Ulnar nerve release surgery

Ulnar nerve release surgery is a surgical procedure to reduce irritation or compression of the ulnar nerve at the cubital tunnel. This can cause tingling, numbness and weakness in the hand, especially in the link and ring finger.

The elbow is a hinge joint that connects the humerus (upper arm bone) to the radius and ulna (forearm bones). The joint allows flexion (bending the elbow) and extension (straightening the elbow) movements as well as supination and pronation (turning your palm up and down).

The elbow is made up of three bones and a multitude of soft tissue structures that are important for the stability, movement and function of the elbow.

One of the most important soft tissue structures passing through the elbow is the ulnar nerve.

The ulnar nerve is one of the three main nerves in your arm. It travels from your neck down into your hand and is important in feeling and sensation, as well as initiating fine motor movements with the arm and hand.

The ulnar nerve runs down the inner side of the back of the elbow joint, sometimes referred to as the funny bone, and lies in a groove covered in a tough layer of tissue known as the cubital tunnel.

The ulnar nerve can become irritated or compressed. The most common place for this to happen is at the elbow and ulnar nerve irritation or compression at this area is known as cubital tunnel syndrome.

In most cases of cubital tunnel syndrome the cause is unknown, however there are a number of potential causes, including; prolonged elbow flexion (bending of the elbow), repetitive movements which cause the nerve to slide across the groove in the elbow, leaning on your elbow for long periods of time, excess fluid or swelling and direct trauma.

Other risk factors to the development of cubital tunnel syndrome include a history of fracture or dislocation, arthritis or bony spurs, elbow swelling and cysts. Cubital tunnel syndrome can cause aching and pain on the inside of the elbow, however the main symptoms are usually experienced in the hand and include;

  • Numbness and tingling in the ring finger and little finger
  • Weakening or loss of grip strength
  • After a longer period of time muscle wasting in the hand can be experienced

Diagnosing cubital tunnel syndrome can be achieved a number of ways. It may be possible to diagnose through a full history taking and physical examination by a doctor or physiotherapist. Imaging, such as X-rays or CT scans, do not usually pick up cubital tunnel syndrome or its causes and are therefore not routinely used, however if the nerve compression is serious enough nerve conduction studies can be performed.

Ulnar nerve release surgery is performed under general or regional anaesthetic as day surgery, meaning you will usually be operated on and released on the same day. An incision is then made over the back of the elbow joint.

The ulnar nerve is identified by the surgeon and is then traced up and down the arm. Any soft tissue or bony structures seen to be irritating the nerve are released.

Usually the nerve is then left in its original groove. However, if there is too much scarring in the area the nerve can be moved and a new groove created by the surgeon. This is known as transposition. Any bleeding is then cauterised and the wound is sealed usually using dissolvable sutures. The entire procedure usually takes between 30-45 minutes.

Shoulder and elbow surgery can result in considerable pain and discomfort after the operation. Traditional painkillers are not always effective and have side effects. We usually offer you a local anaesthetic “block” to reduce the pain and discomfort following the procedure and also allow early more comfortable physiotherapy (if required). This consists of an injection at the side of your neck onto the nerves that supply your shoulder. The injection itself is fairly painless.

What happens?

The procedure is carried out before the start of your operation. You will have a small plastic tube placed in your arm (drip). Then you may have some sedation to make you feel relaxed. A small numbing injection in the skin is placed prior to the block needle (which is smaller than a blood-taking needle). Your arm will then start to feel very heavy and numb (a similar sensation to when you have been lying on it). This spreads down the outside of the arm (and spares the inside).

Surgery is then carried out under sedation (you are comfortable, relaxed and either awake or sleeping if you prefer) or occasionally under general anaesthesia (you are unconscious and unaware). If you are awake, you are welcome to watch the procedure on a TV screen, and we will explain to you what is happening. If you require any extra pain relief during the procedure, we can easily give you this through your drip. The block will reduce the overall amount of painkilling drugs that you will require during and after the operation.

After your operation

The numbness will usually last for between 8 and 24 hours (depending on anaesthetic mixture used). We will leave your arm in a sling; please protect your arm whilst it is numb.

You will initially experience some ‘pins and needles’ as the block wears off and then some pain. Please prepare for this by taking the painkillers that we provide. Start these before the block wears off and expect to need them regularly for around 48hrs.

