Cubital tunnel syndrome is the second most common compressive neuropathy, second to carpal tunnel syndrome---and results in numbness and tingling in the ring and small finger, often exacerbated by elbow flexion, which places strain on the nerve since it courses behind the medial epicondyle. In more severe cases the intrinsic muscles can weaken resulting in decreased pinch and grip strength and loss of coordination. When preoperative nerve studies reveal this, or even for intolerable symptoms when nerve studies are normal, various operative options exist, including moving the nerve in front of the epicondyle. Although surgery is often helpful, it is infrequently 100% successful, and there are patients for which symptoms worsen or do not get better.
Regardless of the cause of patient dissatisfaction or frank failure, revision surgery is an option, but many surgeons are reluctant because of uncertainty about the outcomes. In my practice, it is much easier to advise a patient if postoperative nerve studies have worsened, or when I am concerned about the technical execution of the index procedure. In other cases, such as when concomitant diabetic neuropathy or cervical radiculopathy exist, it is perhaps better to recommend against more surgery because of the unlikelihood of improvement.
Much research on correlation between coping strategies, self-efficacy, and various other psychological parameters reveals that for chronic conditions, helping the patient adapt and live with symptoms and disability may be the wiser and ultimately more successful approach. That having been said, I have revised failed cubital tunnel surgeries for many years and tell interested patients the following: 50% feel as though the surgery helped, but very few are “cured.”
Well—now we have a bit more data thanks to an article attached below by Dr Ryan Calfee and coauthors published in the November 2014 edition of the Journal of Hand Surgery. This study compared the outcomes of 28 revision cases to 28 primary controls---and acknowledged weaknesses such as potential differences in the disease characteristics and the preoperative status of patients, as well as a selection bias in terms of those who were enrolled.
However, the findings are helpful in terms of what I will share with my patients who inquire as to the likely outcome after revision surgery.
2. 25% improved their McGowan grading (a classification of ulnar nerve injury based on objective and subjective status ie atrophy, weakness, numbness )
3. 21% had deterioration in their McGowan grading (meaning they got worse)
4. 53% reported constant residual symptoms---even if better than before
Calfee has also looked at predictors of surgical revision after in situ decompression alone. Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period (2006-2011). Predictors of revision surgery included a history of elbow fracture or dislocation and McGowan stage I disease---minimal findings but with numbness. Concurrent surgery with in situ decompression was protective against revision surgery. The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery.
So, in conclusion, a 20% failure rate may accompany selection of in situ decompression alone. Although these failures could arguably be revised----- it’s really important to select all patients for revision carefully, and to ensure that they have a very realistic view of outcome so that they are not unjustifiably proceeding based on undeliverable results.
But—if a patient is comfortable with a 79% chance of some improvement, despite the potential-- 50% of the time-- that symptoms may remain constant, and one-fifth of the time that they may objectively worsen, then it may be worth considering revision.
As I often advise---“sometimes it’s better to live with the devil you know than the devil you don’t.”
But if a patient seems to have reasonable coping skills and feels that they cannot live with the status of their hand and/or residual symptoms nonetheless, this paper supports revision in selected cases.
