Cubital Tunnel Release Surgery

Hello,
This is a post regarding cubital tunnel release surgery, hoping to get some insight as members on this forum seem to be far more insightful than many doctors.

I fell on my wrist and sprained it in October 2017. I did not immediately notice any issues with my elbow at all. In early December, I could feel that my my ulnar nerve was badly compressed in my elbow on the same arm. It was a very sudden onset.

The EMG showed very severe ulnar neuropathy, but my surgeon recommended trying physical therapy. At the end of physical therapy, I slept in a slightly compromised position, and the nerve pain in my elbow went off the charts. I lost complete use of my arm and struggled even to write. I begged my surgeon to schedule surgery ASAP. I went through 10 days of off the charts nerve pain waiting for surgery.

I finally had endoscopic cubical tunnel release surgery on March 7. I felt much better the day after surgery.

Although the surgery helped very much, I still really have to baby the arm due to nerve pain. I again slept in a slightly compromised position 2 weeks ago, and the nerve flared up a lot. The following week, I got electric shocks going from my elbow into my arm. Those have resolved, but my arm cramps up very easily. The cramping actually started before I slept in a slightly compromised position.

Oddly, I never really had tingling or numbness in my hand, but I would take that over the debilitating nerve pain in my elbow. Sometimes, it's like a sharp pain.

A May 29 EMG done by the same neurologist who did the first EMG showed that the nerve is normal. The nerve does not feel normal at all though.

I have not really had any nerve desensitization therapy so far.

I wish everyday that the surgeon would have skipped physical therapy, as I even told him I didn't think it would work. He was actually my second opinion surgeon. The first surgeon I saw recommended surgery as the only solution, but he does not perform the endoscopic cubital tunnel release.

Both surgeons I saw are highly regarded, but my experience has not been satisfactory.

Thank You.

Hi Karen,
Thank You so Much for your elaborate reply filled with helpful information.

My forearm usually feels pretty normal. Hot is hot. Cold is cold, etc. Sometimes though, my forearm feels very nervy when my elbow flares.

I was told that a nerve with a normal EMG usually should become fairly pain free.

Regarding sleeping position, I used to be a side sleeper, but since my ulnar nerve issue, I always sleep on my back as that's the only position that's "comfortable". I have mild cubital tunnel in my other elbow, which I believe was caused by sleeping on my back. I've tried everything to keep my arms comfortable when sleeping on my back. I currently wrap foam above my elbows to keep them, and the ulnar nerve, from resting on the bed. Then, I rest my forearms on towels so my elbows are slightly bent with both arms at my side. It feels comfortable, but it seems my arms are not completely comfortable. Sometimes my nerve in my mild cubital tunnel elbow twitches in this position, unless it's positioned perfectly. I've noticed that the more a mattress sags, the less comfortable my arms are.

I was given a generic splint, but I never really used it because it was uncomfortable and often slips down. I tried it on my arm with mild cubital tunnel, and it seems I feel worse in the morning.

I very rarely (once in 8 months) wake-up and find either elbow bent, but it could still be happening.

I've read posts by Pitmom (very intuitive), where she mentioned it took about 2 years for her nerve to calm down.

As a side note, it's very curious how my surgeon recommends other treatments when my condition deteriorated very rapidly due to a slightly compromised sleeping position about 4 weeks into his grossly flawed treatment plan.

When my nerve became very painful and hypersensitive, he recommended a mental health provider, and possibly medication to cope with the anxiety. He said my coping mechanism is lacking. Now that the nerve, unsurprisingly to me, hasn't calmed down after 5 months, his nurse practitioner wants me to see a neurologist.

I didn't sign up for any of that when I became his patient. The initial appointment was too rushed.

My surgeon had said the nerve will likely recover, but what else would he say when my condition deteriorated so much and so rapidly about 4 weeks into phase 1 of his treatment plan?

I give him some credit for not wanting to rush into surgery, but his judgment was grossly bad. How did we go from "Let's try physical therapy" to off the charts nerve pain less than 4 weeks later?

