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Cubital tunnel

From Wikipedia, the free encyclopedia
Cubital tunnel
Back of right upper extremity, showing surface markings for bones and nerves.
Anatomical terminology

The cubital tunnel is a space of the dorsal medial elbow which allows passage of the ulnar nerve around the elbow. Persistent compression of the ulnar nerve in the cubital tunnel is known as cubital tunnel syndrome.

Structure

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The cubital tunnel is bordered medially by the medial epicondyle of the humerus, laterally by the olecranon process of the ulna and the tendinous arch joining the humeral and ulnar heads of the flexor carpi ulnaris.[1] The roof of the cubital tunnel is elastic and formed by a myofascial trilaminar retinaculum (also known as the epicondyloolecranon ligament or Osborne band).[2] In 14% of individuals, the roof of this tunnel is covered by the epitrochleoanconeus muscle, an accessory muscle.[3]

Clinical significance

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Schematic diagram of the medial side of the elbow showing the ulnar nerve passing through the cubital tunnel

Chronic compression of the ulnar nerve in the cubital tunnel is known as cubital tunnel syndrome.[4] There are several sites of possible compression, traction or friction of the ulnar nerve as it courses behind the elbow.[5] It may also be caused by repetitive strain from the use of a cell phone for example.[6]

Diagnosis

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There is no reliable test to diagnose CuTS, and no research directly comparing the cost-effectiveness or acceptability of these tests. Consequently, practice varies in the UK with some clinicians using electrodiagnosics, some using ultrasound some using MRI and some using either none of these or a combination.

Clinical tests

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There are numerous provocative manoeuvres (performed manually in the outpatient clinic by the clinician) which are designed to reproduce the symptoms of CuTS but all have poor diagnostic performance.[7] The absence of studies directly comparing clinical tests to psychometrically valid patient-reported outcomes and lack of a consensus on the reference standard, means that clinicians don’t use clinical grading systems to select patients for surgery.[8]

Electrodiagnostics (EDx)

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Nerve conduction studies (NCS) and electromyography (EMG) are unreliable in CuTS (sensitivity 38-89%).[9] They are not associated with objective measures of hand function or health-related quality of life,[10] and don't predict response to treatment.[11]

EDx cannot detect neuropathy until >80% of axons are lost,[12] which explains the high false-negative rate in CuTS.[13][14] When EDx tests are normal in the presence of symptoms, many surgeons still offer treatment and most patients still benefit.[15] Conversely, some surgeons withhold treatment until EDx become abnormal.

EDx provokes anxiety and is a painful invasive test.[16] Overall, EDx is an expensive consultant-delivered test (costly financially and associated with treatment delays) and lacks evidence to justify its use in the NHS.

Ultrasound

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A cross-sectional area >10mm2 is compatible with a diagnosis of cubital tunnel syndrome.

Expert Opionion

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Expert opinion is that all patients should receive both EDx and ultrasound,[17] although there is no evidence on which to base this recommendation.

Treatment

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The treatment for CuTS remains debated given the lack of high-quality studies[18] and absence of research into the natural history of the disease. Some patients with mild/early disease recover spontaneously or with non-surgical treatments (e.g. activity modification, physiotherapy and splints) but surgery is the only reliable cure.

Decompression surgery for CuTS aims to relieve pressure on the ulnar nerve. It is a relatively minor operation which can be done in different ways, all of which are equally effective.[19] However, in-situ decompression appears to be safer than transposition procedures for primary disease,[20] and endoscopic techniques might enable a faster return-to-work. All types of surgery significantly improve hand function and quality of life.[21]

