Role of Sulcus view radiograph of elbow in Ulnar NerveDecompression

Cubital tunnel syndrome is the second most common compressive neuropathy after the median nerve. Different methods of treating have evolved over the years from simple decompression in situ to osteotomies and transpositions. Different modalities have been used to investigate the problem. In our report we would like to show that for a complete working and treating diagnosis of cubital tunnel EMG studies with a sulcus view radiograph are sufficient, cheap and quick. More detailed investigations like MRI, CT scan are although more detailed; do not add anything more worthwhile with regards to the management. An Electromyogram (EMG) will confirm the diagnosis of cubital tunnel decompression and a sulcus view will tell us the state of the ulnar bed for the purpose of deciding whether to do a simple decompression or a transposition. INTRODUCTION AND AIM Cubital tunnel syndrome is the second most common compressive neuropathy after carpal tunnel syndrome. Different methods of treatment have evolved over the years, each with its advantages and disadvantages. A study by Heithoff 1 suggests that for most cases a simple decompression is all that is required. Cases where there were additional problems like cubitus valgus, scarred bed, osteophytes, ganglion or a tumour, may require something other than a simple decompression, and a medial condylectomy was suggested. Our hypothesis in this regard is that if we see bony encroachment of the ulnarnerve bed at the elbow, it may need an anterior transposition. However in most cases a simple decompression would suffice. We propose a simple plain radiograph to diagnose bony encroachment of the cubital tunnel. The aim of our study is to assess the value of a simple sulcus view radiograph of the elbow in deciding whether a patient with cubital tunnel syndrome needs either a simple decompression or a more extensive procedure like transposition of the nerve. MATERIAL AND METHODS A prospective study was carried between June 2003 and November 2004. All patients presenting with signs and symptoms suggestive of ulnar nerve entrapment at the elbow were studied. Detailed history and examination was carried out and patients were graded according to their symptoms using the McGowan’s classification. McGowan established the following classification system: Grade I Mild lesions with paresthesia in the ulnar nerve distribution and a feeling of clumsiness in the affected hand; no wasting or weakness of the intrinsic muscles. Grade II Intermediate lesions with weak interossei and muscle wasting. Grade III Severe lesions with paralysis of the interossei and a marked weakness of the hand. Nerve conduction studies were done to confirm the diagnosis. The exclusion criteria were: diabetic neuropathy, previous surgery or significant trauma to the elbow, and those with ulnar nerve neuropathy due to other causes such as cervical or Guyon’s canal entrapment. Cubital tunnel sulcus view radiographs were taken and evaluated for any evidence of bony encroachment of the ulnar nerve bed. Those with normal cubital tunnel views underwent a simple decompression procedure whereas those having positive findings underwent a subfascial anterior transposition of the nerve. The results of the surgery were then assessed at follow-up using the Wilson and Krout’s 2 criteria: Good: Alleviation of symptoms Role of Sulcus view radiograph of elbow in Ulnar Nerve Decompression 2 of 6 Fair: Improvement with some persistence or recurrence of symptoms or inhibition of elbow function Poor: No improvement after surgery Patients were followed up at 6 weeks, 3 months, 6 months and one year.