I'm trying to picture a 'compromised' sleeping position that you keep referring to. What I see is you, trying to do the job only a professional should be attempting. We can cause ourselves more harm than good, trying to come up with solutions on our own.

You say both surgeons are highly regarded, but because you didn't get the result you wanted...and are doing your own thing...it's the surgeons fault? Grossly flawed treatment??? I'm sorry but a damaged nerve is a damaged nerve.

Why is it the surgeons responsibility to get you into physical therapy? This, in my experience, is usually scheduled before the surgery is even done. Yet, here we are in August and you still haven't gotten it scheduled for yourself!

Are you on any of the medications now available for nerve pain?

I'm sorry if this sounds b*tchy...but I'm confused since you seem to 'know so much about what is the right thing to do' but blame the surgeon. What you are 'playing doctor' with could cause more harm than good.

I slept on the sofa, propped up a little, with my 'surgical arm' on the 'inside' and to keep me from turning onto that side. I slept with a pillow under the upper arm, with my elbow slightly bent and my wrist where my thigh meets my torso. Those powerful electric shock type pains are unbelievable, but they actually mean the nerve is 'waking up'. That thought helped me endure them.

Ice wraps were a huge help to me. Look for the 'sheets' that may be found for coolers, sometimes in the camping sections of stores. I used them frozen at first, but now I keep them in the crisper drawer in the fridge.

You mentioned me in your post.

I mean muscle atrophy he didn't notice when I became his patient on January 30. Also, please take it easy on me. I was in physical therapy for 2 months after surgery (doctor's referral), but he didn't discuss nerve desensitization.

Hi Pitmom,
No worries. Thank you for your reply. Maybe my posts weren't clear, but part of it was venting frustration because my surgeon recommends that I see other doctors who are needed only because he delayed surgery.

I know, you too, are familiar with delayed treatment. Your posts give me hope.

I'm not on pain meds except for Naproxen. I see a neurologist later this month. Sometimes my elbow nerve burns terribly.

I hope your day improves for you. Thank you for your replies.

Back when my surgery was done, the orthopedist put me on Elavil which I believe calmed the nerve a bit. Nowadays, gabapentin is prescribed.

I'm trying to dig through memories...I've had 9 surgeries all together...between both shoulders, the left elbow/carpal tunnel, both wrists...so remembering who did what and when and how did it help, if at all...gets a bit jumbled now and then.

I remember being prescribed Celebrex, Mobic, Naproxen...all of them anti inflammatories...none which touched the nerve pain itself.

You mentioned falling and injuring your wrist...has the shoulder been looked at? The cervical spine? Problems in either of these areas can also wreak havoc on the nerves of the arm/hand.

I had considered revision surgery at one point...in the hopes that it could improve on what I was left with...the surgeon was the top guy in my area who had done revision surgery on one of my wrists...he was honest with me and told me perhaps a 30% chance of improvement...I decided the odds were not good enough for me. This was probably around 2003 or so. I was still working...as a cashier at this point...overuse of my arm/hand would leave me in misery by the end of my shift. Other conditions led to me being declared disabled from working as of 2006, so stressing the arm/hand has been slashed to a minimum, which has helped immensely.

Snow shoveling, gardening, scrubbing the walls, painting them, etc. will get it into a painful flare but I just either ice it or wrap the heating pad around it (if one doesn't work, I try the other), take some Aleve (naproxen) and a Benedryl to help me relax. If my daughter is around, I get her to massage it. Even now, bumping the area where the nerve is now buried can give me the 'funny bone' feeling!!

I know the ulnar nerve subluxates in the right elbow now, if I push hard on anything. I even had to change banks because mine had doors that were just too heavy to push or pull. The epiconyl (sp?) on both arms is hyper sensitive and painful.

When looking for a good physical therapist, you might want to consider one that does a lot of work with golfers...they tend to have similar problems to ours. If you have a golf center near you, take the time to visit and chat with the patrons...perhaps one or two of them can send you in the right direction.

