ther. 2007; 24:996–1005.

21. Assmus H, Antoniadis G, Bischoff C. . Cubital tunnel syndrome: a review and management guidelines. Cent Eur Neurosurg. 2011; 72:90–8.

22. Nathan PA, Keniston RC, Meadows KD. Outcome study of ulnar nerve compression at the elbow treated with simple decompression and an early programme of physical therapy. J Hand Surg Br. 1995; 20:628–37.

23. Goldfarb CA, Sutter MM, Martens EJ, Manske PR. Incidence of re-operation and subjective outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009; 34:379–83.

24. Ogata K, Manske PR, Lesker PA. The effect of surgical dissection on regional blood flow to the ulnar nerve in the cubital tunnel. Clin Orthop Relat Res. 1985; 193:195–8.

25. Gaspar MP, Jacoby SM, Osterman AL, Kane PM. Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome. J Shoulder Elbow Surg. 2016; 25:681–7.

26. Seradge H, Owen W. Cubital tunnel release with medial epi-condylectomy factors influencing the outcome. J Hand Surg Am. 1998; 23:483–91.

27. Shi Q, MacDermid JC, Santaguida PL, Kyu HH. Predictors of surgical outcomes following anterior transposition of ulnar nerve for cubital tunnel syndrome: a systematic review. J Hand Surg Am. 2011; 36:e1–6.

28. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: part 1. Neurosurgery. 2005; 56:522–30.

29. Matsuzaki H, Yoshizu T, Maki Y, Tsubokawa N, Yamamoto Y, Toishi S. Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome. J Hand Surg Am. 2004; 29:373–8.

30. Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery. 2005; 56:108–17.

Figure 1

Radiologically excluded cases (A, B) and included case (C, D) are presented. (A) An anteroposterior radiograph of a 39-year-old male with post traumatic cubitus varus deformity. (B) In an anteroposterior radiograph of a 55-year-old male, there are medial osteophytes on the humerus and the ulna. (C, D) A small osteophytes are identified at the coronoid process and olecranon of a 62-year-old male. There is no medial osteophyte on the humerus and ulna.

Figure 2

Quick disabilities of the arm, shoulder and hand (quick DASH) scores (A), grip strength (B), and pinch strength (C) are shown. *p<0.017; error bars=1 standard deviation.

Table 1

Patient Demographics and Clinical Characteristics at Preoperative Status

Characteristic	Non-improved (n=17)	Improved (n=19)	p-value
Gender (male/female)	15/2	15/4	0.66
Type of operation (in situ decompression/partial epicondylectomy)	8/9	7/12	0.73
Diseased elbow (right/left)	11/6	11/8	0.74
Dominant elbow (dominant/non-dominant)	11/6	12/7	1.0
Smoke (yes/no)	6/11	7/12	1.0
Elbow flexion test (+/-)	7/10	11/8	0.51
Tinel sign (+/-)	13/4	15/4	1.0
Froment sign (+/-)	14/3	13/6	0.45
Egawa sign (+/-)	14/3	11/8	0.16
Age (yr)	53.4±11.9	54.3±12.0	0.71
Duration (mo)	11.5±5.8	16.2±18.2	0.49
2 point discrimination (mm)	4.0±1.4	4.7±1.4	0.18
Range of motion (°)	130.6±10.0	131.8±9.0	0.83
VAS score	7.7±1.2	7.3±1.4	0.27
Initial quick DASH score	51.5±14.5	46.9±15.9	0.37
Initial grip strength (kg)	23.6±7.9	27.6±9.3	0.18
Initial pinch strength (kg)	2.6±1.1	3.7±1.4	0.01

Values are presented as number only or mean±standard deviation. Preoperative pinch strength was different between the groups (p=0.01). VAS, visual analogue score; DASH, disabilities of the arm, shoulder and hand.

Table 2

Preoperative Modified McGowan Grade^*

McGowan grading	Non-improved	Improved
IIa	2	6
IIb	12	9
III	3	4

^* This result was not significantly different between the groups (p=0.28).

Table 3

Postoperative Wilson and Krout's Criteria^*

Postoperative grading	Non-improved						Improved
Postoperative grading	Normal	McGowan grade I	McGowan grade IIa	McGowan grade IIb	McGowan grade III	Sum	Normal	McGowan grade I	McGowan grade IIa	McGowan grade IIb	McGowan grade III	Sum
Excellent	0	0	8	0	0	10	2	1	6	2	0	11
Good	1	0	2	0	0	3	0	2	4	2	0	8
Fair	0	0	1	2	1	3	0	0	0	0	0	0
Poor	0	0	0	1	1	2	0	0	0	0	0	0
Sum	1	0	11	3	2	17	2	3	10	4	0	19

^* This result was significantly different between the groups (p=0.029).

Table 4

Quick DASH Score, Grip Strength and Pinch Strengths at the Preoperative State, 3 Months and 12 Months after the Surgery

Function	Preoperative		3 months after the surgery		12 months after the surgery
Function	Non-improved	Improved	Non-improved	Improved	Non-improved	Improved
Quick DASH score^*	51.5±14.5	46.9±15.9	38.4±13.9	32.3±13.4	24.0±15.4	17.0±11.1
Grip strength (kg)^†	23.6±7.9	27.6±9.3	25.9±8.0	30.8±9.2	27.9±8.1	33.5±9.4
Pinch strength (kg)^‡	2.6±1.1	3.7±1.4	3.2±1.1	4.4±1.4	4.0±1.5	5.1±1.6

Values are presented as mean±standard deviation. DASH, disabilities of the arm, shoulder and hand.

^* Sum of squares for time (SST): p<0.001, Sum of squares for interaction of time and group (SSTG): p=0.640; between group p=0.178.

^† SST: p<0.001, SSTG: p=0.202; between group p=0.101.

^‡ SST: p<0.001, SSTG: p=0.934; between group p=0.012.

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