Anyone here happy with ulnar nerve relocation surgery ?

[Deschodt]

Asking because I have 2 colleagues who had it and neither recommend it...

For those curious and blissfully unaware, the ulnar nerve is a crap evolution branch design wise, being the only nerve running outside of a joint (elbow) instead of inside - the one giving you that nasty feeling when you hit your elbow. Over time it gets trapped/pinched in its small tunnel and makes some fingers numb until you straighten the elbow. A pain to sleep (it wakes you if you bend your elbow in your sleep - the body sends alarm signals), or drive, etc. They relocate it elsewhere outside of the elbow, generally on the inside - but nerves don't take kindly to being messed with and relocated...

Both my colleagues say that now when the lay their arm on a hard surface it feels "weird" and uncomfortable, that getting used to the new location of the nerve took a long time - way longer than they were told (year+), one still experiences the same original symptoms on one of the 2 arms she had surgery on (50% success not great) with some added pain, neither was particularly recommending going ahead with this.. Looking for a bigger sample or people who treated it successfully or differently...

[Noah930]

You're asking two separate questions about cubital tunnel syndrome.

First of all, is it time to have surgery? What are your symptoms? How bad are they? Episodic numbness in the pinky (small finger) and ring finger? Or constant? Pain at the elbow? Hand weakness or muscle atrophy? Or do you actually have a nerve that is snapping/subluxing (rare)?

What treatments have you tried so far? Therapy? Cortisone injection? Behavioral modification?

If you've settled on surgery, there are maybe 4 different ways to do it. The first way is in-situ decompression. The nerve is held in place by connective tissue between the bony medial epicondyle and bony olecranon. That connective tissue is too tight, thereby pinching the nerve. (But God/Darwin put it there for a reason, too.) So in in-situ decompression, the connective tissue is cut. Released. That's it. It takes the compressive pressure of that connective tissue off of the nerve. That's the least invasive open technique of surgery.

The second method of open surgery is in-situ decompression with a subcutaneous anterior ulnar nerve transposition. Do the above in-site decompression. Then, take the nerve, and move it from its natural position "behind" (posterior to) the medial epicondyle, and transpose it (move it) to a new location alongside the medial aspect of the elbow. Transpose the nerve anterior to the bony medial epicondyle. Obviously that's a little more invasive, as now you're moving the ulnar nerve from its natural position. The theory is that anterior transposition also takes some traction tension off of the nerve. When you flex (bend) your elbow, the nerve has to travel the "long way" around the elbow's axis of rotation. Thus, the nerve gets stretched a little bit. Like a rope around a pulley. (Or think of the path an outer wheel travels compared to an inner wheel when you drive a car around a corner.) Maybe that contributes to its irritation in cubital tunnel syndrome. So if we can relieve traction on the nerve, perhaps that helps it recover. Take that rope off the pulley, to give it slack. The theoretical problem with moving the nerve is that the dissection of the nerve from its native bed may damage its blood supply, thereby causing the nerve to die. Maybe this is one of those textbook warnings, as I haven't seen/heard of this ever happening before to anyone I know ... but it's always in the back of my mind when performing this surgery.

The third open method is a submuscular transposition. Do the same as above: release the nerve, move it from its native bed, and transpose it. But instead of just transposing the nerve from the "back" of the elbow joint to the "side" of the elbow joint, you also bury it underneath the common flexor tendon origin--the tendon and muscle that comes off of the medial epicondyle. That also allows for padding the nerve, so it's not just underneath the skin as in an anterior subcutaneous transposition. This surgery requires detaching the big tendon/muscle off the bony medial epicondyle, burying the nerve, and then reattaching the tendon/muscle unit back to the bone. This is the most invasive open surgery technique. This is also the surgery that is usually done (by just about everyone) if a revision surgery is needed. If you ever have to have a second go at it, almost every surgeon will use this technique because it is the most definitive. So some surgeons argue (whether you agree with this logic or not) that why wait for a revision to do the most definitive surgery? Just do it from the get-go and be done with it.

More invasive usually means takes longer surgical time, greater chance of complication, more painful (post-op), and longer recovery timeframe. It doesn't guarantee these things, but these are trends in general.

Looking at the literature, for a first time surgery, all three techniques have similar long term outcomes. So there's no one way that is clearly better than the rest. I wouldn't pick a surgeon based upon which technique he/she uses, for example. I'd pick the surgeon, and then go with whichever way he/she practices. In general, the surgery is usually not a particularly painful one. There may be some medial ("inside" side--the side that brushes up against your body when you walk) elbow pain for a month or two after the surgery, and it may take 6-8 months for all the residual pain to go away, but it's usually not a big enough deal to keep you from living a normal lifestyle after that initial 1-2 months post-op.

The final way of cubital tunnel release is a newer method: endoscopic. But it's just another way of doing the in-situ decompression technique. This is where a camera is used. A small 1- or 2-inch incision is made at the elbow, and the crux of the surgery is done via a blade mounted on the end of a video camera. This really is a newer technique that really has only come into play over the past 5-10 years. Probably closer to 5 than to 10. Each company that makes a kit/system is a little bit different than the next (for intellectual property patents), but the idea is similar. Small incision, and use a canula to introduce a camera to watch a blade cut the connective tissue (and not the nerve!). Smaller incision means less pain and quicker recovery, as the theory goes. But the concern is always that small incision means poorer visibility and greater potential for nerve injury.

