Fascial epicondylar augmentation in cases of cubital tunnel syndrome with ulnar nerve instability
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Date
2021
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Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Kubitālā tuneļa sindroms (CubTS) ir viena no biežākām augšējās ekstremitātes kompresijas-trakcijas neiropātijām. Zelta standarts ir klasiska in situ dekompresija ar potenciālo kompresijas vietu revīziju. Kubitālā tuneļa sindroma kosvervatīva ārstēšana ir efektīvāka salīdzinājumā ar karpālā tuneļa syndrome. Daļai pacientu ar CubTS simptomiem ir ulnārā nerva nestavilitāte (UNI) ar subluksāciju viru mediālā epikondiļa. Šajā gadījumā konservatīva ārstēšana pozitīvu rezultātu nedod. Preoperatīvi UNI var diagnosticēt ar ultrosogrāfijas izmeklējumu, bet dažās situācijās to redz tikai operācijas laikā, veicot elkoņa locītavas fleksiju un ekstenziju. Patreiz populārākā rekonstrukcijas metode klīniski nozīmgā CubTS ārstēšanā ir nerva priekšējā transpozīcija. Savukārt, veicot mūsu tehniku, nervs paliek ortotopiskajā pozīcijā ar saglabātu segmentālu apasiņošanu, netiek apdraudēta flexor carpi ulnaris (FCU) inervācija un nerva slīde ir iespējamā salīdzinot ar standarta zemādas transpozīciju. Mēs nepiecietojam subfasciālu transpozīciju vai bloķējošus lēverus nerva stabilizācijai, ko uzskatām par kontrindikāciju nervu dekompresijas operācijai.
Cubital tunnel syndrome (CubTS) is one of the most common compression-traction neuropathy in the upper extremity. The gold standard is simple in situ decompression with revision of potential compression sites through skin incision as small as rationally possible. Properly conducted conservative treatment is more effective in CubTS as opposed to carpal tunnel syndrome. At the same time, optimal management of CubTS remains controversial. Nevertheless, there is a subclass of patients with symptoms of CubTS that have ulnar nerve instability (UNI) with subluxation of the nerve over the medial epicondyle where conservative treatment would not be successful. UNI can be diagnosed by ultrasound preoperatively, but there are situations where the ulnar nerve becomes unstable with elbow flexion already on the operating table. Currently the most popular surgical reconstruction for clinically relevant UNI is anterior transposition of the nerve. With the proposed technique the nerve stays in orthotopic position, and the segmental vascularity is preserved, innervation to the flexor carpi ulnaris muscle is not jeopardized and ulnar nerve glide-floss exercises are possible as opposed to the standard subcutaneous transposition technique. No subfascial transposition, slings or blocking flaps are used for nerve stabilization which we consider contradiction to the surgery of nerve release.
Cubital tunnel syndrome (CubTS) is one of the most common compression-traction neuropathy in the upper extremity. The gold standard is simple in situ decompression with revision of potential compression sites through skin incision as small as rationally possible. Properly conducted conservative treatment is more effective in CubTS as opposed to carpal tunnel syndrome. At the same time, optimal management of CubTS remains controversial. Nevertheless, there is a subclass of patients with symptoms of CubTS that have ulnar nerve instability (UNI) with subluxation of the nerve over the medial epicondyle where conservative treatment would not be successful. UNI can be diagnosed by ultrasound preoperatively, but there are situations where the ulnar nerve becomes unstable with elbow flexion already on the operating table. Currently the most popular surgical reconstruction for clinically relevant UNI is anterior transposition of the nerve. With the proposed technique the nerve stays in orthotopic position, and the segmental vascularity is preserved, innervation to the flexor carpi ulnaris muscle is not jeopardized and ulnar nerve glide-floss exercises are possible as opposed to the standard subcutaneous transposition technique. No subfascial transposition, slings or blocking flaps are used for nerve stabilization which we consider contradiction to the surgery of nerve release.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
kubitālā tuneļa sindroms, in situ dekompresija, ulnārā nerva subluksācija, unlārā nerva nestabilitāte, cubital tunnel syndrome, in situ release, ulnar nerve subluxation, ulnar nerve instability