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Cubital tunnel surgery in patients with cervical radiculopathy: double crush syndrome?

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Abstract

To determine differences in clinical outcomes in patients harboring both cubital tunnel syndrome (CuTS) and cervical radiculopathy and the influence of the so-called double crush syndrome. Both procedures were performed in 24 patients, mean age 55 years; first group of 14 patients underwent CuTS surgery as a first procedure. Second group of 10 patients underwent anterior cervical discectomy and fusion (ACDF) then ulnar nerve release (UNR). Two patients underwent bilateral nerve surgery and six multiple cervical discectomies. Surgeries consisted in 26 nerve releases with associated external neurolysis in five, and 34 ACDF procedures, with plating in six. Clinical complaints (mean time 12 months) were sensory in 20 arms, with associated motor weakness and hypothenar atrophy involvement in another six. Electromyography changes were mild (two arms), moderate (16 arms), and severe (eight arms). Mean time of follow-up was 3 years (range 18 months–14 years). Clinical improvement was evidenced in 14 patients. Sensory nerve symptoms improved in 13 limbs in both groups and motor improvement was evident in three patients with UNR as first surgery. A comparative cohort of 20 patients with UNR but without cervical radiculopathy was studied to disclose outcome differences. Of these, 13 patients had clinical improvement. No differences were found among groups. In patients with double crush syndrome, factors that seemed to influence a poor CuTS outcome were evolution of symptoms longer than a year, history of multiple neuropathies or radiculopathies, and ACDF performed before UNR.

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Authors and Affiliations

  1. Department of Neurosurgery, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain

    Marcelo Galarza

  2. Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy

    Roberto Gazzeri

  3. Department of Neurosurgery, San Filippo Neri Hospital, Rome, Italy

    Giovanni Gazzeri

  4. Department of Neurosurgery, Veterans Administration Medical Center, Cincinnati, OH, USA

    Mario Zuccarello & Jamal Taha

  5. Regional Service of Neurosurgery, Hospital Universitario Virgen de la Arrixaca, E-30120 El Palmar, Murcia, Spain

    Marcelo Galarza

Authors
  1. Marcelo Galarza
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  2. Roberto Gazzeri
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  3. Giovanni Gazzeri
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  4. Mario Zuccarello
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  5. Jamal Taha
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Correspondence to Marcelo Galarza.

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Comments

Kartik G. Krishnan, Frankfurt, Germany

The optimal strategy for the surgical treatment of cubital tunnel syndrome (synonym: retrocondylar groove syndrome or ulnar sulcus syndrome) has been till recently [or perhaps is still] under dispute: simple in situ decompression, anterior subcutaneous transposition, and anterior submuscular or intramuscular transposition with or without an epicondylectomy. It has been agreed, after much discussion and meta-analysis of literature resources, that the simple in situ decompression should be the choice in the simple ‘text book’ case of cubital tunnel syndrome, whereas the other options may be reserved for unusual presentations and relapses1.

Double crush or multiple crush syndromes fall under a category that is indeed rare in clinical practice. Although usually involving one nerve at multiple points (e.g., loge-de-Guyon, cubital tunnel, and thoracic outlet, as pertinent to the ulnar nerve), double crush may also present with pathologies at the level(s) of the cervical vertebra(e), as in the presented series. That being said, some patients might show peripheral neuropathy and cervical radiculopathy as phenomena independent of each other: the differentiation is difficult.

The precise diagnosis of multiple crush is a challenging venue. Apart from meticulous clinical examination, electrophysiological techniques and imaging modalities are employed. Before the instrumental diagnostic techniques are brought into play, a suspicion of multiple crush has to be arrived upon. Nerve conduction velocity and inching techniques would provide information on the site of peripheral nerve dysfunction along its course in the extremity. Recently introduced ultrasound imaging of peripheral nerves at the area of the lesions reveals (as opposed to MRI) not only static, but also dynamic changes of the nerve with movement of the extremity2,3. Whereas, MRI is the method of choice in diagnosing cervical radiculopathy.

Now, the diagnostic puzzle has to be put together and a decision has to be made, which area has to be surgically addressed [first], i.e., if an indication for a surgical procedure is seen. As usually is the case in patients with multiple or double crush syndromes, there is always one leading syndrome that causes the major clinical symptoms and reduces the quality of life, whereas those of the concomitant crushes are masked underneath, only to become evident as soon as the leading syndrome is treated. More often, conservative management of the ‘milder’ peripheral nerve crushes, or even a radiculopathy, would alleviate the condition. Thus an unsuccessful conservative treatment trial is a prerequisite for one to resort to surgery. The patients have to be observed by the same surgeon under non-surgical treatment during a period of at least 3 months before deciding on surgery; there are exceptions here, of course.

As pertinent to radiculopathy, the underlying cause of the nosology has to be revealed in order to conclude upon the proper surgical strategy (this also varies from simple foraminotomy to anterior cervical disk fusion at various involved levels). These are parts of the puzzle too.

It becomes evident that patients suffering from true multiple crush syndromes make a completely heterogeneous lot and the evaluation of what is best for them becomes a difficult ordeal altogether. Galarza et al. have attempted to bring in a system in this paper and answer the question “what is the outcome of ulnar nerve decompression after a patient has undergone anterior cervical discectomy and fusion?”

The answer was: patients with prolonged [neglected] symptoms of ulnar nerve entrapment and patients that had undergone anterior cervical decompressive surgery beforehand show inferior outcomes as opposed to patients undergoing ulnar nerve decompression [alone] in a timely manner.

The main shortcoming of this paper is the choice of patients: is the cohort a ‘true’ double crush or are the diseases ‘concomitant’ and ‘independent’ of each other. Despite the small disagreement here, the attempt to systematize the issue is laudable. In light of this commentary, their conclusions have to the critically viewed. Prospective randomized trials might bring further clarification. Since double crush is a rare nosology, several centers should be involved in such a study—which has been prudently pointed out by the authors. In view of the heterogeneity of the multiple crush syndromes, an individual approach to patients, having all the management armamentaria in store, should still remain the strategy, until such randomized, multi-centric trials are completed and guidelines are evolved.

References

1. Assmus H, Antoniadis G, Bischoff C et al. (2009) Diagnosis and therapy of cubital tunnel syndrome—state of the art. Handchir Mikrochir Plast Chir 41(1):2–12.

2. Beekman R, van der Plas JP, Uitdehaag BM et al. (2004) Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve 30:202–208.

3. Martinoli C, Bianchi S, Pugliese F et al. (2004) Sonography of entrapment neuropathies in the upper limb (wrist excluded). J Clin Ultrasound 32:438–450.

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Galarza, M., Gazzeri, R., Gazzeri, G. et al. Cubital tunnel surgery in patients with cervical radiculopathy: double crush syndrome?. Neurosurg Rev 32, 471–478 (2009). https://doi.org/10.1007/s10143-009-0219-z

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