Ulnar Nerve Surgery Update

[lucidmaster]

I had a submuscular ulnar nerve transposition 10 days ago. I've had difficulty gathering first hand information from patients while considering surgey, so I decided to document and share my experience with folks if there is interest. I can provide more updates as I go along.

Prior to surgery my 4th and 5th fingers were going numb after I bent my elbow. EMG revealed slowed conduction in the elbow. I managed it and did not bend my elbow more than 45 degrees for 4 months, and the situation did not improve. The specialist observed that my ulnar nerve was popping out of its grove, and recommended surgery, stating it would not go away given it was not staying where it was supposed to be.

The surgery has gone well. I currently don't have any numbness or pain in my hand, and can move all of my fingers as I want. There was some moderate pain around my elbow the day of surgery, but I could tolerate it, and did not have to take any painkillers at all! I am currently typing with both hands.

My arm was in a semi-plaster splint during the first 4 days. Then the splint started putting pressure on my swollen elbow (the swelling response kicks in 2-3 days after surgery), and I began to have some numbness in the fingers. They told me I could remove the splint if I didn't have any pain, which is what I did, and the numbness went away. I haven't worn the splint since then.

At the end of the 7th day there was some minor swelling and discoloration in my hand and wrist. Based on my description, they told me not to worry about it as long as I don't have pain or numbness, and that it was simply blood and other fluids moving down to my hand from my elbow after the surgery. The swelling in my hand and elbow has since gone down, and the discoloration is slowly going away. My elbow is still swollen, but that is going down as well. I stopped covering my arm in the shower after day 7.

My overall arm strength and range of motion improves on a daily basis. I can lift/manipulate light objects with ease. The staples will be removed in 2 days (I counted 20 staples along the 20-25 cm incision), and I am assuming they will refer me to physical therapy then.

Let me know if you would like to hear further updates...

[Silverlady]

Wish you continued success.
Billye

[lucidmaster]

The staples were removed on the 24th, 2 weeks after surgery. The minor swelling in my hand was gone by then, and the elbow was still somewhat swollen. After they removed the staples, I was sent to occupational therapy. The therapist took some measurements: I could bend my elbow 110 degrees, and the incision was actually just 12 cm, and not 20cm as I guessed earlier. She gave me some minor exercises.

Today, 3 weeks after surgery, I saw the therapist again. My ROM was up to 145 degrees. I was feeling some minor "dullness" on the 4th and 5th fingers earlier, but in the past few days, that has not happened at all. I continue to have no pain, and at times, forget that I even had surgery, which is dangerous since the tendon is held in place by internal stitches and should not be loaded (the doc said no more than 5 pounds).

Considering how well things have been going, I kind of wish I had the surgery earlier. The ulnar nerve was not significantly damaged prior to surgery, but there was still some evidence of muscle wasting between my thumb and index finger, which seems to have resulted in a slight tremor in the index finger. The doc said it might take the muscle 3-5 years to regrow and the tremor to go away. [the ulnar nerve provides sensation to the 4th and 5th fingers, and controls many of the fine muscles that attach to all fingers of the hand. Therefore, although the sensory symptoms are felt in the 4th and 5th digits, motor symtoms can be observed anywhere in the hand]. I doubt that I will still be posting here in 3 years, but I'll try to keep this going for the next 2-3 months.

[lucidmaster]

4 weeks out of surgery; everything is going well. I got full range of motion at 3.5 weeks. The swelling is almost all gone. The surgeon checked things out and said I could start lifting moderately heavy weights at week 6, which will be 2 weeks from today. I am using my hand/arm freely. I can easily pick up small things like a laptop and open doors, drive etc. The "dullness" around the 4th and 5th fingers seldomly shows up (once a day maybe), but goes away quickly if I start moving my arm. Also, there is sometimes a very slight tremor in all fingers, but the doc said it was nothing to worry about and that it would go away once the nerve settles in. It is great to be able to bend my elbow again whenever I want! I guess I will do one more report in a few weeks and then tune out...