[wdfifteen]

I'm not sure what method the surgeon used, but I had the surgery. I have no bad side affects. I went to see the hand surgeon because of pain in my left thumb. They did a test where the shot electric currents down my arms. The test felt weird. As a result of the test he asked me if I had any pain or numbness in my right hand. As a matter of fact I did, but it wasn't as big a problem as the pain in my left thumb. He said the pain in my thumb is from arthritis and their isn't a lot that can be done about it, but the slight pain and numbness in my right hand would probably get worse and offered me this surgery. The pain and numbness went away a few weeks after the surgery.

[Deschodt]

Noah930, thanks for taking the time, that was educational. Wdfifteen, thanks for the actual experience.

For me, years of tennis, rock climbing, computer, if I bend my elbow 90 degree+ more than 20 seconds, I start losing feeling in the pinkie and ring finger - both sides. Unflex - 5 seconds later all is well.. Not a huge deal, zero pain, zero muscle loss. But the problem is it wakes me up at night, MANY times. The brain sends a warning or something and wakes me up. I've been sleeping with splints but frankly it makes it hard to get a good night sleep so I often wake up with the splint 10 ft away ;-) Apparently I'm angry in my sleep!

The specialist I saw IMMEDIATELY was signing me up for the transposition surgery detailed above by Noah, no injections, no therapy, nothing, boom, "I'll slice this and in 6 months you'll be able to sleep on your belly again with the arm bent under the pillow" followed reluctantly by "maybe - for most people, some have weird tingling for longer, the nerve doesn't like being moved"... And when I brought that up with friends at work I heard lots of so-so feedback on this procedure's results (trasnposition). So all I'm doing here is gathering data. I am not planning on doing it unless it stays numb or gets painful.

Right now I'm stretching / gliding the nerve and mousing left handed, and also no longer commuting thanks to Covid so it's less pronounced during the day (Right is way worse than left but I have both). Also it's worse in the AM right after waking up, first drive of the day I'd often have numb fingers... Rest of the day is fine - no issues unless I'm on the phone holding it to my ear. Not even typing... Mostly a sleep issue for me.

Will take more comments if any. Thanks again...

PS: also gotta go do a sleep apnea test, so good sleep matters, if I end up on CPAP + splints, I might as well buy Darth Vader's special seat and forget about ever getting shuteye ;-)

[cashman]

My wife had it done 20 years ago. Symtoms were numb fingers. Funny bone "zingers" whenever she reached for something. Uncomfortable all the time.

Her response: "would recommend persuing all other possible avenues before surgery. Helped some but still had some issues afterwards".

[Deschodt]

Originally Posted by cashman

My wife had it done 20 years ago. Symtoms were numb fingers. Funny bone "zingers" whenever she reached for something. Uncomfortable all the time.

Her response: "would recommend persuing all other possible avenues before surgery. Helped some but still had some issues afterwards".

Thanks for that. Sounds like my friends !

[Embraer]

I had the surgery two years ago....life changing. It was so bad that I couldn't get more than two hours of sleep a night without my arm being on fire. Excruciating pain that reared it's ugly head most often while lying down. They did the ulnar nerve transposition and a carpal tunnel release during the same surgery. The specialist who did mine was the main hand/arm surgeon for the Indianapolis Colts. I had the surgery on a Tuesday (my Friday) and was back at work on Friday night for my "Monday."

I followed the proper rehab procedures, including keeping a jar of Play-doh at work so that I could casually squeeze it throughout my shift. The only side effect, was that my elbow was numb to the touch for about a year afterwards...but no pain at all. The first month or so I was pretty limited on what I could do, but after about the 2 month mark, I was almost normal with activities.

[Noah930]

The last branch off the ulnar nerve is the muscular branch to the adductor pollicis. That's the fleshy muscle in the first webspace of your hand. Look at the back of your hand. Look between the thumb and the index (pointer) finger. That's the first webspace, and it's filled with the adductor pollicis. If you have waited until that muscle starts to atrophy away, you've waited too long for the surgery. Go get it immediately, and maybe it'll come back (fill back in).

Not all surgeons believe in the steroid injection prior to surgery, so just because you're not offered it doesn't necessarily mean a step was missed in the treatment algorithm. But unless you're presenting with late findings (like first webspace atrophy) or constant, dense numbness in the ring and small fingers, I think it's worthwhile to try things like therapy, nocturnal bracing, home stretching exercises, behavioral modification, ergonomic changes, etc.

[Embraer]

Originally Posted by Noah930

The last branch off the ulnar nerve is the muscular branch to the adductor pollicis. That's the fleshy muscle in the first webspace of your hand. Look at the back of your hand. Look between the thumb and the index (pointer) finger. That's the first webspace, and it's filled with the adductor pollicis. If you have waited until that muscle starts to atrophy away, you've waited too long for the surgery. Go get it immediately, and maybe it'll come back (fill back in).

Not all surgeons believe in the steroid injection prior to surgery, so just because you're not offered it doesn't necessarily mean a step was missed in the treatment algorithm. But unless you're presenting with late findings (like first webspace atrophy) or constant, dense numbness in the ring and small fingers, I think it's worthwhile to try things like therapy, nocturnal bracing, home stretching exercises, behavioral modification, ergonomic changes, etc.

That explains why when I went for my consultation, the Dr had me do a grip strength test, and then grabbed my hand and felt around....within 5 seconds he said that steroids or non-surgical treatments were off the table...surgery would be the only chance, and even then there was no guarantee. I was in surgery 3 days later...