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 Table of Contents  
COMMENTARY
Year : 2017  |  Volume : 2  |  Issue : 3  |  Page : 123-124

Assessing surgical methods for treatment of cubital tunnel syndrome - which is the best?


Keck School of Medicine of the University of Southern California, Los Angeles, California, USA

Date of Web Publication31-Aug-2017

Correspondence Address:
Brian Wu
Keck School of Medicine of the University of Southern California, Los Angeles, California
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2542-4157.213700

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  Abstract 

Cubital tunnel syndrome is a common and debilitating cause of upper extremity neuropathy. Several surgical options exist for treating this condition, including simple decompression, subcutaneous anterior transposition, and submuscular anterior translocation. The literature shows no clear differences in outcomes of these procedures. Consequently, the decision of which procedure to perform is often a matter of surgeon preference. Liu et al. has designed a blinded, randomized clinical trial to compare outcomes at 6 months postoperatively. This commentary addresses strengths and potential areas of improvement in the study protocol. With revision, the aforementioned study could provide clinical value in determining the ideal surgical option for cubital tunnel syndrome that maximizes reduction of symptoms while minimizing complications.

Keywords: cubital tunnel; upper extremity neuropathy; surgical methods; complications


How to cite this article:
Burtt KE, Badash I, Wu B. Assessing surgical methods for treatment of cubital tunnel syndrome - which is the best?. Clin Trials Orthop Disord 2017;2:123-4

How to cite this URL:
Burtt KE, Badash I, Wu B. Assessing surgical methods for treatment of cubital tunnel syndrome - which is the best?. Clin Trials Orthop Disord [serial online] 2017 [cited 2019 Sep 19];2:123-4. Available from: http://www.clinicalto.com/text.asp?2017/2/3/123/213700

Cubital tunnel syndrome (CTS), characterized by compression or irritation of the ulnar nerve as it runs under the medial epicondyle of the humerus, is the second most common entrapment neuropathy of the upper extremity. [1] A number of surgical options exist for treating CTS when nonoperative options have failed or neurologic deficits exist. These include simple decompression, which involves lysis of adhesions to free the ulnar nerve, and anterior transposition, in which Osborne's ligament is cut and the ulnar nerve is moved out of the tunnel to a more anterior location in which it experiences less tension during arm flexion. Peer reviewed studies investigating these surgical options have found similar outcomes. [2],[3],[4] Consequently, the choice of surgical procedure is often a matter of physician and patient preference. When anterior transposition is performed, the nerve and associated vessels may be placed in a subcutaneous or submuscular location. No significant difference in clinically relevant improvement in function from baseline has been found between these two options of nerve placement. [5] Thus, the study designed by Liu et al., [6] which aims to establish quantitative and objective data on outcomes of the aforementioned surgical options, will produce clinical data to assist surgeons in optimizing their approach to patients with cubital tunnel syndrome.

The study by Liu et al. has a number of strengths which may result in clinically and statistically significant data not elucidated by prior investigations. Inclusion and exclusion criteria are extensively documented, and interventions are detailed and consistent with prior literature. [7],[8],[9] Randomization of patients with blinding of outcome assessors and statisticians will reduce biases in selection and reporting. Outcomes are well defined and extensive; use of several criteria for outcome measures (muscle strength, sensation, EMG, pain, and incision complications) will allow for a multifaceted investigation of patient outcomes. Preliminary data shows promising outcomes overall; it will be valuable to determine if significant data arises out of a larger sample size.

Several aspects of the study protocol may be improved. Patients and implementers are not blinded, which could introduce reporting bias. Moreover, it is unclear how many participants the study seeks to enroll. Based on the likelihood of negative results given their prevalence in the literature, care must be taken to include a sample size that is large enough to establish an acceptable level of power to minimize type II error, and a power analysis should be performed and reported. Furthermore, the choice to use broad inclusion criteria may mask significant differences in outcomes present between specific populations. For example, prior studies have found duration of symptoms and advanced age to be negatively correlated with outcomes. [10],[11] Moderate and severe cubital tunnel syndrome have also previously shown differences in efficacy of surgical options. [12] Thus, while the authors plan to distribute patients with moderate and severe symptomatology non-discriminately, this may obscure significant results. It may be preferential to randomize patients into groups, such as moderate and severe CTS, in order to highlight differences that may be present between these populations. Finally, one of the study's exclusion criteria is unsatisfying efficacy of the procedure necessitating other therapies. This criterion may bias results since patients with poor outcomes will be removed from the study.

