RU2705407C1 - Method for surgical management of cubital tunnel syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used in treating cubital tunnel syndrome. Method involves access to the elbow joint at the level of the cubital tunnel, dissection of the fibrotic changed Osborn's ligament, performance of neurolysis with hydropreparation, epineurium opening along the whole pathological process and excision of the pinched nerve from cicatrixes. At the level of pinching, the ulnar nerve is enveloped with a collagen membrane "Kollost", with formation of a channel by suturing the membrane edges along the length of interrupted sutures with a biodegradable suture. It is followed by hemostasis and wound closure. Drainages, an aseptic dressing and Deso's dressing are placed.

EFFECT: method provides the maximum reduction of the risk of nerve injuries and the probability of recurrence, is simple to implement, is performed using available materials by forming a channel from a collagen membrane isolating the pinched nerve from mechanical action on it.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of cubital canal syndrome.

One of the most difficult problems in traumatology and orthopedics is surgery for neuropathy of the ulnar nerve - cubital canal syndrome. The best known methods for treating cubital canal syndrome are. So generally accepted, among surgical methods, are neurolysis and transposition of a nerve into a site with good blood supply, without minimal risk of scar tissue formation. Moreover, a number of authors indicate that the percentage of successfully operated patients using these options is approximately the same [1].

Often, at the first clinical manifestations, in order to achieve a positive result, and with the least trauma to the tissues, the decompression of the ulnar nerve in the form of neurolysis, which can be performed either openly or endoscopically, acts as a surgical technique. One of the main conditions for the implementation of this technique is decompression of the nerve distal to the medial epicondyle by at least 5-6 cm. Decompression with neurolysis is also the method of choice if there are pathological soft-tissue and bone structures in the projection of the cubital canal that violate the normal anatomy of the area under consideration [2] . However, the data available in the literature claim that with decompression of the nerve only temporary improvement is achieved, the regression of clinical manifestations is not constant, and subsequently a relapse of the disease is possible [3].

There are two types of anterior transposition of the ulnar nerve. The first involves laying the nerve directly under the skin, but in this case there is a significant percentage of complications in the form of severe neuropathy of the elbow joint area due to the constant mechanical effect on the ulnar nerve. The second type is the anterior transposition of the ulnar nerve with the formation of a channel in the flexor muscles of the hand and fingers [1]. The disadvantages of transposition are trauma to the nerve and its devascularization with damage to the branches.

Despite the widespread use of various methods of treatment, there remains a high disability of patients, the need for repeated operations. Peripheral nerve regeneration, as a rule, does not end with a complete restoration of structure and function. So, repeated operations after surgical treatment of cubital canal syndrome are associated with dense fibrosis around the nerve, and with transposition of the nerve, with its adhesions with surrounding tissues [4].

The invention consists in a combination of essential features sufficient to achieve the desired technical result, which consists in minimizing the risks of nerve injury, ease of surgery, accessibility of material and reducing the likelihood of relapse.

The essence of the method of channel formation for ulnar neuropathy includes access to the elbow joint at the level of the cubital canal, dissection of Osbourne’s fibrotic ligament, neurolysis with hydropreparation, opening of the epineuria along the entire pathological process, isolation of the transferred nerve from scars. At the level of squeezing, the ulnar nerve is wrapped with the Collost membrane collagen membrane with the formation of a channel by stitching the edges of the membrane along the length of the interrupted sutures with a biodegradable thread. Hemostasis. Wound closure. Drainage. Aseptic dressing.

The formation of the channel from the Collost membrane collagen membrane allows isolating the transmitted nerve from mechanical impact on it, ensuring its vascularization without damage to the branches innervating the ulnar joint and ulnar flexor of the hand, which reduces the occurrence of relapse of the disease.

The method is illustrated in the illustrations, where in FIG. 1 and FIG. 2 shows intraoperative photos:

in FIG. 1 - ulnar nerve after hydrotreating with 0.25% novocaine solution;

in FIG. 2 - ulnar nerve in the formed channel from the collostic membrane “Kollost”;

in FIG. 3 - data of electroneuromyography (ENMG) of the right ulnar nerve at the level of the cubital canal at the time of hospitalization;

in FIG. 4 - ENMG data of the right ulnar nerve at the level of the cubital canal 3 months after the operation.

The method is as follows.