[dahlek]

COUNT YOUR BLESSINGS EVERY SINGLE DAY!!! Believe, truly believe you have beaten the odds! Think that way and it could really be true!

Remember, that such surgery will likely bring up bruises for several weeks, up to 10-12 weeks, due to the 'invasion' I call surgery thru the different levels of skin, muscle and tendons docs have to navigate to get to -to do what they did.

All the best! Please keep us updated on your progress. I'm jealous! - j

[joy]

Glad to hear it is going well. I too appreciate the updates on how things are doing for you.

[supahjew]

I'm an 18 year old who has very minor neuropathy, the major problem is I want to work out and can't really with my nerves popping in and out.

Where are you located?
What kind of surgeon performed your operation? I'm supposed to have it done by one of the best hand surgeons in NYC, Dr. Patel (he owns www.handsurgeon.com) - but I heard neurosurgeons are better at it because they use microscopes?
Was there any mention of the nerve deteriorating/inflaming over the years, as I've read cases where people's pain returns after 20 or so years.
Do you "feel" the nerve underneath the muscle as you bend your elbow?
What feeling have you lost as a result of the surgery? Is it just around the area of the incision, or were branches from the ulnar nerve removed to allow for the transposition?

[lucidmaster]

I'm in Boston. My surgery was done by the chief of orthopedic hand surgery at Mass General.

I don't think that a neurosurgeon would be better choice IF you are having this surgery because your nerve is popping out like mine because that condition requires the nerve to be moved out of its environment under the muscle, which requires tendon dissection and reattachment and that's what orthopedic surgeons do best. It should not require operating on the nerve itself unless your nerve is severely damaged. (The nerve can also be moved under the skin without tendon dissection, but that leaves it vulnerable for potential future injuries.)

However, if you are having surgery because your ulnar nerve is compressed in some other way, or is damaged by trauma and has accumulated scar tissue, then a neurosurgeon would probably a better option since then they might need to operate on the nerve itself without moving it anywhere.

No, I don't feel the nerve under my muscle. Your median nerve actually naturally travels under the same muscle as the ulnar is moved underneath, so it is not such an artificial situation. I have not lost any feeling at all--all branches of the nerve were preserved. I read that in some cases (less than 15%) some branches might not make it, but they are usually fairly minor sensory branches local to the elbow area to begin with. Even if they are lost, they are supposed to regenerate over time.

I haven't seen any data suggesting there is a statistically significant possibility that the nerve will be inflamed in the long run though I guess it is possible. The main issue was that if I did not have the surgery, the nerve would have continued to slowly degrade, given it was moving over the bone every time I bent my elbow. So, the benefits outweighed the risks in my case, which is when one needs to have surgery.

Good luck!

[lucidmaster]

It's now been exactly 2 months since surgery, and I started strengthening exercises yesterday. Mainly squeezing puddy and some curls with a 5 lb weight. There is still some minor swelling around the bone where the tendon was reattached; I was told that might take another 2-3 months to go away. No pain overall as long as I remember I had surgery and don't lift a bucket full of water or something. The dullness that I was rarely experiencing around the 4th and 5th fingers is even rarer now. I'll see the surgeon again in 6 weeks for follow-up. I will also discuss getting the right arm fixed as well; the nerve is also popping on the right elbow, but I've been watching it, so it's been in check.

When I was doing my research, I ran into the two abstracts in another forum. I'll post them here separately.

[lucidmaster]

Int Orthop. 2003;27(4):232-4. Epub 2003 Jun 12.

Stabilized subcutaneous transposition of the ulnar nerve.

Hashiguchi H, Ito H, Sawaizumi T.

Department of Orthopaedic Surgery, Nippon Medical School Second Hospital, 1-396 Kosugicho, 211-8533, Nakahara-ku, Kawasaki City, Kanagawa, Japan.

