Anatomy
Center the incision on the medial epidcondyle itself. Extend proximally and distally about 3 cm. This image is of the left arm.
The cubital retinaculum bridges the gap between the medial epicondyle and olecranon. The ulnar nerve passes below it.
Positioning
Supine on a regular table, relevant arm extended at a 90-degree angle and elbow flexed at a 90 degree angle. The shoulder is externally rotated. Bed is turned such that the arm is away from anesthesia.
Prep
Prep before the patient goes to sleep. Ask the patient to raise their arm, then prep from the fingertips to the shoulder.
Draping
- Unroll a stockinette over the hand and down the forearm and arm
- Place a drape on the armboard followed by a blue towel nearest the patient's axilla
- Ask the patient to let the arm rest on the arm board
- Place another blue towel on top the shoulder
- Secure the top blue towel to the one under the arm with towel clips above and below
- Pass the arm through the arm-hole of the carpal tunnel drape and pass the "up" part to anesthesia
Medications
Cut through the stockinette with scissors to expose the arm. Infiltrate the planned incision with lidocaine. Moossy does not like epi.
Procedure
The procedure is done sitting on a stool. Sit on the side of the patient on the ulnar side of the arm (i.e. in the axilla).
Make the skin incision with a 15 blade, going through the skin to the subcutaneous tissue.
Place a self-retaining retractor.
Use Metzenbaum scissors to sharply dissect the subcutaneous tissue to the level of the fascia of the flexor carpi ulnaris where it attaches to the medial epicondyle.
Find the ulnar nerve proximally first by sharp dissection with the Metzenbaum scissors just above the medial epicondyle.
Use the Metzenbaum scissors with the tips closed to dissect the space between the cubital retinaculum and the ulnar nerve. Be sure to stay directly on top of the ulnar nerve since roots leave the nerve periodically along the medial and lateral borders. Sharply incise the cubital retinaculum with the scissors.
Use a 15 blade to incise the fascia of the flexor carpi ulnaris muscle parallel to the muscle fibers. Use a 4 Penfield to separate the muscle fibers and expose the fascia on the deep surface of the muscle overlying the ulnar nerve. Sharply incise this fascia to complete the ulnar nerve release.
You have release far enough distally once you see the first motor branch of the ulnar nerve.
The final step before closing is to flex the arm and watch what happens to the ulnar nerve. Ideally, it should stay in place within the cubital tunnel. If it moves out of that space or "perches" on the medial epicondyle, you will have to construct a fascial or soft tissue sling to keep it in place during flexion.
Closure
Close the deep dermal layer with 3-0 Vicryl or Polysorb suture. Use a single layer of 3-0 Nylon interrupted suture to close the skin and soft tissue.
Dressing:
- Bacitracin ointment
- Xeroform over the incision
- "Fluffed" 4x4 gauze
- Webril wrap
- Ace bandage
- "Swiss cheese" yellow foam arm support
Postop
Patients go home the same day. The bandage stays on for 3 days then can be removed and the patient can shower. Send home with two 5 mg tablets of oxycodone. Most pain can be controlled with Tylenol. Return to clinic in 2 weeks for a wound check.
Dictation
DATE OF SURGERY: ***
SURGEON: Dr. ***
ASSISTANT: Dr. ***
PREOPERATIVE DIAGNOSIS: *** symptomatic cubital tunnel syndrome
POSTOPERATIVE DIAGNOSIS: *** symptomatic cubital tunnel syndrome
PROCEDURE PERFORMED:
1. Release, decompression and neuroplasty of *** ulnar nerve
CPT Coding:
64708 Neuroplasty major peripheral nerve, arm or leg: other than specified
ANESTHESIA: Local with IV sedation
ESTIMATED BLOOD LOSS: 5 ccs
FINDINGS: Significant *** ulnar nerve entrapment in the cubital tunnel
DRAINS: None
COMPLICATIONS: None.
DISPOSITION: stable to PACU
INDICATIONS FOR PROCEDURE
HISTORY: Patient is a *** who presented with ***
DIAGNOSTIC STUDY: EMG demonstrated ***
SURGICAL RISKS: The patient was well apprised of all objectives, benefits,
risks, and potential complications of the procedure, including but not limited
to:
worsening of motor nerve paralysis as well as loss of sensory function in the
noted distribution, the possible need for further procedures, the risk of
infection, hemorrhage, sepsis, coma, and even death.
No assurance was given whether symptoms would improve following the procedure.
Informed consent was obtained and secured in the chart after the patient voiced
understanding of these risks and decided to proceed with the operation.
DESCRIPTION OF THE PROCEDURE
The patient was transferred to the operating room and was given preoperative
prophylactic IV antibiotics.
ANESTHESIA: The patient was given IV conscious sedation by the anesthesia
service. A Bair Hugger was placed to maintain control of core body temperature.
POSITIONING: The patient was positioned in the supine position with the *** arm
extended, resting on an arm board. All pressure points were carefully padded.
The planned cubital tunnel incision was demarcated posterior to the medial
epicondyle.
OPERATIVE TECHNIQUE:
The patient was prepped and draped in the standard sterile fashion.
CUBITAL TUNNEL:
A curvilinear incision was drawn out posterior to the medial epicondyle. The
marked incision was infiltrated with a local anesthetic along the line of the
skin incision, which was subsequently opened sharply with a #15 scalpel blade.
This was carried through the level of the subcutaneous fat. Hemostasis was
meticulously maintained utilizing bipolar electrocautery. Blunt dissection was
carried out utilizing Metzenbaum scissors. The superficial veins were coagulated
utilizing monopolar as well as bipolar electrocautery. Exposure of the ulnar
nerve was achieved just proximal to the medial epicondyle head; posterior to the
medial intermuscular septum. Dissection was carried down distally towards the
medial epicondyle head incising the cubital ligament. Meticulous care was taken
to adequately preserve all branches of the ulnar nerve. After incising this
fibroaponeurotic covering of the epicondylar groove, the nerve was freed
distally through the flexor-pronator head. All fascial bands were lysed and
subsequently meticulous hemostasis was again utilizing bipolar electrocautery.
The wound was irrigated until clear. The subcutaneous tissue was approximated
utilizing interrupted 3-0 polyglactin synthetic absorbable (Vicryl) suture and
the skin closed with interrupted vertical mattress 3-0 Nylon suture. The wound
was dressed in a clean, dry dressing after the procedure
All sponge counts, needle counts and instrument counts were correct at the end
of the case. The patient tolerated the procedure well, without any complications
and was transferred in stable condition to the recovery room. Dr. *** was present
during the critical portions of the case.
