Estudio comparativo entre la descompresión simple y la transposición nerviosa en el tratamiento del síndrome del túnel cubital

Resumen

Introducción y objetivos El tratamiento quirúrgico del síndrome del túnel cubital es de elección en casos moderados y graves. Existen numerosas técnicas, sin un Gold Estándar definido. En este estudio, comparamos dos de ellas: descompresión sin o con trasposición nerviosa.

Material y Método Estudio descriptivo retrospectivo de 67 pacientes intervenidos quirúrgicamente por síndrome del túnel cubital entre enero del 2006 y diciembre del 2016. Los pacientes se clasificaron en dos grupos según la cirugía realizada: descompresión aislada o asociada a trasposición. Se recogieron variables demográficas (edad, género), clínicas (lateralidad y gravedad) y electrofisiológicas (DML, CMAP, MCV, EMG). La variable principal de resultado fue la mejoría o ausencia de ella al año de la intervención.

Resultados 67 pacientes se incluyeron en el estudio definitivo, 37 varones (55,2%) y 30 mujeres (44,8%), sin diferencias en la distribución entre los dos grupos en edad, género o lateralidad. Según la clasificación clínica de Dellon, 14 pacientes (20,9%) se correspondieron con el grado I (leve), 24 (35,8%) con el II (moderado) y 29 (43,3%) con el grado III (grave), sin diferencias significativas entre los dos grupos. Los resultados del estudio electrofisiológico también fueron similares en ambos. En el grupo sometido a descompresión in situ, 16 pacientes mejoraron (84,2%, n = 19). A los que se le realizó la trasposición, 39 mejoraron tras la intervención (81,3%, n = 48). Se observa que no existen diferencias en los resultados posquirúrgicos entre los pacientes según la técnica quirúrgica. Tampoco se encuentra una relación entre las variables recogidas y los resultados posquirúrgicos analizados según el tipo de cirugía realizada.

Conclusión La descompresión con trasposición no es superior a la descompresión aislada en nuestra muestra. El tiempo quirúrgico y las complicaciones asociadas a la trasposición, parecen más frecuentes, por lo que se recomendaría la descompresión in situ en casos de compresión primaria.

Abstract

Introduction and objectives Surgical treatment of moderate to severe cubital tunnel syndrome is elective. A general agreement regarding the best technique is far from being achieved. In this work we aim to compare simple decompression with subfascial transposition.

Methods This is a descriptive study of 67 consecutive patients diagnosed with cubital tunnel syndrome surgically treated at a single institution from january 2006 to december 2016. They were distributed according to the type of surgery: simple decompression or transposition. Demographic, clinical and electrophysiological data were recorded. Main outcome variable was improvement or the lack of it at one year of treatment.

Results There were 37 male (55.2%) and 30 female (44.8%), without any difference between the two groups regarding age, gender or laterality. According to Dellon’s classification, 14 had mild symptoms (20.9%), 29 (35.8%) moderate and 29 (43.3%) severe, without any significant difference. Electrophysiological results were similar too. 16 patients (84.2%, n = 19) from the decompression group improved. Of those treated with transposition, 39 showed improvement (81.3%, n = 48). There were no significant differences in the results after surgery according to surgical technique. There were not differences between preoperative data and results after surgery classified by procedure.

Conclusion Transposition associated with decompression is not superior to simple decompression in our cohort. Surgical time and complications related to transposition tend to be more frequent, so it would be recommended simple decompression in primary cubital tunnel syndrome.