We treated 50 patients (average age 47.9 years) with a stabilized subcutaneous transposition of the ulnar nerve. The average follow-up period was 42.4 months. The indication was cubital tunnel syndrome in 19 patients and injuries around the elbow in 31 patients. Postoperatively, satisfactory results were obtained in all the patients, and there was no complication or aggravation of the preoperative symptoms. None of the patients experienced slipping back of the nerve to the cubital tunnel. In the 31 patients with injuries around the elbow, there was only one patient with transient aggravation of parasthaesiae in the ulnar nerve region. Stabilized subcutaneous transposition is a simple and less invasive procedure that can facilitate decompression and prevent slipping back of the nerve. This procedure also can be applied to patients with injuries around the elbow that require ulnar nerve transfer.

[lucidmaster]

: J Bone Joint Surg Am. 2000 Nov;82-A(11):1544-51.

Stabilized subcutaneous ulnar nerve transposition with immediate range of motion. Long-term follow-up.

Black BT, Barron OA, Townsend PF, Glickel SZ, Eaton RG.

C.V. Starr Hand Surgery Center and St. Luke's-Roosevelt Hospital, New York, NY 10025, USA.

BACKGROUND: Anterior transposition of the ulnar nerve at the elbow produces generally good results regardless of whether the nerve is transposed subcutaneously, intramuscularly, or submuscularly. The eventual recovery of nerve function is related less to the specific surgical technique than to the severity of the intrinsic nerve pathology. A primary variable in surgical management is the duration of postoperative elbow immobilization. The purpose of this study was to review the longterm results of a specific technique of subcutaneous anterior transposition of the ulnar nerve that utilizes a stabilizing fasciodermal sling. The study compared the results of immediate and late institution of a range of motion postoperatively. METHODS: Forty-seven patients with fifty-one elbows were reexamined, by an investigator who had not been involved in their treatment, at a minimum of two years (range, twenty-four months to fourteen years) after an anterior transposition. Of the fifty-one elbows, twenty-one were immobilized for two to three weeks whereas thirty were managed with an immediate range of motion. RESULTS: At the latest follow-up evaluation, there were occasional, mild paresthesias in 16 percent of the limbs and there was still subjective weakness of 19 percent. Both pinch and grip strength had increased substantially. No patient had lost elbow motion. A positive Tinel sign persisted in 31 percent of the limbs, but it was mildly positive in most of them. The elbow flexion test was uniformly negative. The results for 92 percent of the limbs were satisfactory to the patients, who stated that they would undergo the same procedure again if necessary. Overall, 73 percent of the limbs had an excellent result; 18 percent, a good result; 4 percent, a fair result; and 6 percent, a poor result. With the numbers available, no significant difference could be detected, with regard to these outcomes, between the group managed with elbow immobilization and that managed with immediate elbow mobilization. However, patients treated with a postoperative cast returned to work at an average of thirty days after surgery whereas the group treated with immediate motion of the elbow returned to work at an average of ten days. CONCLUSIONS: This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately.

[supahjew]

Wow, you're TWO months in and still lifting only 5 pound weights? My doc said I could resume normal activity after a month.

[joy]

Although I'm not having that particular problem, I just want to thank you again for keeping us updated. You never know when it might be just the information you need.

[lucidmaster]

Supah, well, the surgeon also told me I can resume normal activity after 6 weeks, and I have, meaning I go about my daily business without noticing a thing. Loading the tendon is a different story though. I am sure it can handle more than 5 lbs, but the therapist has told me not to push things too fast. Tendon heals slowly. If you push it, you can actually tear the whole thing, or pieces of it, off the bone, and you will need elbow reconstruction surgery. I tore a minor tendon in my wrist a few years ago, and it took over a year to heal properly. I wouldn't take your doctors comments to be, "you can start bench pressing 200lbs in a month" unless he has recommended a procedure something other than a submuscular transposition that does not require tendon dissection.

