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J Korean Soc Surg Hand. 2015 Sep;20(3):148-152. English.
Published online September 30, 2015.  https://doi.org/10.12790/jkssh.2015.20.3.148
Copyright © 2015. The Korean Society for Surgery of the Hand
Identification of Double Compression Lesion of Ulnar Nerve after Cubital Tunnel Release
Joon Yub Kim, Ho Il Kwak, Jeong Hyun Yoo, Joo Hak Kim, Dong Wook Sohn and Jae Ho Cho
Deaprtment of Orthopedic Surgery, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea.

Correspondence to: Ho Il Kwak. Department of Orthopedic Surgery, Myongji Hospital, Seonam University College of Medicine, 55 Hwasu-ro 14 beon-gil, Deokyang-gu, Goyang 10475, Korea. TEL: +82-31-810-5114, FAX: +82-31-969-0500, Email: khinael@naver.com
Received May 27, 2015; Revised August 28, 2015; Accepted August 31, 2015.

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

The double compression syndrome of the ulnar nerve is a rare condition. Herin, we experienced double compression of ulnar nerve at cubital tunnel and Guyon's canal by re-evaluation after surgical decompression of cubital tunnel. We might suspect the double compression lesion in cases of worsening of symptom or nerve conduction velocity findings in a relative short duration of symptom as in our case. Meticulous physical examination might be needed to detect the Guyon's canal syndrome as a comorbidity in the treatment of cubital tunnel syndrome and re-evaluation for dual compression might be recommended if the resolution of symptom was not achieved after surgical decompression of single nerve lesion.

Keywords: Cubital tunnel syndrome; Guyon's canal syndrome; Double crushing syndrome; Double compression syndrome; Surgical decompression

INTRODUCTION

Ulnar neuropathy is a common condition and cubital tunnel syndrome is the second most common nerve compression syndrome in the upper extremity after carpal tunnel syndrome1. The double compression or crushing syndrome was first described by Upton and McComas2 and it is a compression neuropathy with dual compression of the single nerve along with its pathway. The proximal compression lesion of a single nerve might cause the disruption of axonal flow and neurofilament architectures resulting in the distal nerve to be vulnerable to the compression and make clinical symptom worse than the simple addition of symptoms of two compression lesions1 Both surgical releases of double compression lesion were thought to be optimal rather than the single lesion release1. The double compression syndrome of the ulnar nerve, especially occurring at the cubital tunnel and Guyon's canal simultaneously was reported before but is rare3, 4. Herein, we experienced the double compression syndrome of ulnar nerve which was diagnosed late after the surgical decompression of the cubital tunnel. The blind faith to the result of nerve conduction study which was the compression of ulnar nerve at distal cubital tunnel and mild compression of median nerve at wrist as well as non-meticulous initial physical examination and rarity of the disease itself made authors miss the compression lesion at Guyon's canal.

