(1) Consultant Orthopaedic Surgeon, Queen Anne Street Medical Centre, 18-22 Queen Anne Street, Off Harley Street, London, W1G 8HU
(2) General Practitioner, Westside Surgery, Sleaford Road, Boston, PE21 8EG
(3) Director, Turnpike Medical Wide Awake Orthopaedic Surgery, Horncastle Road, Louth, Lincolnshire, LN11 9QT
(4) Consultant Orthopaedic Surgeon,
Corresponding author Email:
The wide awake approach to hand surgery is gaining increasing popularity worldwide, but PubMed search does not reveal any publications on wide awake ulnar nerve surgery. In this research study, we describe our surgical experience, techniques and results of the wide awake management of ulnar nerve entrapment at both elbow and wrist. This study is based on a background of having established the world’s first totally one stop wide awake (OSWA) hand surgery service, with published outcomes.
Materials and methods
We performed a retrospective review of our 2011/12 ulnar nerve entrapment cases, which comprised 40 patients with ulnar nerve dysfunction.
The main outcome measures were sensorimotor improvement, including improvement of the QuickDASH score, patient satisfaction and cost-effectiveness and efficiency.
No surgical complications were experienced by the patients and all of them were satisfied with their treatment. All patients were followed-up to a good outcome including objective sensorimotor improvement in ulnar nerve function.
The wide awake approach to ulnar nerve decompression is safe, effective and comparable to the historical approach; and is amenable to a one stop patient pathway.
Wide awake hand surgery enables treatment in one management stop, through a patient-centric pathway, which is broadly more akin to dental treatment than a traditional multi-stop surgical approach. The one stop wide awake (OSWA) hand surgery service is now well-described in the worldwide published literature[1,2]. Wide awake hand surgery, is hand surgery, without general anaesthesia or regional anaesthesia or sedation or tourniquets. There have been great advances in the technique(s) for hand surgery, over the last decade. It is now over 30 years, since the first peer reviewed publications on wide awake hand surgery, and despite inherent potential advantages (lower risk, a more convenient pathway for the patient and cost-savings for national state-funded healthcare)[1,2], the worldwide transition to the technique has been slow, according to the published literature[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22]. The published literature on ulnar nerve compression/decompression, reflects that there are two encouraging case series, each comprising 20 cases, which were performed using a local anaesthetic technique in 2001 and 1982[23,24]. However, a contemporaneous search on PubMed for the relevant terms is instructive: Ulnar Nerve and Local An(a)esthesia or local an(a)esthetic; or wide awake ulnar nerve; or wide awake cubital tunnel; or wide awake ulnar tunnel; or ulnar nerve entrapment. This demonstrates that there has been little recent progress with wide awake ulnar nerve surgery as would have been expected; despite the recent advances with wide awake hand surgery. There is no previous description of an all-encompassing or totally OSWA surgical pathway for the totality of ulnar nerve entrapment, irrespective of site. The aim of this research study was to discuss the wide awake approach to ulnar nerve entrapment, which we have pioneered in the UK.
All the patients in this study were managed according to the OSWA ulnar nerve entrapment pathway, with a clinical diagnosis of unilateral isolated ulnar nerve dysfunction (Figure 1).
OSWA Ulnar Nerve Pathway.
The conduction of clinical evaluation included the following:
History: Sensorimotor ulnar nerve dysfunction distal was observed on the site of entrapment.
Biro Test: Sympathetic dysfunction resulted in reduced sweating in little (ulnar nerve) versus index (median nerve) pulp biro slides more easily on affected digits.
Scratch Collapse Test: The patient was asked to resist bilateral shoulder external rotation, with the elbows fully flexed. The area of suspected ulnar nerve compression was then lightly scratched and then resisted shoulder external rotation was immediately repeated. In ulnar nerve dysfunction, there was momentary loss of shoulder external rotation resistance on the affected side.
Tinel’s Test: The ulnar nerve irritability was reproduced by percussion over the cubital or ulnar tunnel.
Surgery was performed under local anaesthesia using a lignocaine (lidocaine) and low-dose adrenaline mix, with no tourniquet. A tourniquet on the upper arm was painful for the wide awake patient and would encroach upon the surgical field for proximal operations. In our experience of wide awake surgery, meticulous dissection enabled surgery without diathermy. The standard for ulnar nerve surgery was 10 ml of 2% lignocaine, with adrenaline 1:200,000, which was drawn up, with a 21-gauge needle and infiltrated with a 25-gauge needle.
The following steps were followed in this technique, also see Table 1:
1. The patient lied down in supine position.
2. Surgical marking positioning was done as depicted in Figure 2. The following were the findings observed for this surgical mark:
a. Double sandbag was large at base, smaller on top and tucked into axilla.
b. Shoulder abduction was at 60°.
c. External rotation was maximal.
d. Mark was epicondyle/condyle.
e. Curvilinear incision was guided by palpation of the nerve and in relation to the medial epicondyle.
3. Locate the nerve on proximal forearm.
4. Decompress cubital tunnel full-length nerve hook should pass easily around the nerve (Figure 3).
Keys to successful one stop wide awake management (adapted from original OSWA paper).
Cubital Tunnel Release Positioning.
Cubital Tunnel Release Intraoperative.
The following steps were adhered to in this technique, also see Table 2:
1. The patient was positioned supine.
2. Forearm of the patient was supinated on arm table.
3. Palpate the pisiform and flexor carpi ulnaris (FCU) as shown in Figure 4.)
4. Longitudinal incision was made over the FCU as shown in Figure 5.)
5. Locate the ulnar nerve in relation to the FCU, mobilise the FCU and identify ulnar nerve and protect ulnar artery (Figure 6).