One other comment, which you might or might not welcome. I know you are young and eager to work out, just the way I was back then. Now, in my mid 30s I really am paying for pushing my body waaay too hard in my teens and 20s. And I see it all around me with the people who were really into competitive sports--my discus thrower friend for example. Although, I don't regret anything, I kind of wonder what that was all about...

And Joy, I am glad you are finding this information useful.

[supahjew]

They took your tendon right off of the bone? I thought they cut it. I'm not deathly eager to work out, but it'd be nice, plus I already feel some numbing and pain of my ring and pinky. I just hope if I have this surgery around Dec 23 I will be able to at least pick a bookbag up or open a door by Jan 22 when school starts again, so it can be completely healed by the summer.

lucidmaster, I sincerely thank you for your help, there has been not a single person on the internet to share their experiences besides you.

[joy]

I am hoping that people will take lucidmaster's comments about not overdoing things to heart. When I was middle-aged I discovered the joys of walking. I loved it and it was not long before I lost weight but more than that, I slept better at night. So I added the little 3.3 pound weights in each hand and did all kinds of lifting contortions with those weights, putting them on a sawed-off broom handle and raising them with one arm, etc. When I complained to my rheumy doctor he told me not to walk as much. So I lost the weights and walked faster. Finally the doctor told me not to walk at all. I have arthritis in every joint in my body now. So really in the long run, it was not worth it for me. I should have just stuck to a nice leisurely walk around the neighborhood and maybe I’d still be doing the same today.

Oh yes, I have had a torn ligament and you are so right about taking it ever so slow with it. One in an ankle and the other something different, a partial torn rotator cuff. The specialist with the cuff would not do surgery because I had peripheral neuropathy and he said my chances of it healing properly was less than 40% chance so he did not want to do surgery on me.

[lucidmaster]

I was able to move around fine, drive, carry a laptop and open doors and all that 3 weeks out of surgery, so if things go well, you should be fine by the time shcool starts.

Yes, they shave the tendon off the bone in the submuscular transposition. There is no way the nerve can be moved to the inside of your elbow from the outside without completely detaching the muscle. Look at your elbow and think about it, and you'll see. They also cut along--not across--the muscle above and below your elbow to be able to properly move the nerve out of the cubital tunnel. That's why you end up with a 20 cm incision. It sounds much worse than it is, so don't let that scare you.

I think the key thing with recovery is moderation. If you don't load your elbow at all, you will not heal and you won't get your range of motion back. If you load it too much too early, you'll mess up what the surgeon put back together.

The therapist is saying I can actually swim now, but I can't because of a busted disc in my thoracic spine, which I am having surgery for in a couple of months. So, the ulnar nerve is just peanuts in comparison to what I am about to go through...

[supahjew]

I'm confused, if you can carry heavier things like laptops and open doors, then why are you doing only 5 pound girls? Is there a reason that your therapist gave you, I'm just curious.

Also, how did they reattach the tendon to the bone with staples? It seems like it'd make more sense to cut the tendon in half and reattach the two halves so they'd grow back. Again, just curious. :)

[lucidmaster]

The 5lb curls are repetitive. Opening doors and dealing with a laptop aren't. They want to keep the weight down so that the area does not get too inflamed. I am sure I can do the curls with more weight, but it's not clear there is anything to be gained by doing so at this point. Also, the therapist is playing it safe to cover herself, and that's understandable.

The tendon is stitched back to the bone. That's what the surgeon told me. I didn't have the time to ask more, and I am curious as to how that is done, too.

If you cut the tendon in half it will never heal properly, and will lose considerable strength. The interface between the tendon and the bone regenerates faster and heals much better (that's what my bio-engineering faculty member colleague told me).

[supahjew]

I guess it's typical that surgeons don't operate on both arms at once, but I really wanted this over with and was kind of upset when he said I'd need to have one of my other arms done at a later time (like summer break). Maybe I should just postpone surgery completely till the summer so I can suffer a week with my mom helping me and then slowly regain mobility. I'd rather suffer a little than go through surgery AND physical therapy twice. In any case, it's scheduled for January 2nd and I hope to recover enough to normally function when I get back to school on January 22nd.