References

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  1. ^ Moore, Keith L. (2010). Clinically Oriented Anatomy 6th Ed. Baltimore, MD: Lippincott, Williams and Wilkins. p. 770. ISBN 978-07817-7525-0.
  2. ^ Macchi, Veronica; Tiengo, Cesare; Porzionato, Andrea; Stecco, Carla; Sarasin, Gloria; Tubbs, Shane; Maffulli, Nicola; De Caro, Raffaele (2014-08-01). "The cubital tunnel: a radiologic and histotopographic study". Journal of Anatomy. 225 (2): 262–269. doi:10.1111/joa.12206. ISSN 1469-7580. PMC 4111932. PMID 24917209.
  3. ^ Suwannakhan, Athikhun; Chaiyamoon, Arada; Yammine, Kaissar; Yurasakpong, Laphatrada; Janta, Sirorat; Limpanuparb, Taweetham; Meemon, Krai (2021). "The prevalence of anconeus epitrochlearis muscle and Osborne's ligament in cubital tunnel syndrome patients and healthy individuals: An anatomical study with meta-analysis". The Surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 19 (6): e402 – e411. doi:10.1016/j.surge.2020.12.006. ISSN 1479-666X. PMID 33551294.
  4. ^ Szabo RM; et al. (2007). "Natural History and Conservative Management of Cubital Tunnel Syndrome". Hand Clinics. 23 (3): 311–318. doi:10.1016/j.hcl.2007.05.002. PMID 17765583.
  5. ^ Graf, A; Ahmed, AS; Roundy, R; Gottschalk, MB; Dempsey, A (July 2023). "Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy". Journal of Hand Surgery Global Online. 5 (4): 547–560. doi:10.1016/j.jhsg.2022.07.008. PMC 10382899. PMID 37521554.
  6. ^ "Cubital Tunnel Syndrome: Cell Phone Elbow | Health News and Tips For Computer Users and Abusers". Archived from the original on 2007-07-14. Retrieved 2007-08-31.
  7. ^ Novak, Christine B.; Lee, Gilbert W.; Mackinnon, Susan E.; Lay, Laurel (September 1994). "Provocative testing for cubital tunnel syndrome". The Journal of Hand Surgery. 19 (5): 817–820. doi:10.1016/0363-5023(94)90193-7.
  8. ^ Power, Hollie A.; Peters, Blair R.; Patterson, J. Megan M.; Padovano, William M.; Mackinnon, Susan E. (July 2022). "Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters". Plastic & Reconstructive Surgery. 150 (1): 115e – 126e. doi:10.1097/PRS.0000000000009255.
  9. ^ Campbell (1999). "The electrodiagnostic evaluation of patients with ulnar neuropathy at the elbow: Literature review of the usefulness of nerve conduction studies and electromyography". Muscle Nerve. 22: 175–205.
  10. ^ Power, Hollie A.; Sharma, Ketan; El-Haj, Madi; Moore, Amy M.; Patterson, Megan M.; Mackinnon, Susan E. (17 April 2019). "Compound Muscle Action Potential Amplitude Predicts the Severity of Cubital Tunnel Syndrome". Journal of Bone and Joint Surgery. 101 (8): 730–738. doi:10.2106/JBJS.18.00554.
  11. ^ Florczynski, Matthew M.; Kong, Lingxuan; Burns, Patricia B.; Wang, Lu; Chung, Kevin C. (January 2023). "Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve". The Journal of Hand Surgery. 48 (1): 28–36. doi:10.1016/j.jhsa.2022.10.008. PMC 10161202.
  12. ^ Gordon, T.; Yang, J.F.; Ayer, K.; Stein, R.B.; Tyreman, N. (January 1993). "Recovery potential of muscle after partial denervation: A comparison between rats and humans". Brain Research Bulletin. 30 (3–4): 477–482. doi:10.1016/0361-9230(93)90281-F.
  13. ^ Greenwald, Daniel; Blum, Louis C.; Adams, Dawn; Mercantonio, Cynthia; Moffit, Moriah; Cooper, Benjamin (April 2006). "Effective Surgical Treatment of Cubital Tunnel Syndrome Based on Provocative Clinical Testing without Electrodiagnostics:". Plastic and Reconstructive Surgery. 117 (5): 87e – 91e. doi:10.1097/01.prs.0000207298.00142.6a.
