Skip to main content

Advertisement

SpringerLink
Log in

Epineurotomy for leprous, high ulnar neuropathy: defining a safe corridor based on the epineural vascular anatomy

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Background

Leprous neuropathy is treatable but still a source of disability worldwide. Multidrug therapy (MDT) and oral steroids are the main stay of treatment. Ulnar nerve, at the elbow, is commonly involved. Nerve decompression may be required in selected cases by an epineurotomy (internal neurolysis). The preferred surface of ulnar nerve for performing this procedure to minimize iatrogenic vascular compromise is a matter of debate.

Questions/purposes

We describe the epineural vessel arrangement on the medial and lateral surface of ulnar nerve around the medial epicondyle while performing epineurotomy for leprous neuropathy.

Methods

We enrolled patients of symptomatic leprous ulnar neuropathy of less than one year duration on MDT that did not respond to steroids, for surgical decompression. Ten patients underwent epineurotomy of ulnar nerves (N = 11) around medial epicondyle. The epineural vessels were classified as per Sunderland’s classification of arteriae nervorum. The number of epineural vessels was assessed on the medial and lateral surface of the ulnar nerve adjoining the medial epicondyle. The epineurotomy incision was placed over the surface of ulnar nerve having relatively less vessels.

Results

The mean number of epineural vessels on the medial surface was 9.72 (range; 7–14) and on the lateral surface were 4.72 (range; 3–6). The average number of vessels per cm2 of the medial and lateral surface of the nerve was 0.94 and 0.48, respectively. The most common type of epineural vessel was type 3 on both medial and lateral surface of the nerve. Lateral epineurotomy was performed in all 11 cases. All the patients had relief from neuropathic pain. The mean VAS score improved from 3.20 ± 0.89 to 0.50 ± 0.34 at 2 years follow-up (p = 0.02). The mean motor score improved from 9.31 ± 4.12 to 15.42 ± 3.10 and sensory score improved from 40.0 ± 30.70 to 85 ± 9.90 at two years follow-up (p < 0.01).

Conclusion

Lateral surface (facing the medial epicondyle) of ulnar nerve has a lesser density of epineural vessels in comparison to its medial (subcutaneous) surface.

Clinical relevance

This anatomical understanding may be helpful in minimizing the iatrogenic vascular compromise of ulnar nerve while performing its epineurotomy around the medial epicondyle for leprous neuropathy. The findings may be extrapolated to other clinical indications of epineurotomy of ulnar nerve, for example, in cubital tunnel syndrome, traumatic ulnar neuroma in continuity, and benign ulnar nerve tumors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Graph 1
Graph 2
Graph 3

Similar content being viewed by others

Availability of data and materials

Yes

References

  1. Nickerson D, Nickerson D (2010) A review of therapeutic nerve decompression for neuropathy in Hansen’s disease with research suggestions. J Reconstr Microsurg 26(4):277–284

    Article  Google Scholar 

  2. Pandya NJ, Antia NH (1978) Elective surgical decompression of nerves in leprosy- Technique and results: a preliminary study. Leprosy Rev 49:53–62

    Article  CAS  Google Scholar 

  3. Brandsma JW, Nuateren WA, Andersen JB, Naafs B (1983) Changes of the ulnar nerve in leprosy patients following neurolysis. Lepr Rev 54(1):31–38

    CAS  PubMed  Google Scholar 

  4. Husain S (2013) Decompression of peripheral nerve trunks in leprosy prevents the development and progression of deformities? Indian J Lepr 85(4):163–169

    CAS  PubMed  Google Scholar 

  5. Boucher P, Millan J, Parent M, Moulia-Pela JP (1999) Randomized controlled trial of medical and medico-surgical treatment of Hansen’s neuritis. Acta Leprol 11(4):171–177

    CAS  PubMed  Google Scholar 

  6. Dandapat MC, Sahu DM, Mukherjee LM, Panda C, Baliarsing AS (1991) Treatment of leprous neuritis by neurolysis combined with perineural corticosteroid injection. Lepr Rev 62(1):27–34

    CAS  PubMed  Google Scholar 

  7. Kumar K (1982) Surgical management of leprous ulnar neuritis. Clin Orthop Relat Res 163:235–242

    Google Scholar 

  8. Van Veen NHJ, Schreuders TAR, Theuvenet WJ, Agrawal A, Richardus JH (2012) Decompressive surgery for treating nerve damage in leprosy. Cochrane Database Syst Rev 12:CD006983

    PubMed  Google Scholar 

  9. Yamaguchi K, Sweet FA, Bindra R, Gelberman RH (1999) The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J Shoulder Elbow Surg 8(1):17–21

    Article  CAS  Google Scholar 

  10. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ (1993) The extrinsic blood supply of the ulnar nerve at the elbow: an anatomic study. J Hand Surg 18(3):433–438

    Article  CAS  Google Scholar 

  11. Künzel KH, Fischer C, Anderl H (1986) The ulnar nerve as vascularized nerve transplant. J Reconstr Microsurg 2(3):175–179