6. Decompress the entirety of the ulnar tunnel.
Typical equipment required and practical considerations for wide awake ulnar nerve surgery.
Ulnar Tunnel Release Step 1.
Ulnar Tunnel Release Step 2.
Ulnar Tunnel Release Step 3.
At the OSWA service we operate continuous audit processes. All patients were requested to contact us immediately in case of any problems. For the purposes of this audit, all patients were seen once by the orthopaedic surgeon in the clinic. Online follow-up was then continued for at least three months post-surgery.
The protocol for the one stop wide awake ulnar nerve pathway is depicted in Figure 1. There were 40 cases of clinical ulnar nerve compression. Three injections (mild syndrome as per QuickDASH score) were administered. Thirty-seven operations (moderate to severe syndrome as per QuickDASH score) were performed, of these three operations were ulnar tunnel decompressions and 34 operations were cubital tunnel decompressions. The cubital tunnel patients’ diagnoses were made clinically and the diagnosis was confirmed with nerve conduction studies as required. The three ulnar tunnel syndrome cases were diagnosed clinically. Two of the ulnar tunnel patients previously had cubital tunnel release, with no improvement. There were no intra-operative surgical complications experience by the patients and there were no microbiologically-proven post-operative infections. In all the patients, there were significant subjective and objective improvements in ulnar nerve sensorimotor function post-surgery, including improvements in the validated QuickDASH score.
All the patients were satisfied with the OSWA treatment pathway.
Surgery was provided to the National Health Service at around 50% of tariff.
The OSWA ulnar nerve pathway is depicted in Figure 1.
All patients were managed to a successful outcome through the OSWA ulnar nerve pathway, and nerve conduction studies did not affect the management. As part of the informed consent and the discussion of pros and cons and risks and benefits, all the patients were offered electrodiagnostic studies, but in this case series, these tests did not affect the management pathway in any case. All the patients who had undergone surgical treatment, showed positive Ulnar Biro, Scratch Collapse and Tinel’s tests. In the ulnar tunnel syndrome, there was irritability of the ulnar nerve in the ulnar tunnel rather than in the cubital tunnel, and sensorimotor dysfunction was distal to the site of compression.
It is now generally accepted that the standard procedure for ulnar nerve entrapment proximally in the cubital tunnel is simple decompression, but more extensive surgery is also described in the literature. Distal entrapment in the ulnar tunnel is less well described, but in our experience it is not uncommon, and decompression is the standard surgical procedure. As per the recent paper by Hagert on wide awake treatment of (occult) proximal median nerve entrapment: it is our experience that distal ulnar nerve entrapment may similarly be overlooked and is not usually detected on nerve conduction studies. Moreover, in the present series all the three cases of ulnar tunnel syndrome had a false negative nerve conduction study result for ulnar tunnel entrapment; and this has confounded the diagnosis of their clinically obvious ulnar tunnel syndromes. This underlines the general recognition in the literature that electrophysiology is a possible adjunct to thorough clinical assessment in peripheral nerve entrapment; but that these syndrome are essentially clinical diagnoses.
In this research study, we describe a totally wide awake approach to ulnar nerve entrapment, irrespective of the site, and all management was performed in one discrete management stop. The wide awake hand surgery techniques we utilize enable optimisation of patient pathways. Through the wide awake approach, patients can be safely and effectively treated in one management stop and outside the main operating theatre[5,6,7].
A wide awake injection technique using epinephrine is now standard worldwide. A multitude of recent studies have conclusively demonstrated that a wide awake injection technique using local anaesthesia with low-dose epinephrine is safe and effective. This refutes decades of surgical dogma[1,2,9,10,11,12,13]. The injection technique can be optimised to minimise the associated pain.
The wide awake approach enables intra-operative optimisation, and as described by Lavyne and Bell in the original case series of local anaesthetic surgery for cubital tunnel syndrome: the usual scenario is an immediate sensorimotor improvement on the surgical table; once the complete decompression has been performed. Feedback from the wide awake patient can therefore be used to optimise the surgery. Usually, this is the best guide to ensure that a complete decompression has been performed, but moreover, this can be a guide to fine tune the procedure with techniques, such as epineurotomy.
Wide Awake Hand Surgery (WAHS) techniques rebalance surgical risk: by eliminating the risks of general anaesthesia, regional anaesthesia, sedation and tourniquets; there is a rebalancing of risk for patients undergoing totally wide awake ulnar nerve decompression. The present audit demonstrated that a one stop wide awake (OSWA) approach to ulnar nerve entrapment is safe and effective, with high levels of patient satisfaction, and is efficient in terms of processes and cost-savings for state healthcare.
FCU, flexor carpi ulnaris; OSWA, one stop wide awake.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Keys to successful one stop wide awake management (adapted from original OSWA paper
|Local anaesthetic technique:
|Careful surgical dissection and meticulous technique
|Experienced, small team with clear and defined roles
|Compact functional outpatients and theatre space enabling easy, safe and effective patient flow.|
|Efficient, thorough evidence-based treatment with robust audit and governance facilities/mechanisms/processes.|
Typical equipment required and practical considerations for wide awake ulnar nerve surgery.
|Ulnar nerve decompression at elbow||Abduct shoulder 60°
|Ulnar nerve decompression at wrist||Patient supine with arm extended and supine on hand table|