While the study design addresses that adverse events will be investigated, the authors do not define which specific adverse events will be recorded and included in the study. Common surgical complications, including symptom recurrence, procedure revision, and limited work capacity, would be beneficial for the authors to compare between procedures. Validated functional outcome scales assessing duration of limited work capacity, including the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire or Bishop-Kleinman rating, may be useful and have been utilized in other studies investigating surgical treatment of cubital tunnel syndrome. [13] Lastly, the authors may wish to follow the patients for greater than 6 months postoperatively in order to observe long-term outcomes of these procedures. For example, grip strength has been found to improve up to a year after decompression. [14]

CTS is a debilitating condition without clear evidence for a preferred surgical option. Overall, the study design of Liu et al.'s clinical trial is promising, and the results have the potential to impact the way in which hand surgeons approach cubital tunnel syndrome. If the considerations discussed in this commentary are addressed, this study could provide valuable evidence giving preference to one surgical modality.

 
  References Top

1.
Assmus H, Antoniadis G, Bischoff C. Carpal and cubital tunnel and other, rarer nerve compression syndromes. Dtsch Arztebl Int. 2015;112:14-25.  Back to cited text no. 1
    
2.
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;56:522-530.  Back to cited text no. 2
    
3.
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;30:521-524.  Back to cited text no. 3
    
4.
Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89:2591-2598.  Back to cited text no. 4
    
5.
Liu CH, Wu SQ, Ke XB, et al. Subcutaneous versus submuscular anterior transposition of the ulnar nerve for cubital tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials and observational studies. Medicine (Baltimore). 2015;94:e1207.  Back to cited text no. 5
[PUBMED]    
6.
Liu QQ, Li R. Cubital tunnel syndrome treated with ulnar nerve simple decompression, anterior intramuscular or subcutaneous transposition: a parallel randomized controlled clinical trial. Clin Trials Orthop Dis. 2016;1:15.  Back to cited text no. 6
    
7.
Henry M. Modified intramuscular transposition of the ulnar nerve. J Hand Surg Am. 2006;31:1535-1542.  Back to cited text no. 7
[PUBMED]    
8.
Li WJ, Tian GL, Chen SL, et al. Clinical analysis of subcutaneous anterior transposition of the ulnar nerve in 135 patients of cubital tunnel syndrome. Zhonghua Shouwaike Zazhi. 2008;24:326-328.  Back to cited text no. 8
    
9.
Murata K, Omokawa S, Shimizu T, et al. Risk factors for dislocation of the ulnar nerve after simple decompression for cubital tunnel syndrome. Hand Surg. 2014;19:13-18.  Back to cited text no. 9
    
10.
Gökay NS, Bagatur AE. Subcutaneous anterior transposition of the ulnar nerve in cubital tunnel syndrome. Acta Orthop Traumatol Turc. 2011;46:243-249.  Back to cited text no. 10
    
11.
Huang W, Zhang PX, Peng Z, Xue F, Wang TB, Jiang BG. Anterior subcutaneous transposition of the ulnar nerve improves neurological function in patients with cubital tunnel syndrome. Neural Regen Res. 2015;10:1690-1695.  Back to cited text no. 11
[PUBMED]    
12.
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;106:327-334.  Back to cited text no. 12
[PUBMED]    
13.
Fitzgerald BT, Dao KD, Shin AY. Functional outcomes in young, active duty, military personnel after submuscular ulnar nerve transposition. J Hand Surg Am. 2004;29:619-624.  Back to cited text no. 13
    
14.
Karthik K, Nanda R, Storey S, Stothard J. Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression. J Hand Surg Eur Vol. 2012; 37:115-122.  Back to cited text no. 14
    

Author contributions
All authors contributed to the concept of the manuscript. KEB and IB contributed to manuscript preparation, and all authors worked on manuscript editing, review and approval. All authors took responsibility for the integrity of the work as a whole from inception to the published article.
Conflicts of interest
None declared.
Plagiarism check
Checked twice by iThenticate.
Peer review
Externally peer reviewed.
Open access statement
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.



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