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Surgical Decompression of Cubital Tunnel

- Isolated Division of the Aponeurosis:
    - involves division of aponeurosis between the humeral and ulnar origins of the FCU;
    - theoretical disadvantages:
         - in addition to decreases in the cross sectional area of the cubital tunnel which occur w/ flexion, there is also a decrease in the mean cross sectional
               anatomy of the ulnar nerve (about 35-40%) w/ elbow flexion;
               - this indicates that elbow flexion increases traction on the ulnar nerve, which is  independent of any extrinsic traction;
         - therefore, decompression of the cubital tunnel will not alter traction on the ulnar nerve which occurs with elbow flexion;
         - in the study by Dellon et al (1989), only 33% of patients who underwent isolated cubital tunnel release achieved an excellent result;
         - references: 
               - Review of treatment results for ulnar nerve entrapment at the elbow.
               - Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera.                      

- Indications:
    - limit this procedure to patients whose symptoms seem to arise from compression over the FCU aponeurosis;
          - a positive Tinel's sign over the cubital tunnel is a supporative finding;

- Relative Contra-indications:
    - ulnar nerve subluxation;
         - about 10 percent of the population is prone to subluxation of the ulnar nerve w/ elbow flexion beyond 90 deg;
         - these patients would be expected to experience symptomatic subluxation of the ulnar nerve postoperatively;
         - likewise, the intraoperative finding of ulnar nerve subluxation following release is an indication that a transposition procedure is necessary;
    - osteophytes surrounding cubital tunnel;
    - rheumatiod arthritis;

- Anatomy & Sites of Compression

- Technique:
    - incision:
           - longitudinal incision 8 cm in length;
           - attempt to identify the medial antebrachial cutaneous nerve; (may be found crossing the FCU);
    - ulnar nerve is identified and tagged in the proximal portion of the incision;
    - aponeurosis of the cubital tunnel and the aponeurosis of FCU is incised;
    - nerve is then examined for evidence of gross deformation (c/w entrapment underneath FCU aponeurosis);
           - if no abnormality is found, then consider submuscular or subcutaneous transposition;
    - following decompression it is important to check the effect of flexion on the nerve;
           - elbow flexion may reveal excessive ulnar nerve tension;
           - ulnar nerve subluxation may be found following cubital tunnel release, in which case a subcutaneous transposition is indicated; 
           - another consideration would be epicondylectomy

Compression neuritis of the ulnar nerve treated with simple decompression

Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition

Ulnar nerve decompression at the cubital tunnel.

Review of treatment results for ulnar nerve entrapment at the elbow.

Simple Decompression or Subcutaneous Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome.

Anterior Transposition Compared with Simple Decompression for Treatment of Cubital Tunnel Syndrome. A meta-analysis of randomized, controlled trials

The Minimal Clinically Important Difference After Simple Decompression for Ulnar Neuropathy at the Elbow