  14. ^ Kortlever, Joost T.P.; Brandsema, Berdien; Gradl-Dietsch, Gertraud; Zhao, Meijuan; Ring, David (February 2023). "Electrodiagnostic test results in people with a working diagnosis of cubital tunnel syndrome". Journal of Orthopaedics. 36: 114–119. doi:10.1016/j.jor.2023.01.003. PMC 9860396.
  15. ^ Townsend, Clay B.; Katt, Brian M.; Tawfik, Amr; DeMarco, Michael; Lutsky, Kevin F.; Matzon, Jonas L.; Rivlin, Michael; Beredjiklian, Pedro K. (July 2023). "Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies". Plastic & Reconstructive Surgery. 152 (1): 110e – 115e. doi:10.1097/PRS.0000000000010185.
  16. ^ Jan, Mohammed M.S.; Schwartz, Murray; Benstead, Timothy J. (November 1999). "EMG Related Anxiety and Pain: A Prospective Study". Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 26 (4): 294–297. doi:10.1017/S031716710000041X.
  17. ^ Pelosi, Luciana; Arányi, Zsuzsanna; Beekman, Roy; Bland, Jeremy; Coraci, Daniele; Hobson-Webb, Lisa D.; Padua, Luca; Podnar, Simon; Simon, Neil; van Alfen, Nens; Verhamme, Camiel; Visser, Leo; Walker, Francis O.; Yoon, Joon Shik; Cartwright, Michael S. (September 2021). "Expert consensus on the combined investigation of ulnar neuropathy at the elbow using electrodiagnostic tests and nerve ultrasound". Clinical Neurophysiology. 132 (9): 2274–2281. doi:10.1016/j.clinph.2021.04.018. hdl:2066/238533.
  18. ^ Caliandro, Pietro; La Torre, Giuseppe; Padua, Roberto; Giannini, Fabio; Reale, Giuseppe; Padua, Luca (29 April 2025). "Treatment for ulnar neuropathy at the elbow". Cochrane Database of Systematic Reviews. 2025 (4). doi:10.1002/14651858.CD006839.pub5.
  19. ^ Wade, Ryckie G.; Griffiths, Timothy T.; Flather, Robert; Burr, Nicholas E.; Teo, Mario; Bourke, Grainne (24 November 2020). "Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis". JAMA Network Open. 3 (11): e2024352. doi:10.1001/jamanetworkopen.2020.24352. PMC 7686867.
  20. ^ Wade, Ryckie G.; Griffiths, Timothy T.; Flather, Robert; Burr, Nicholas E.; Teo, Mario; Bourke, Grainne (24 November 2020). "Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis". JAMA Network Open. 3 (11): e2024352. doi:10.1001/jamanetworkopen.2020.24352. PMC 7686867.
  21. ^ Teunissen, Joris S.; Griffiths, Timothy T.; van der Heijden, Brigitte E. P. A.; Wade, Ryckie G.; Lane, Jennifer C. E.; Hovius, Steven E. R.; Bourke, Grainne; Issa, Fadi; Rodrigues, Jeremy N.; Harrison, Conrad J.; Graham, Alastair; Logan, Andrew; McKee, Andy; Heywood, Anthony; Gozzard, Charles; Edwards, Claire; Sammut, Donald; Eastwood, Gillian; Cheung, Graham; Lyall, Harry; Grant, Ian; McNab, Ian; Roushdi, Ibrahim; Chakrabarti, Indranil; Nicholl, James; Field, Jeremy; Arrowsmith, Jill; Harrison, John; Jones, Jonathan; Owers, Kate; Muir, Lindsay; Leonard, Lisa; Jones, Malcolm; Birks, Margaret; Hobson, Mark; Wood, Martin; Eames, Michael; Shanahan, Michael; Downing, Nicholas; Harley, Oliver; Critchley, Paul; Stuart, Paul; Chennagiri, Ramesh; Bassi, Rashpal; Dunlop, Rebecca; Savage, Rob; Harper, Rosalyn; Walsh, Sean; Knight, Simon; Gangopadhyay, Soham; Bostock, Stephen; Royle, Stephen; Hodgson, Steve; Fullilove, Sue; Davis, Tim; Hems, Timothy; Lees, Vivien; Mason, Will (March 2025). "Changes in hand function and health state utility after cubital tunnel release using the United Kingdom Hand Registry". Journal of Hand Surgery (European Volume). 50 (3): 344–351. doi:10.1177/17531934241275487. PMC 11849257.
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