The wide awake approach to ulnar nerve entrapment: results of an integrated one stop wide awake surgical pathway

Introduction The wide awake approach to hand surgery is gaining increasing popularity worldwide, but PubMed search does not reveal any publications on wide awake ulnar nerve surgery. In this research study, we describe our surgical experience, techniques and results of the wide awake management of ulnar nerve entrapment at both elbow and wrist. This study is based on a background of having established the world’s first totally one stop wide awake (OSWA) hand surgery service, with published outcomes. Materials and methods We performed a retrospective review of our 2011/12 ulnar nerve entrapment cases, which comprised 40 patients with ulnar nerve dysfunction. Results The main outcome measures were sensorimotor improvement, including improvement of the QuickDASH score, patient satisfaction and cost-effectiveness and efficiency. Discussion No surgical complications were experienced by the patients and all of them were satisfied with their treatment. All patients were followed-up to a good outcome including objective sensorimotor improvement in ulnar nerve function. Conclusion The wide awake approach to ulnar nerve decompression is safe, effective and comparable to the historical approach; and is amenable to a one stop patient pathway. Introduction Wide awake hand surgery enables treatment in one management stop, through a patient-centric pathway, which is broadly more akin to dental treatment than a traditional multistop surgical approach. The one stop wide awake (OSWA) hand surgery service is now well-described in the worldwide published literature1,2. Wide awake hand surgery, is hand surgery, without general anaesthesia or regional anaesthesia or sedation or tourniquets. There have been great advances in the technique(s) for hand surgery, over the last decade. It is now over 30 years, since the first peer reviewed publications on wide awake hand surgery3, and despite inherent potential advantages (lower risk, a more convenient pathway for the patient and costsavings for national state-funded healthcare)1,2, the worldwide transition to the technique has been slow, according to the published literature1–22. The published literature on ulnar nerve compression/decompression, reflects that there are two encouraging case series, each comprising 20 cases, which were performed using a local anaesthetic technique in 2001 and 198223,24. However, a contemporaneous search on PubMed for the relevant terms is instructive: Ulnar Nerve and Local An(a)esthesia or local an(a)esthetic; or wide awake ulnar nerve; or wide awake cubital tunnel; or wide awake ulnar tunnel; or ulnar nerve entrapment. This demonstrates that there has been little recent progress with wide awake ulnar nerve surgery as would have been expected; despite the recent advances with wide awake hand surgery. There is no previous description of an all-encompassing or totally OSWA surgical pathway for the totality of ulnar nerve entrapment, irrespective of site. The aim of this research study was to discuss the wide awake approach to ulnar nerve entrapment, which we have pioneered in the UK. Materials and methods All the patients in this study were managed according to the OSWA ulnar nerve entrapment pathway, with a clinical diagnosis of unilateral isolated ulnar nerve dysfunction (Figure 1). Clinical evaluation The conduction of clinical evaluation included the following: History: Sensorimotor ulnar nerve dysfunction distal was observed on the site of entrapment. Biro Test: Sympathetic dysfunction resulted in reduced sweating in little (ulnar nerve) versus index (median nerve) pulp biro slides more easily on affected digits. Scratch Collapse Test: The patient was asked to resist bilateral shoulder external rotation, with the elbows fully flexed. The area of suspected ulnar nerve compression was then lightly scratched and then resisted shoulder external rotation was immediately repeated. In ulnar nerve dysfunction, there was momentary loss of shoulder external rotation resistance on the affected side. Tr au m a & Or th op ae di cs Corresponding author Email: enquiries@expertorthopaedics.com 1 Consultant Orthopaedic Surgeon, Queen Anne Street Medical Centre, 18-22 Queen Anne Street, Off Harley Street, London, W1G 8HU 2 General Practitioner, Westside Surgery, Sleaford Road, Boston, PE21 8EG 3 Director, Turnpike Medical Wide Awake Orthopaedic Surgery, Horncastle Road, Louth, Lincolnshire, LN11 9QT 4 Consultant Orthopaedic Surgeon, ExpertOrthopaedics.Com Ltd. 2, Allington Garden, Boston, Lincolnshire, PE21 9DP Research study Page 2 of 5 Co m pe ti n g in te re st s: n on e de cl ar ed . C on fl i ct o f i nt er es ts : n on e de cl ar ed . A ll au th or s co nt rib ut ed to th e co nc ep ti o n, d es ig n, a nd p re pa ra ti o n of th e m an us cr ip t, a s w el l a s re ad a nd a pp ro ve d th e fi n al m an us cr ip t. A ll au th or s ab id e by th e A ss oc ia ti o n fo r M ed ic al E th ic s (A M E) e th ic al ru le s of d is cl os ur e. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Bismil QMK, Lowe S, Viner L, Bismil MSK. The wide-awake approach to ulnar nerve entrapment: results of an integrated one-stop wide-awake surgical pathway. OA Case Reports 2013 Jun 21;2(5):44. Tinel’s Test: The ulnar nerve irritability was reproduced by percussion over the cubital or ulnar tunnel. Surgery was performed under local anaesthesia using a lignocaine (lidocaine) and low-dose adrenaline mix, with no tourniquet. A tourniquet on the upper arm was painful for the wide awake patient and would encroach upon the surgical field for proximal operations. In our experience of wide awake surgery, meticulous dissection enabled surgery without diathermy. The standard for ulnar nerve surgery was 10 ml of 2% lignocaine, with adrenaline 1:200,000, which was drawn up, with a 21-gauge needle and infiltrated with a 25-gauge needle. Cubital tunnel decompression technique (proximal) The following steps were followed in this technique, also see Table 1: 1. The patient lied down in supine position. 2. Surgical marking positioning was done as depicted in Figure 2. The following were the findings observed for this surgical mark: a. Double sandbag was large at base, smaller on top and tucked into axilla. b. Shoulder abduction was at 60°. Figure 1: OSWA Ulnar Nerve Pathway. Figure 2: Cubital Tunnel Release Positioning. Figure 3: Cubital Tunnel Release Intraoperative. Table 1. Keys to successful one stop wide awake management (adapted from original OSWA paper1).