Palabras clave

Síndrome del túnel cubital - descompresión - trasposición - nervio cubital - cirugía

Keywords

cubital tunnel síndrome - decompression - transposition - ulnar nerve - surgery

• Bibliografía

• 1 Mondelli M, Padua L, Giannini F, Bibbò G, Aprile I, Rossi S. A self-administered questionnaire of ulnar neuropathy at the elbow. Neurol Sci 2006; 27 (06) 402-411 . Doi: 10.1007/s10072-006-0719-3
• 2 Panas P. Sur Une Cause Peu Connue de Paralysie Du Nerf Cubital, Par Le Dr Panas. P. Asselin; 1878
• 3 Buzzard EF. SOME VARIETIES OF TRAUMATIC AND TOXIC ULNAR NEURITIS. Lancet 1922; 199 (5138): 317-319 . Doi: 10.1016/S0140-6736(01)27078-0
• 4 Feindel W, Stratford J. Cubital tunnel compression in tardy ulnar palsy. Can Med Assoc J 1958; 78 (05) 351-353
• 5 Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg 2007; 15 (11) 672-681
• 6 Calfee RP, Manske PR, Gelberman RH, Van Steyn MO, Steffen J, Goldfarb CA. Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms. J Bone Joint Surg Am 2010; 92 (17) 2801-2808 . Doi: 10.2106/JBJS.J.00097
• 7 Shah CM, Calfee RP, Gelberman RH, Goldfarb CA. Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. J Hand Surg Am 2013; 38 (06) 1125-1130.e1 . Doi: 10.1016/j.jhsa.2013.02.039
• 8 Robertson C, Saratsiotis J. A review of compressive ulnar neuropathy at the elbow. J Manipulative Physiol Ther 2005; 28 (05) 345 . Doi: 10.1016/j.jmpt.2005.04.005
• 9 Assmus H, Antoniadis G, Bischoff C. , et al. Cubital tunnel syndrome – a review and management guidelines. Cent Eur Neurosurg 2011; 72 (02) 90-98 . Doi: 10.1055/s-0031-1271800
• 10 Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev 2016; 11: CD006839 . Doi: 10.1002/14651858.CD006839.pub4
• 11 Chen HW, Ou S, Liu GD. , et al. Clinical efficacy of simple decompression versus anterior transposition of the ulnar nerve for the treatment of cubital tunnel syndrome: A meta-analysis. Clin Neurol Neurosurg 2014; 126: 150-155 . Doi: 10.1016/j.clineuro.2014.08.005
• 12 Macadam AS, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg Am 2008; 33 (08) 1314.e1-1314.e12 . Doi: 10.1016/j.jhsa.2008.03.006
• 13 Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2007; 89 (12) 2591-2598 . Doi: 10.2106/JBJS.G.00183
• 14 Mowlavi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg 2000; 106 (02) 327-334
• 15 Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery 2006; 58 (02) 296-304, discussion 296–304 . Doi: 10.1227/01.NEU.0000194847.04143.A1
• 16 Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery 2005; 56 (01) 108-117 , discussion 117
• 17 Bartels RHMA, Verhagen WIM, van der Wilt GJ, Meulstee J, van Rossum LGM, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery 2005; 56 (03) 522-530 , discussion 522–530
• 18 Jablecki CK, Andary MT, So YT, Wilkins DE, Williams FH. ; AAEM Quality Assurance Committee. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve 1993; 16 (12) 1392-1414 . Doi: 10.1002/mus.880161220
• 19 Kern RZ. The electrodiagnosis of ulnar nerve entrapment at the elbow. Can J Neurol Sci 2003; 30 (04) 314-319
• 20 McGOWAN AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br 1950; 32-B [phone]
• 21 Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am 1989; 14 (04) 688-700
• 22 R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2018. https://www.R-project.org/
• 23 Davies MA, Vonau M, Blum PW, Kwok BC, Matheson JM, Stening WA. Results of ulnar neuropathy at the elbow treated by decompression or anterior transposition. Aust N Z J Surg 1991; 61 (12) 929-934
• 24 Keiner D, Gaab MR, Schroeder HWS, Oertel J. Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome–a prospective study. Acta Neurochir (Wien) 2009; 151 (04) 311-315, discussion 316 . Doi: 10.1007/s00701-009-0218-4
• 25 Landau ME, Campbell WW. Clinical features and electrodiagnosis of ulnar neuropathies. Phys Med Rehabil Clin N Am 2013; 24 (01) 49-66 . Doi: 10.1016/j.pmr.2012.08.019