| 10/16/09 10:29 pm
Anterior submuscular transposition of the ulnar nerve. That is the surgery I am going in for this Tuesday. Below is a rundown of the whole thing for those interested. I copied and pasted from the some doctor's website (hence the references to him) but this seemed to be the most thorough and easy to understand summation. My recovery time may not be as long as noted below due to my younger age than most patients and the fact that I will be going through physical therapy.
The Problem Nerve compression problems behind the elbow are called cubital tunnel syndrome. The ulnar nerve passes through the cubital tunnel which is a bony passageway. When you "hit your funny bone" and have tingling in the small and ring fingers, you are hitting the ulnar nerve at the cubital tunnel.
The tunnel has a bone passageway on both sides and the base. A ligament holds the nerve into the tunnel by crossing from one bone to the other. The ulnar nerve controls muscles used for gripping, primarily of the little, ring, and sometimes middle fingers. It also controls muscles in the hand used for strong pinch, and other muscles that coordinate fine movements. This includes most of the muscles in the hand except two muscles that lift the thumb up and out of your palm, turning the thumb into a better position for pinching. The ulnar nerve also receives feeling from the small and ring fingers from both the palm and backside of your hand.
Your complaints may result from either sensory or motor (muscle) nerve compression. For example, cubital tunnel syndromeyour symptoms may primarily involve numbness and tingling in the little and ring fingers, the side and back of the hand. These complaints occur or worsen when the elbow is bent, as when: 1) holding a telephone in the hand, 2) resting the head on the hand, 3) crossing the arms over the chest, 4) curling the arm under the body during the night. Your hand may also become cold or numb when it is on top of a steering wheel. The other group of symptoms involves motor functions of the nerve. You may be aware that the hand has become weaker, resulting in trouble opening jars. You may drop things, or your hand may not perform quite as easily as it did before. For example, you may have difficulty coordinating your fingers while typing or playing the violin, guitar, or piano. The problems usually worsen with extended activities. Frequently there are both sensory and motor symptoms present. Often we do not know the cause of this problem. Often, the patient experienced some injury to the region of the elbow: Examples include fractures, dislocations, direct blows, and severe twisting of the elbow. The nerve can also be injured with a sudden forceful flexion and extension of the elbow as may occur when the hands are on the wheel of a car in a rear ended automobile accident. Occupations requiring significant elbow flexion throughout the day, such as typing, computer data or assembly line work may contribute toward problems with pressure on this nerve. Nerve compressions are more common in people with arthritis, diabetes, thyroid problems, and those who consume a great deal of alcohol.
The Operation The operation is designed not only to take pressure off the nerve, but also to move the nerve to a position to reduce compression during common daily activities. There are many operations for compression of the ulnar nerve at the elbow. We will concentrate on the procedure to move the ulnar nerve to the front of the elbow. The nerve will no longer have the added pressure of being pulled into the bony groove when bending the elbow. Placing the nerve beneath a muscle layer prevents it from slipping back in the bony groove and provides an increased blood supply to help heal the nerve. The placement under the muscle also protects the nerve from injury. With a new location, The nerve can become compressed or pinched by the new anatomic structures the nerve must pass through. The operation is also designed to remove these potential sites.
This operation is called an anterior submuscular transposition of the ulnar nerve. The incision is made behind the elbow. The length of the incision varies, depending on the thickness of the arm, the size of the arm, the amount of fat tissue, and the presence of any unusual anatomic arrangements. A longer incision gives a better view of the delicate structures Dr. Bermant is trying to protect. A nerve crosses the area of the incision. This is a small nerve that supplies the skin behind the elbow and in part of the forearm. This nerve and others may become injured during the operative procedure. After surgery, pain in the scar and loss of sensation are possible despite Dr. Bermant's care to protect these nerves at the time of surgery. Magnifying glasses (operating microscope or loupes) show detail during the operation to reduce the chances of injury. The ulnar nerve is identified in the bony tunnel and the bands causing pressure on it are released. The muscles that start from the elbow and cross down the forearm are called the flexor - pronator muscle mass. They turn the forearm, bend the wrist, and bend some of the fingers. These muscles are lifted from the bone. The strong tissue that covers this mass is lengthened to reduce compression in the nerve's new position. The areas above and below the elbow that the nerve passes through are treated to diminish future nerve compression. Patients who have constant numbness, severe weakness, or muscle wasting may have scar tissue inside the nerve. In these cases, microsurgical release of scar tissue in the nerve is performed with magnifying glasses or microscope. The outer wrapping of the nerve is opened and the scar tissue within the nerve is freed. Care is taken to limit any injury to the small connections between the nerve fibers.
Recovery Phase The recovery process occurs generally in two phases. The operation releases pressure on the nerve and blood flow improves in the nerve immediately. Frequently, by the time the sutures are removed, you will note some improvement in the numbness and tingling in the fingers. Nerves that scar or degenerate do not recover this quickly. Actual degeneration of nerve fibers may result in muscle wasting or inability to discriminate fine points with the ends of the fingers. Nerve fibers must regenerate from the elbow, the site of the nerve injury, through the forearm and hand to the fingertips. Gripping strength (muscles in the forearm) takes about 4 to 5 months to start improving. The small muscles of the hand take 1 to 1 1/2 years for this to occur. Sensation in the small and ring fingers may take as long to regenerate. The process slows for older individuals. There is no way to hurry this neural regeneration process. In some patients with a very severe degree of nerve compression, recovery may be incomplete.
If the scar becomes painful during healing, this may improve by massaging with a cortisone-containing cream. If sensory loss is due to injury to small nerves, the areas affected frequently diminish in size over time. The loss may be permanent. Nerve regrowth may be associated with pain, similar to that experienced when your leg and foot "come back to life" after falling asleep. The pain may progress down the side of the forearm to the wrist and finally into the little finger. Such pain may last more than six weeks and require additional postoperative medication, massage, and therapy.
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