Q22:
Your nerve pain is real. Whether the peripheral ulnar nerve was compressed by bony structure at the elbow or compressed between contracting muscle, whether the nerve is hyper-reactive from surgical handling and surgical trauma, whether the nerve is encountering transient re-entrapment from positions assumed during sleep, whether the nerve is buffering inflammation due to demands from your keyboard work as a programmer . . .

The nerve will be best served by the grace of time to allow for innate healing and quieting of excessive nerve impulse firing. 8-9 months.

You do NOT want to pursue exploratory surgery as a possible option in the short and medium timeframe.

A nerve that is irritated and inflamed by injury and surgical repair will not take well to an additional insult (surgery). You could well find yourself in a worsened state post-operatively with even higher nerve irritation and neuropathic pain, aka reflex sympathetic dystrophy also called central regional pain syndrome. An additional exploratory surgery would be akin to disrupting a nest of bees.

Focus on rest for the arm with low intensity movement/range of motion, fabricated resting splint, desentization techniques, and pharmaceuticals as indicated (muscle relaxants; neuromodulating neurotin or gabapentin or preganalin or elavil or similar; anti inflammatory agent Mobic or Relafen or similar.

Pitmom’s suggestion of scouting golfers and soliciting their opinions on a competent physical or occupational therapist has merit. So, too, your medical insurance provider will have a listing of in-network occupational hand therapists.

Allowing the peripheral nerve to soothe and quiet along the length of its distribution is of prime importance.
Karen

Seashell,
You mentioned that peripheral nerve injuries take time, and that healing progress fluctuates. Maybe a nerve becomes more painful and causes cramping as it starts to wake up? I also read that it can take up to a year to see any improvement.

Also, my surgery date was March 7. When should it be ok to maybe have a revision surgery as I'm considering going to the Mayo Clinic at some point as they are in my insurance network, and I live about 300 miles from Rochester, MN.

I was feeling much better prior to this flare up. Now, I feel worse than I did weeks after surgery.

Thank You.

Post Edited (Q22) : 8/7/2018 9:27:20 AM (GMT-6)

Q22:
I am glad that Pitmom is weighing in on this conversation with her narrative and personal experience.

I am a visual learner. To help illustrate the peripheral nerve exquisite sensitivity and pain that you are experiencing, picture:
a. A downed high voltage power line. Erratically sparking with powerful bursts of electricity.
b. An inconsolable child, high pitched wailing and screeching.

Absolutely, it is oft the case that a traumatized/injuried peripheral nerve will be more sensitive during recovery, with a higher level of experienced pain. What you are experiencing - more pain, more sensitivity, more bursts of electrical “zings” - is a common finding.

Variables that affect the degree of neuropathic pain:
a. A peripheral nerve that has been compromised/compressed for a prolonged period before surgical release will fare less well than a nerve that was compromised for a short period.
b. The degree of impulse disruption. A nerve that is completely compressed or severely compressed (75% of impulses fail to be transmitted distally as assessed by EMG or objective muscle atrophy of affected musculature) will fair less well than a nerve that is partially or moderately compromised (able to transmit 50% or more of generated impulses or externally applied low amp electrical voltage).
c. Intervening variables: History of anxiety; sensory processing disorder; low vitamin B12; seizure disorder.

Desensitization of a peripheral nerve is a process that occurs over time.

I would certainly encourage you to pursue a consultation with a physician at Mayo. It can take several months to schedule a new patient consultation with some specialities, so you may want to be proactive and start the referral and scheduling process now for an appointment 3-4 months in the future. Take care on researching a physician who can address your needs. Ex. A plastic/reconstructive surgeon, often who specialize in the arm/hand or a neurosurgeon.

I would encourage you to refrain from entertaining an additional surgery for 8-9 months from your original operative date to allow for natural quieting of the nerve. You do not want to inflict additional surgical trauma on an already reactive peripheral nerve.

Exceptions that would warrant prompt surgery:
a. Noticeable muscle atrophy of any of the muscles supplied by the ulnar nerve, suggesting acute entrapment.
b. Loss of fine motor control. Ex. Dropping a set of key, unable to manipulate a pencil.
c. Symptoms suggestive of cervical impingement. Ex. Widely radiating pain from the shoulder to the hand/fingers; problems with fine motor coordination (ex. unable to touch the top of your thumb to the tip of each finger in rapid succession).