Here's a blog of a guy, not too old, that posted about his experience with the surgery. It goes from the beginning of April to mid-May, hope it helps anyone looking for a detailed account of what the the surgery and therapy hold.

http://quitelucid.blogspot.com/2006_04_01_archive.html

What a strange coincidence between "lucidmaster" and "quitelucid"!

Which arm was yours operated on, lucidmaster? Did the scar heal well?

[lucidmaster]

I was told my scar has healed well. It is still somewhat sensitive if I put pressure on it while I am asleep and so on, but I am happy with the progress. It seems like I started the strengthening exercises too early though (at week 8) as I had some minor pain and numbness in my pinky finger shortly after I started the exercises. So, I backed off, and things are back to normal again. As the other post states, take it easy on the recovery, especially the strengthening exercises. The main goal is to get your range of motion back, and that does not require using weights, etc. As to the slight tremors the other post mentions, I have those, too, and my surgeon said that they are the result of tendons getting weak and the nerve getting used to its new environment, and that it would take several months for them to go away.

It is a good idea to put some time (5-6 months or so) in between surgeries for a submuscular transposition. You need one arm to be in good shape to carry things like groceries, etc without worrying about injuring something.

[supahjew]

I was told my scar has healed well. It is still somewhat sensitive if I put pressure on it while I am asleep and so on, but I am happy with the progress. It seems like I started the strengthening exercises too early though (at week 8) as I had some minor pain and numbness in my pinky finger shortly after I started the exercises. So, I backed off, and things are back to normal again. As the other post states, take it easy on the recovery, especially the strengthening exercises. The main goal is to get your range of motion back, and that does not require using weights, etc. As to the slight tremors the other post mentions, I have those, too, and my surgeon said that they are the result of tendons getting weak and the nerve getting used to its new environment, and that it would take several months for them to go away.

It is a good idea to put some time (5-6 months or so) in between surgeries for a submuscular transposition. You need one arm to be in good shape to carry things like groceries, etc without worrying about injuring something.

I have a 4 month break basically over the summer and figured I could get both arms at once. This is this pretty much impossible you're saying?

[curiousforever]

I don't know supahjew. I had mine done - one in Feb, one in Mar - healed (and ready to work) by end of May. I did NOT have them put under the muscle however. Just decompression.

Most docs will NOT do both arms at the same time. Mine was willing to to do mine 3 weeks apart so that I had enough function out of one at all times.

[lucidmaster]

Curious, the local decompression does not involve moving the nerve or significant tendon dissection, so I hear surgeries can be much closer to each other. With the submuscular transposition, recovery is much longer. It was only after 3 months postop that I could start doing strengthening exercises on a regular basis. I am now 4 months out, and it feels much better, but I still wouldn't carry anything too heavy with it.

Supah, 4 months might be enough of a gap, although based on my experience, I'd feel more comfortable with 5 or 6. You should have one done and then see how it heals and use that information as a basis for the decision on the second surgery. That's pretty much what my surgeon and neurologist told me. Who knows, you are very young, and might heal very quickly.

Now that I have my left arm back, I can once again brush my teeth, eat, etc comfortably without causing any more damage, so I put my right arm to rest when it comes to bending the elbow, and will wait for another month before deciding on what I should do with it. The hypermobility on my right elbow is not as bad. If I bend my elbow completely, the nerve travels to the tip of the ulna, but does not move all the way over it, which was what the left ulnar nerve was doing before surgery.

[supahjew]

Lucid, do you mind posting some before/after shots of your scars?

Also, maybe I'm missing something, but why can't they make a few small incisions along the elbow instead of cut the entire thing open? Don't they have cameras and stuff to maneuver around inside there? My dad had shoulder surgery and he only had a few tiny scars as a result.