CASE REPORT

A 56-year-old female patient, who was a housewife, visited the outpatient clinic with a complaint of tingling sensation in her ring and little fingers for the last eight months. On physical examination, the Tinel's sign in the medial elbow was positive and the elbow flexion test induced tingling sensation in the ring and little fingers. Also, there was a diminished sensation of dorsoulnar aspect of hand with a light touch. The Tinel's sign at the level of the wrist for median nerve was positive and tapping induced tingling sensation in the middle and ring fingers, however the Tinel's test for ulnar nerve at wrist was not performed initially. The Phalen's test was positive and no definite motor compromise was found, such as atrophy of the thenar, hypothenar, and interossei muscles, decrease in pinching power, and difficulty in finger abduction. A nerve conduction velocity (NCV) study revealed a decrease in conduction velocity, between the mid-forearm and elbow segment of the motor component of the ulnar nerve, to 43.2 m/sec, compared with the contralateral side of 63.1 m/sec; and a decrease in conduction velocity, of the sensory component of the ulnar nerve, to 39.6 m/sec at the elbow to wrist segment and 41.5 m/sec at the wrist to finger segment, compared with 56.7 m/sec for the contralateral side of the elbow to the wrist and the wrist to finger segments. Decreased conduction velocity of sensory component of median nerve was also observed. Conservative treatment was prescribed, as follows: a night splint for the elbow for five months and non-steroidal antiinflammatory drugs (NSAIDs, Aceclofenac 100 mg, twice a day) for two months. However, the patient still complained of discomfort and tingling sensations in the wrist, and middle, ring, and little fingers. The patient's main complaint was tingling in the ring and little fingers, and the NCV study supported the diagnosis of cubital tunnel syndrome with mild carpal tunnel syndrome. A surgical decompression of the cubital tunnel with subcutaneous ulnar nerve anterior transposition was performed and a mild fusiform swelling of ulnar nerve, distal to cubital tunnel, was observed (Fig. 1). For the carpal tunnel syndrome, 1 mL of triamcinolone was injected into the carpal tunnel. After the operation, the Tinel's sign at distal cubital tunnel was completely disappeared; but, the tingling sensation in the ring and little fingers persisted with a little improvement. Six months after the operation, the patient still complained of tingling sensations in the middle, ring, and little fingers. In the follow-up nerve conduction study, the motor component conduction velocity of the ulnar nerve between elbow and forearm had recovered to 56 m/sec; however, the sensory component conduction velocity of ulnar nerve between wrist and finger were still decreased to 48.9 m/sec, and conduction velocity of dorsal sensory branch of ulnar nerve was recovered from 38.6 to 47.3 m/sec but still decreased compared with 60.9 m/sec of the contralateral side. On repeated physical examination, the meticulous compression around the Guyon's canal evoked abrupt aggravation of the tingling sensation in the ring and little fingers. After this, a wrist magnetic resonance imaging was performed. It revealed a dumbbellshaped ganglion at the pisotriquetral joint volarly abutting the Guyon's canal (Fig. 2). The surgical decompression of Guyon's canal with excision of the ganglion and transverse carpal ligament release were performed (Fig. 3). After the surgery, tthe tingling sensation was almost completely disappeared.


Fig. 1
Surgical decompression of cubital tunnel and subcutaneous ulnar nerve anterior transposition were performed. Focal mild swelling of the ulnar nerve was observed (white arrow).
Click for larger image


Fig. 2
Magnetic resonance imaging of Guyon's canal. A dumbbell-shaped ganglion at the pisotriquetral joint volarly abutting the ulnar nerve at Guyon's canal was observed. (A) T2 fat suppression coronal image. (B) T2 fat suppression axial image.
Click for larger image


Fig. 3
Guyon's canal decompression with excision of the ganglion and carpal tunnel release. (A) Ganglion was observed on the pisotriquetral ligament. (B) After excision of the ganglion, the capsule was opened. (C) Carpal tunnel release was also performed with Guyon's canal release.
Click for larger image

DISCUSSION

The most common compression site of the ulnar nerve is the cubital tunnel5 and compression at the Guyon's canal is infrequent but it can occur. The double compression syndrome, including the combination of cervical radiculopathy with carpal tunnel syndrome, has been reported earlier by several authors2, 6. However, the double compression syndrome of the ulnar nerve at the cubital tunnel and Guyon's canal was seldom reported before3, 4. In our case, we experienced the double compression syndrome of the ulnar nerve, which was diagnosed late after the surgical decompression of the cubital tunnel. Pearce et al.7 emphasized the importance of electrodiagnosis and stated that the electrodiagnostic study was sensitive in the detection of compression of the ulnar nerve at Guyon's canal. However, Osterman8 reported that similar motor latencies were demonstrated between an isolated carpal tunnel syndrome and double compression syndrome and it seemed difficult to classify a single nerve lesion as the double crush syndrome by an electrodiagnostic study. We also experienced the double compression syndrome of the ulnar nerve that could not be correctly diagnosed at initial work up although the NCV study was performed. An ulnar nerve lesion at Guyon's canal might be difficult to diagnose by NCV and a proximal compression lesion at the cubital tunnel might hinder diagnosis of the distal compression lesion at Guyon's canal. The clinical features and neurophysiologic findings of double compression syndrome exceed the addition of two single compression lesions, hence and one should suspect the double compression lesion in the cases where there is a worsening of symptoms or NCV findings in a relative short duration of symptoms, as in our case8. Meticulous physical examination might be needed to detect Guyon's canal syndrome as a comorbidity in the treatment of cubital tunnel syndrome and re-evaluation for dual compression might be recommended if the resolution of symptoms was not achieved after surgical decompression of single nerve lesion.

References
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