What is Ulnar Nerve Release and Transposition?
Ulnar Nerve Release and Transposition is a surgical procedure designed to alleviate pressure on the ulnar nerve, commonly known as the "funny bone" nerve.
The ulnar nerve passes through a tunnel behind the elbow called the cubital tunnel. When this nerve is compressed or irritated, it can cause numbness, tingling, or weakness in the hand and arm, a condition known as Cubital Tunnel Syndrome. Ulnar nerve transposition involves relocating the nerve to a less confined space to reduce pressure and irritation.
Who is Suitable for Ulnar Nerve Release and Transposition?
Ulnar Nerve Release and Transposition may be considered for individuals who experience the following:
- Persistent symptoms of cubital tunnel syndrome, such as numbness, tingling, or weakness in the hand and arm that do not improve with non-surgical treatments such as splinting, hand therapy, or anti-inflammatory medications.
- Severe compression of the ulnar nerve, as evidenced by nerve conduction studies or electromyography (EMG).
- Decreased hand strength or coordination due to ulnar nerve compression.
- Significant functional limitations affecting daily activities or work.
What are the Benefits of Ulnar Nerve Release and Transposition?
Ulnar Nerve Release and Transposition can provide several benefits:
- Relieves Pressure:
Moving the ulnar nerve to a less confined area helps alleviate pressure and irritation.
- Reduces Symptoms:
After surgery, many patients experience significantly reduced numbness, tingling, and pain.
- Improves Function: The procedure can help restore strength and coordination in the hand and fingers, allowing patients to return to normal activities.
- Successful Outcomes: Many patients achieve good long-term outcomes from the surgery with appropriate post-operative care and rehabilitation.
Types of Ulnar Nerve Release and Transposition
Several types of ulnar nerve release and transposition procedures may be performed. They include:
- Subcutaneous Ulnar Nerve Transposition:
The ulnar nerve is released from its original position and moved to a new position in front of the medial epicondyle (a bony prominence on the inner side of the elbow) to reduce tension and pressure on the nerve during elbow flexion. The nerve is then secured in its new position, just under the skin, with sutures.
- Subfascial Ulnar Nerve Transposition: This is similar to subcutaneous transposition. The difference is that the nerve is secured in its new position by a sling that the surgeon makes from some of the linings of the surrounding muscle.
- Submuscular Ulnar Nerve Transposition:
This technique involves releasing the ulnar nerve and moving it beneath the forearm muscles. The nerve is rerouted through a muscle tunnel, typically created by splitting or releasing a portion of the flexor muscles of the forearm. The muscle tissue provides additional cushioning and protection for the nerve.
- Medial Epicondylectomy
removes a portion of the medial epicondyle to create more space for the ulnar nerve. Removing the bony prominence makes the nerve less likely to be compressed during elbow movements.
- In Situ Decompression:
Sometimes, the ulnar nerve may not be transposed. Instead, it is released from surrounding structures to decompress it. The surgeon may perform a meticulous dissection to free the nerve from any constricting tissue or remove any scar tissue that may be compressing the nerve.
Alternative Options to Ulnar Nerve Release and Transposition
Before considering ulnar nerve release and transposition, it is advisable to explore conservative treatment options. These alternatives aim to alleviate symptoms and improve the condition without surgery. Here are some non-surgical options to consider:
- Rest and Activity Modification
- Immobilisation
- Hand Therapy
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Ergonomic Modifications
- Nerve Gliding Exercises
If conservative treatments do not provide sufficient relief or the nerve compression is severe, your doctor may recommend ulnar nerve release and transposition as a surgical option.
What to Do Before Ulnar Nerve Release and Transposition?
Before the procedure, patients should:
- Consult an orthopaedic surgeon to evaluate their symptoms and discuss surgery's potential benefits and risks.
- Follow any preoperative instructions provided by the surgical team, which may include temporarily discontinuing certain medications and fasting for six hours during the procedure.