Under conduction anesthesia, after triple treatment of the surgical field with alcohol, an arcuate incision is made in the area of the elbow joint 5-7 cm long, and the scars are excised. Stupidly and sharply secrete the ulnar nerve. Before entering the canal, the nerve is thickened, swollen, of stony density. The neurolysis of the ulnar nerve is carried out with hydraulic preparation of 0.25% novocaine solution, while nerve obstruction in the area of the cubital canal is felt. Then, in the region of its maximum pressure, a channel is formed by the Collost membrane by sewing together the edges of the membrane along the length of the interrupted sutures with a biodegradable thread. Hemostasis. Wound closure. Drainage. Aseptic dressing. Bandage Deso.

Clinical example

Patient K., 58 years old, was admitted to the Department of Orthopedics No. 1 of the State Autonomous Institution “RKB MZ RT” on August 18, 2018. Diagnosis: Mixed contracture of the right elbow joint. Compressive neuropathy of the right elbow joint. Cubital channel syndrome on the right. The circumstances of the injury: November 6, 2017, a fall on the right elbow joint. I did not receive treatment. On examination: mixed contracture up to 120 g., Hyposthesia of 4.5 fingers of the right hand, severe pain, hypotrophy of the interosseous muscles, difficulty in bringing the first finger; there is no reduction / abduction of the fifth finger of the right hand.

08/19/2018, the operation was performed according to the proposed method. After processing the surgical field three times with alcohol, an arcuate incision was made in the area of the elbow joint, and the scars were excised. Stupidly and sharply allocated an ulnar nerve. The nerve is swollen, there are signs of ischemia in the area of the cubital canal, its stony density is felt. They performed neurolysis of the ulnar nerve with dissection of the Osbourne fibrotic ligament, hydrotreated 0.25% solution of novocaine, and the nerve in the area of the cubital canal is difficult to pass. The channel was formed by the “Collost” collagen membrane by wrapping a nerve and stitching the edges of the membrane along the length of the interrupted sutures with a biodegradable thread. Hemostasis. Wound closure. Drainage. Aseptic dressing. Bandage Deso. Primary healing. Skin sutures were removed after 14 days.

Control examination was performed 3 months after the operation with the data of ENMG and ultrasound. The patient disappeared pain both during exercise and at rest, numbness of 4.5 fingers of the right hand, difficulty in moving the thumb of the right hand. The range of motion in the right elbow joint is complete.

Objectively: comparison of ENMG data of the right ulnar nerve at the level of the cubital canal at the time of hospitalization and 3 months after the operation shows a significant improvement in the postoperative period.

The patient is satisfied with the result of the operation.

Thus, the proposed "Method for the formation of an artificial canal with neuropathy of the ulnar nerve" allows you to eliminate pain both during exercise and at rest, numbness of 4.5 fingers of the right hand, difficulty in moving the thumb of the right hand.

Information sources

1. Macadam S.A., Gandhi R., Bezuhly M., Lefaivre K.A. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a metaanalysis // J. Hand Surg. Am. - 2008 .-- 33 (8). - 1314. - P. e1 - 12.

2. Assmus H., Antoniadis G., Bischoff C., Hoffmann R., Martini AK, Preissler P., Scheglmann K., Schwerdtfeger K., Wessels KD, WustnerHofmann M. Cubital tunnel syndrome - a review and management guidelines // Cent. Eur. Neurosurg. - 2011 .-- 72 (2). - P. 90-98].

3. Masgutov P.O., Gods A.A., Galyamov A.P., Rogozhin A.A., Valeeva L.R., Hannanova I.G., Filipov V.L., Akhtyamov I.F., Bogov A.A. Cubital channel syndrome, diagnosis and treatment tactics. 4 (89) June 2015 / Volume 1 pp. 110-111.

4. Filippi R. 1., Charalampaki P., Reisch R., Koch D., Grunert P. Recurrent cubital tunnel syndrome. Etiology and treatment // Minim Invasive Neurosurg. - 2001 .-- 44 (4). - P. 197-201.

Claims (1)

The method of channel formation in neuropathy of the ulnar nerve, including access to the elbow joint at the level of the cubital canal, dissection of the fibrotic ligament of Osborne, neurolysis with hydropreparation, opening of the epineuria along the entire pathological process, isolation of the transferred nerve from scars, characterized in that at the level of ulnar pressure the nerve is wrapped with the Collost membrane collagen membrane, with the formation of a channel by stitching the edges of the membrane along the length of the interrupted sutures with a biodegradable thread, hemost az, suturing wounds, install drainage, aseptic dressing and Deso dressing.

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