In the interim, things you can try/experiment with to see if there is benefit for you and your angry peripheral nerve:
a. Swaddle the affected area of the arm with stretchy Coban or kinesotape or an ace wrap. Mild compression that envelops the affected area of heightened sensitivity. Constant sensory input through swaddling is based on the same principle when soothing a crying infant with a comforting wrap. Constant sensory input limits the nerve to fire erratically owing to the effects of the gate theory. Presenting an influx of incoming stimuli floods the available transmission channels, dampening an expression of errant nerve firing. It is analogous to an incoming telephone line where all of the incoming lines are blinking with calls on hold. The telephone operator can only answer and respond to one call at a time.

b. Brush the skin of the affected area with fabrics of different textures (discussed in a previous post). You are re-educating the nerve, introducing the nerve to normal and familiar stimuli. The nerve becomes more “behaved” through repeated tactile stimuli.

c. Cool/warm therapy. Apply a cool, wet washcloth to the area. Remain in place 2-3 minutes. Rest for 5 minutes. Apply a warm buckwheat pack or warm, wet washcloth to the are. Remain in place for 2-3 minutes. This technique reprograms the autonomic nervous system and temperature regulation to the area.

Pitmom has discussed that her therapist employed a modality she called “points.” I suspect this was a modality where a low voltage electrical stimuli was applied at different points along the distribution of the peripheral nerve. This modality is very helpful, as it provides an external stimuli to the nerve allowing it to relearn how to transmit a purposeful impulse.

There are any number of supportive techniques and therapeutic modalities that may benefit you - lowering the pain you experience and giving you a degree of hope that recovery is possible.

Nerve pain is it’s own entity. Nerve pain is uniquely different than bone pain or soft tissue pain. Nerve pain is high in pitch and high in intensity. Nerve pain is uniquely disrupting to one’s day to day life.

All to say . . . Anyone with neuropathic pain will be empathetic to your plight. Look for rehabilitation options that seem to have a good degree of “fit” to your situation. A good therapist will always listen to a patient’s feedback and constantly adjust the plan of care based on what treatments/modalities are working and working well and those treatments/modalities that are of marginal benefit or no benefit at all.

Sending healing wishes,
Karen

Hi Everyone,
Thank you again to everyone who replied. Just a quick update:
I saw a highly rated neurologist today, and we're going to take an MRI of the elbow. He said it will help show nerve issues. He offered nerve meds which I declined for now. They can have side effects, and I didn't have nerve meds before surgery when the pain was much worse.

Maybe this will help someone: He said that an EMG does not detect damage to small fibers of the ulnar nerve. I would think that applies to all nerves. The small fiber damage causes the burning.

I feel better since the flare up almost a month ago, but it's still very debilitating. The electric zaps have decreased a lot. I start occupational therapy tomorrow to hopefully desensitize the nerve.

Hi Pitmom,
Always nice to hear from you.

I will post the MRI results. The hospital has not called to schedule yet, so I need to follow-up with them. They usually call promptly to schedule.

The OT mentioned trying TENS or electrical stimulation, but was leaning towards TENS. I did mention the points you posted about, and that you felt it contributed to a better outcome for you.

Hi Darla,
That's an excellent question.

That is the impression I was under, but I can't say for certain now that you asked. The neurologist mentioned it would image the nerve too, but now I don't know to what extent. He mentioned that a follow-up surgery could be done if warranted by the MRI.

I just read another forum, and it seems an MRI might not detect small fiber nerve damage.

Post Edited (Q22) : 9/1/2018 8:36:19 AM (GMT-6)

Q, I did a search & found an excellent article from the National Institute of Health regarding an MRI of the elbow. They described how the MRI should be done, very informative article. And according to this article it will show nerves because of the approach used. You can do a google search for this article, if you have trouble finding it let me know. The EMG studies are like checking electrical impulses on an electrical board. Yes, if there is slowing of a nerve it will detect damage.

I am glad you got in to see the neurologist.