- Undergo diagnostic tests, such as an X-ray of the elbow, to assist the surgeon with pre-operative planning. Nerve conduction studies or EMG is not usually required.
Ulnar Nerve Release and Transposition Procedure
During an ulnar nerve release and transposition procedure, the following steps are typically involved:
- Anaesthesia:
You will be given anaesthesia to ensure you are comfortable and pain-free during the surgery. The type of anaesthesia used can vary, ranging from local anaesthesia (numbing the specific area) to general anaesthesia (rendering you unconscious).
- Incision:
The surgeon will make an incision over the inner side of the elbow, exposing the ulnar nerve and surrounding tissues.
- Nerve Release: The surgeon will carefully identify and release any structures or tissues compressing or putting pressure on the ulnar nerve. This can involve removing scar tissue, releasing tight bands of tissue, or removing a portion of the medial epicondyle (medial epicondylectomy) to create more space for the nerve.
- Nerve Transposition: If deemed necessary, the ulnar nerve will be repositioned to a new location towards the front of the elbow to prevent further compression or irritation. This can involve subcutaneous transposition (moving the nerve under the skin), subfascial transposition (moving the nerve under a sling made from the lining of muscle) or submuscular transposition (moving the nerve beneath the forearm muscles).
- Fixation:
Once the nerve is transposed, the surgeon may secure it in its new position to prevent it from returning to its original location.
- Closure:
The incision is closed using sutures, and a sterile dressing is applied.
What to Expect After an Ulnar Nerve Release and Transposition?
After the ulnar nerve release and transposition surgery, you will be monitored in a recovery room, where you will be monitored until the effects of anaesthesia wear off if you had a general anaesthetic. Pain medication will be administered to manage post-operative pain.
Ulnar Nerve Release and Transposition Recovery Plan
Early Post-Operative Period (First Few Days to Weeks):
- You will be given specific instructions regarding wound care, such as keeping the incision site clean and dry.
- Hand therapy will be initiated early to promote range of motion, prevent stiffness, and maintain muscle strength in the affected arm and hand.
- You may be advised to avoid activities that stress the elbow, such as heavy lifting or repetitive motions.
- Regular follow-up appointments with your surgeon and hand therapist will be scheduled to monitor progress, assess wound healing, and make necessary adjustments to your recovery plan.
Rehabilitation and Recovery (Weeks to Months):
- Hand therapy will play a crucial role in your recovery. Your therapist will guide you through exercises and techniques to improve the affected arm's range of motion, strength and coordination.
- Gradual return to normal activities will be encouraged, but following your surgeon's and therapist’s instructions is important. Do not advance your exercises without appropriate guidance to avoid re-injury.
- Pain and swelling should gradually subside over time, although it is normal to experience some residual symptoms during the healing process.
- Follow-up appointments with your surgeon and hand therapist will continue to monitor progress and address any concerns.
Ulnar Nerve Release and Transposition Prognosis
After ulnar nerve release and transposition surgery, the prognosis is generally positive, with most patients experiencing significant improvement in their symptoms. The surgery aims to relieve pressure on the ulnar nerve, restore its function, and alleviate pain and other associated symptoms.
While many individuals experience relief from symptoms following surgery, it is possible for some residual symptoms to persist or for symptoms to recur over time. Full recovery and return to normal activities may take several months, and rehabilitation and hand therapy are crucial in achieving optimal outcomes.
Ulnar Nerve Release and Transposition Risks
Potential procedure risks include infection, nerve injury, and the need for additional surgery. There is also a risk of persistent or recurrent symptoms. However, complications are relatively rare, and most patients experience successful outcomes.
Delaying Ulnar Nerve Release and Transposition
If ulnar nerve release and transposition surgery is delayed, the symptoms associated with cubital tunnel syndrome may persist or worsen. Delaying surgery can lead to ongoing nerve compression, resulting in progressive nerve damage and increased symptoms such as pain, numbness, tingling, and weakness in the affected hand and fingers. If surgery is delayed for too long, the nerve and affected muscles will not recover, even if ulnar nerve and transposition is performed.