    Article  Google Scholar 

  12. Smith JW (1966) Factors influencing nerve repair: I. Blood supply of peripheral nerves. Arch Surg 93(2):335–341

    Article  CAS  Google Scholar 

  13. Sunderland S (1945) Blood supply of the nerves of the upper limb in man. Arch Neurol Psychiatry 53(2):91–115

    Article  Google Scholar 

  14. Strauch B, Lang A, Ferder M, Keyes-Ford M, Freeman K, Newstein D (1997) The ten test. Plast Reconstr Surg 99(4):1074–1078

    Article  CAS  Google Scholar 

  15. Campbell WW (2013) The Neurological Examination, 7th edn. Lippincott Williams & Wilkins, Philadelphia , pp 518–519

    Google Scholar 

  16. Park K (2015) Preventive and social science medicine, 23rd edn. M/s Banarsidas Bhanot, Nagpur, p 690

    Google Scholar 

  17. Ridley DS, Jopling WH (1966) Classification of leprosy according to immunity: a five groups system. Int J Lepr Other Mycobact Dis 34(3):255–273

    CAS  PubMed  Google Scholar 

  18. Theuvenet WJ, Gavin-Finlay K, Roche PW (2006) Change of sensation in leprosy by selective meshing of the epineurium. Euro J Plastic Surg 28(6):393–399

    Article  Google Scholar 

  19. Enna CD (1974) Neurolysis and transposition of the ulnar nerve in leprosy. J Neurosurg 40(6):734–737

    Article  CAS  Google Scholar 

  20. Jambeiro JE, Barbosa Junior AA, Reis MG, Guedes A, Cordeiro Neto AT (2008) Assessment of ulnar neurolysis in leprous neuropathy. Acta Ortop Bras 16(4):207–213

    Article  Google Scholar 

  21. Kulkarni GS (2008) Textbook of orthopedics and trauma, 2nd edn. Jaypee Publishers, New Delhi, p 665

    Book  Google Scholar 

  22. Payne R, Baccon J, Dossett J, Scollard D, Byler D, Patel A, Harbaugh K (2015) Pure neuritic leprosy presenting as ulnar nerve neuropathy: a case report of electrodiagnostic, radiographic, and histopathological findings. J Neurosurgery 123(5):1238–1243

    Article  Google Scholar 

  23. Wan EL, Rivadeneira AF, Jouvin RM, Dellon AL (2016) Treatment of peripheral neuropathy in leprosy: the case for nerve decompression. Plast Reconstr Surg Glob Open 4(3):e637

    Article  Google Scholar 

  24. Shukla M, Tiwari A, Srivastava A, Sharma G (2016) Role of surgical decompression of peripheral nerves in leprosy. Indian J Res 5(6):57–59

    Google Scholar 

  25. Wan EL, Noboa J, Baltodano PA, Jousin RM, Ericson WB, Wilton JP et al (2017) Nerve decompression for leprous neuropathy: a prospective study from Ecuador. Lepr Rev 88:95–108

    Article  Google Scholar 

  26. Kumar B, Kar HK (2017) IAL textbook of leprosy, 2nd edn. Jaypee Publishers, New Delhi, p 485

    Google Scholar 

  27. Bernardin R, Thomas B (1997) Surgery for neuritis in leprosy: indications for and results of different types of procedures. Lepr Rev 68(2):147–154

    CAS  PubMed  Google Scholar 

  28. Sardana K (2020) Jopling’s Handbook of Leprosy, 6th edn. CBS Publishers, New Delhi, p 331

    Google Scholar 

  29. Nunzi E, Massone C (2012) Leprosy a practical guide, 1st edn. Springer, Italy, p 303

    Google Scholar 

Download references

Acknowledgements

The authors wish to acknowledge the contributions from Dr K Deb Barman, Professor of Dermatology, Maulana Azad Medical College, New Delhi (India) and Dr Kabir Sardana, Professor of Dermatology, ABVIMS & Dr Ram Manohar Lohia Hospital, New Delhi (India).

Author information

Authors and Affiliations

  1. Department of Orthopaedics, ESIC Medical College & Hospital, Faridabad, Haryana, India

    Anil Dhal

  2. Department of Orthopaedic Surgery, The Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, 110002, India

    Yasim Khan & Sumit Arora

Authors
  1. Anil Dhal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yasim Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sumit Arora
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Anil Dhal (conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; supervision; validation; reviewing — original draft; writing — review and editing).

Yasim Khan (data curation; formal analysis; investigation; methodology; project administration; resources; validation; writing — original draft; writing — review and editing)

Sumit Arora (data curation; formal analysis; investigation; methodology; project administration; resources; supervision; validation; reviewing — original draft; writing — review and editing)

The manuscript has been read and approved by all the authors and requirement for authorship of this document has been met.

Corresponding author

Correspondence to Sumit Arora.

Ethics declarations

Ethics approval

Ethics approval was granted from IEC. Each author certifies that the work and all investigations were conducted in conformity with ethical principles of research. Each author believes that the manuscript represents honest work.

Consent to participate

Consent to Participate was taken from each patient.

Consent for publication

Consent to publish was taken from each patient.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Level of evidence: Level IV

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dhal, A., Khan, Y. & Arora, S. Epineurotomy for leprous, high ulnar neuropathy: defining a safe corridor based on the epineural vascular anatomy. International Orthopaedics (SICOT) 45, 1783–1792 (2021). https://doi.org/10.1007/s00264-021-05084-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-021-05084-4

Keywords

Search

Navigation