[lucidmaster]

I'd be fine posting pics, but there doesn't seem to be an easy way of doing that here (I can't just copy and paste; it requires a url).

Why are you so concerned about the scar anyway? Yeah, it looks kind of bad, but I was told it would blend in with time. You should really be concerned about the well-being of your ulnar nerve, and not worry too much about the scar...

They can't use endescopes to move the nerve from where it is to underneath your muscles. The nerve travels first along the "inside" of the arm and the bicep muscle, and then along the "outside" of your elbow, through the cubital tunnel, which is the depression on the tip of your ulna. In our situation, the nerve is not stable (the tendons that are supposed to be holding it in place are not doing that for various reasons) and pops out of the tunnel at the elbow causing irritation and damage. The point of the surgery is to move the nerve to the "inside" of your elbow so that it is not constantly irritated by popping out of its grove and by being stretched every time you bend your elbow. That cannot be accomplished by using an endescope. They have to make a long incision along its path around the elbow, cut through the tendons that are kind of holding it in place, and completely free the nerve. Only then it can be moved to the inside. Then you have 3 options. It can be moved under the skin, in between the muscles that run all the way up to your hand and allow your hand and fingers to flex, or under those muscles (the muscles converge into a tendon that attaches to the tip of your ulna). Putting it under the skin leaves your nerve exposed; if you cut your arm or bump it hard, the nerve could be severely damaged. That also does not necessarily shorten the path of the nerve, so it continues to be stretched slightly when you bend your elbow, which might or might not cause irritation. I don't know much about putting it in between the muscles. Putting it under the muscles is the best alternative for a young active person as it shields the nerve and shortens its path. And in order to move it under the muscles, they have to shave the tendon off the ulna, slip the nerve in there, and reattach the tendon to the bone. I hope this helps...

[lucidmaster]

I had my right ulnar nerve transposed as well 4 days ago. The experience so far resembles my previous experience with the left elbow. I took off the splint on day 2 after checking with the surgeon. He said I've gone through this before and did not need it. I had some minor dullness in my hand on the 3rd day, but I haven't felt it since. No pain in the hand. I am typing with both hands although my right elbow is rather swollen, and my whole arm is pretty much yellow on the inside. Surprisingly, it doesn't really hurt all that much--especially consider how much slicing and dicing had to be done for the submuscular transposition. I was told the surgeon was really good, but I didn't realize he was this good; he repeated the same excellent surgical performance.

My left arm is fine as long as I don't try to lift weights with it repeatedly. I was beginning to strengthen my arm by curling 15 lbs in 3x40 sets, but that ended up irritating things, so I backed off. It is surely much better than it was before surgery, but it is not back to what it was 3 years ago. I can use my arm without restrictions and don't notice a thing as long as I don't lift heavy, so I'm happy. The resident said it's been 9 months, and full recovery takes more like 18, so I'll wait and see.

[joy]

lucidmaster you have been so thorough and good to post your ordeal. It is nice to know you are continuing to follow up and not rush the heavy lifting. I wish you continued success with healing.

[lucidmaster]

Thanks for the good wishes Joy. I hope this information helps people who are suffering from ulnar nerve compression in some way. I must say that the surgeries I had to decompress nerves, including the thoracotomy for my spinal cord, worked in the sense that I am better off than I was before having the procedures. In my opinion, with nerve compression of any kind, if symptoms do not improve within 2-3 months and continue to worsen, it is best not to wait around hoping it will somehow get better, and have the surgery as soon as possible to prevent further damage as nerves take forever to heal.

[hholmes314]

lucidmaster, did you ever recover to the point where you were able to lift weights? I am in exactly the same situation you were prior to your surgery and trying to decide whether to have it done. For the most part I am OK if I do not move my arm, so the main reason I would like to have the surgery is so I can do things like kayaking again.
Thanks for writing about your experiences in so much detail. It's been really helpful to me.