Treatment / Management
Pathological findings should undergo careful evaluation when deciding on treatment options. Patients can often benefit from non-surgical interventions; therefore clinician should evaluate and determine an end goal with the patient for treatment before deciding on the route of treatment.
Non-surgical treatment:
If the symptoms are purely the result of mechanical factors such as leaning over the desk at work with weight on the elbows or sleeping with bent elbows, then correcting these postures that provoke ulnar neuropathy can be the mainstay of treatment.
In an Italian study, Padua et al. followed up 24 patients who had willingly declined surgery after the initial diagnosis. About half of these patients reported improvement in their symptoms during their follow-up appointments. Their further nerve conduction studies also showed an improvement, which further supports the evidence that patients with mild symptoms can be managed without surgical interventions.
Splinting at night time to keep the elbows straight, has been suggested in published papers as an initial management option in patients with mild symptoms.
Simple analgesia such as NSAIDs will also help with the pain.
Surgical treatment: Patients with severe signs and symptoms such as atrophy of interossei and handgrip strength weakness might not improve with conservative management. Also, patients who have failed conservative treatment for 6 months would require surgical intervention to improve their symptoms. Surgical management involves decompression of the nerve throughout the entire cubital tunnel. Some surgeons release the pressure in the cubital tunnel region while others prefer free mobilization of the ulnar nerve.
Various methods of surgical treatment have been discussed and performed. Some of the well-accepted surgical procedures for the treatment of cubital tunnel syndrome are 1) in-situ decompression; 2) endoscopic decompression; 3) decompression followed by subsequent subcutaneous transposition, intramuscular transposition, or submuscular transposition and 4)medial epicondylectomy along with in-situ decompression. Studies have shown no benefit of one over the other in terms of clinical outcomes.
Prognosis
About half the patients achieve an improvement in their symptoms with conservative management.
Complications
One in eight patients may find that their symptoms recur after surgical decompression. Insufficient decompression has been the most frequent cause for revision surgery.
Recovery may be slow and incomplete
Symptoms may worsen before they improve
Injury to the medial antebrachial cutaneous nerve of the forearm is a common complication with cubital tunnel release and can lead to a painful neuroma
Postoperative and Rehabilitation Care
Patients are generally allowed a full range of motion of the elbow following surgical intervention. Normally post-operative physical therapy is not necessary unless there is significant muscle weakness. Patients can return to light work in 3 to 4 weeks.
Deterrence and Patient Education
Patient education about the etiology and pathophysiology is of great importance if the aim is to manage the patient with conservative means as slow improvement of symptoms can put people off from conservative management.
If using non-steroidal anti-inflammatory medications, then education about the use of NSAIDs and gastric protection is a necessary discussion to have with patients. Gastric protection is obtainable by using proton pump inhibitors (PPIs). It is also suggested to take NSAIDs with or after food.
Pearls and Other Issues
Ulnar nerve neuropathy can be due to multiple etiologies. Differential diagnosis should be kept in mind while evaluating patients with ulnar neuropathy. Thorough knowledge of the motor and sensory distribution of the ulnar nerve is critical in evaluating patients with ulnar neuropathy and to identify the site of pathology.
Enhancing Healthcare Team Outcomes
An interprofessional team including a nurse, physical therapist, and clinician input can enhance recovery. Physiotherapy can provide significant help if muscle weakness is present. Discussion with the pharmacist can help patients to understand the use and side-effects of analgesic medications. The surgeon should discuss the surgical approach and the potential risks/benefits of the procedure. The nurse should assist in follow up care and monitoring for complications.