Occasionally we may recommend that at the time of the block we also place a small tube (catheter) that is fixed in place and through which we can give you further local anaesthetic to prolong your numbness for a few days. We would recommend this in situations where your pain after the operation is likely to be severe.

Complications of Anaesthesia

Anaesthesia is fairly safe for most people. If your health is not good the risks may be increased. Commoner complications include nausea and sore throat.

Local anaesthetic nerve blocks are generally considered to be safe. There is an approximately 5% (1 in 20) chance that they will fail or not work as well as expected. They tend to cause a small pupil and droopy eyelid temporarily and you may notice a hoarse voice or slight breathlessness.

Rare complications include reactions to the local anaesthetic solutions and nerve injury (the risk of temporary nerve symptoms e.g. tingling, numbness or weakness for a limited period is around 1 in 100 blocks and the overall risk of permanent injury approximately 1 in 5,000- 10,000 injections).

Analgesics (painkillers)

Paracetamol and an anti-inflammatory drug (if suitable for you – usually ibuprofen or diclofenac) are often used in combination. Take these regularly for the first few days.

Stronger painkillers:

Your anaesthetist will talk to you about strong painkillers, usually codeine, tramadol, oxycodone or morphine. Take these if your pain is poorly controlled (instructions will be on the packet). Some patients experience light-headedness when taking stronger painkillers; so be careful especially at first (rest up after taking them, don’t carry hot drinks or anything sharp) and take them only to counteract severe discomfort. Nausea and constipation can also occur, so drink plenty of water and increase the fibre in your diet; occasionally laxatives may be required (available from chemists).

Discharge

If you are discharged on the same day as your operation, there should be someone keeping an eye on you during the first 24 hour period. If the painkillers make you excessively drowsy, then your carer needs to rouse you and ensure you not too sensitive to them.

Emergency contact numbers will be available on your discharge information if you or your carer wishes to talk to a trained member of staff.

The risks of ulnar nerve release surgery will be discussed with you in detail at your pre-admission clinic appointment. Risk factors which can affect a very small percentage of patients include: 

  • Infection: The risk of infection is increased with open elbow debridement surgery compared to arthroscopic procedures due to it being an open surgery, however infection is very rare. Our theatres use industry standard ultra-high flow air systems which results in highly filtered and very rapid changes in air pressure ensuring the environment is as clean as possible. We also have fixed antibiotic treatment protocols drawn up by microbiologists to help reduce the risk of infection.
  • Nerve injury/damage: There is a small risk of nerve injury or damage during elbow surgery as the surgeon is operating so close to the nerves. They know where they are and make every effort to avoid injuring or damaging the nerves but it is important to understand there is a small risk and the damage can be permanent.
  • Stiffness: there is a risk of stiffness following your elbow surgery.
  • Pain: Initially following your ulnar nerve release surgery you will feel some pain. This is a natural part of the healing process. We will help you to manage this with medication and advice. The pain will generally subside with time and recovery.
  • Thrombosis/blood clot: There is a small risk of thrombosis or blood clotting following your surgery. In this case you may be given compression sleeves in order to improve circulation and reduce the risk.
  • Failure to relieve symptoms: There is a very small chance that the surgery will not relieve cubital tunnel syndrome symptoms.

You should notice an improvement in symptoms within a few weeks but full recovery can take many months. Avoid forced gripping or heavy lifting for 2-3 weeks.

In order to return to driving your hand needs to have full control of the steering wheel and if your left arm was operated on then also the gear stick.

In terms of returning to work it will depend on your work environment. Returning to heavy manual labour should be prevented for approximately 4-6 weeks. Early return to heavy work may cause problems with your recovery. You will be given advice on your own particular situation.

Immediately after your surgery you will be referred for outpatient physiotherapy.

You will follow a regimented physiotherapy programme that will allow you to start to regain movement in your elbow and then strengthen the muscles in order to return to all of your normal activities as follows:

  • 0-3 weeks: Surgical site protection, ice, compression, elevation, pain relief, passive and gentle elbow range of movement exercises, maintenance exercises for the wrist and hand.
  • 3-6 weeks: Progression to active range of movement exercises, gentle isometric strengthening exercises, gentle gripping and squeezing exercises.
  • 6-12 weeks: Continued range of movement and stretching exercises, emphasis on strengthening exercises for the elbow and progressive resistance exercises, function activities including those related to work or leisure activities that you are aiming to return to.

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