August 4, 2016
Failed Cubital Tunnel Surgery
Recurrent or persistent cubital tunnel/ulnar nerve symptoms or failed cubital tunnel surgery.
Risk of Cubital Tunnel Syndrome Recurrence
For the past 10 years there has been a lot of interest in the failure rate of cubital tunnel surgery. In review of the English literature up to 1989, Dr. Dellon at John Hopkins concluded the risk of recurrence of cubital tunnel syndrome after surgery was about 3%.
Since then, however, the topic has gained greater scrutiny. Of the five surgical techniques used for cubital tunnel syndrome, it is unclear that any one works superior to another as long as the patient is educated and cooperative with sleeping with his elbows straight, i.e. breaking the habit that causes a problem in the first place.
The Correspondence of Sleeping Habits with Syndrome Recurrence
The largest series of patients failing cubital tunnel surgery and requiring a return to the operating room was published by the Washington University School of Medicine in 2014. Five surgeons using the same technique of in-situ ulnar nerve release, i.e. taking the pressure off the nerve without moving it, reported a 20%, i.e. 1 out of 5, failure rate.
Looking at their surgical findings, for the most part, other than they didn't identify any technical problems. They did not, however, discuss the likelihood of their patients continuing to sleep with the elbow bent, thus continuing to subject the nerve to pressure and stretching at night.
In-situ release of the ulnar nerve, the least painful technique and done with the smallest surgical incision of about 1 inch or less, demands the patient quit sleeping with the elbow bent. Progress on that related to posture really needs to be made before taking the person to surgery. Braces are available to help a person.
Other Surgical Technique Options
There are also four other surgical techniques that hurt more but are a better guarantee against failure. One must try to determine how cooperative a person is and only offer in-situ release to those who are cooperating with a change in their posture at night, using subcutaneous transposition or medial epicondylectomy for those with more advanced disease at great risk of claw hand or simple failure to relieve symptoms because of lack of cooperation. Quantitative sensory examination (formerly known as PSSD) now marketed as the AcrovalTM byAxogen (axogen.com) is very useful in the assessment.