Treatment for ulnar neuropathy at the elbow
Editorial Group: Cochrane Neuromuscular Disease Group
Published Online: 11 JUL 2012
Assessed as up-to-date: 20 FEB 2012
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD006839. DOI: 10.1002/14651858.CD006839.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 11 JUL 2012
Ulnar neuropathy at the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical but optimal management remains controversial. This is an update of a review first published in 2010.
To determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow.
We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 February 2012), CENTRAL (2012, Issue 2), MEDLINE (January 1966 to February 2012), EMBASE (January 1980 to February 2012), AMED (January 1985 to February 2012), CINAHL Plus (January 1937 to February 2012), LILACS (January 1982 to Feburary 2012), PEDro (January 1980 to February 2012), and the papers cited in relevant reviews.
The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of ulnar neuropathy at the elbow. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of ulnar neuropathy at the elbow with or without neurophysiological evidence of entrapment.
Data collection and analysis
Two authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The authors extracted data from included trials and assessed trial quality independently. They contacted trial investigators for missing information.
We identified six RCTs (430 participants), with moderate quality evidence, for inclusion in the review. When the searches were updated in 2012 we found no further studies. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical (three trials, 261 participants included) and neurophysiological (two trials, 101 participants included) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.
We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). In the simple decompression group 91 out 131 patients clinically improved; in the transposition group 97 out 130 patients improved. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85).
In one trial (47 participants) the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.
One trial (51 participants) assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement.
The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small RCT of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.
Plain language summary
Treatment for ulnar neuropathy at the elbow
Ulnar neuropathy at the elbow is the second most common form of nerve irritation from a trapped or compressed nerve, after carpal tunnel syndrome. People with the condition normally have tingling of the fourth and fifth finger at night, pain at the elbow, and altered sensation on prolonged bending of the elbow. In severe cases the condition causes weakness in the muscles of the hand, which is innervated by the ulnar nerve. Diagnosis is based on signs, symptoms, and nerve conduction studies. The treatment of ulnar neuropathy at the elbow can be conservative (splint devices, physical therapy, rehabilitation) or surgical. We found one randomised controlled trial (RCT) of conservative treatment involving 51 participants, which supports the opinion that conservative treatment is effective in clinically mild or moderate ulnar neuropathy. In this study, provision of written information on avoiding movements or positions provoking the symptoms, either alone, combined with night splinting for three months, or combined with nerve gliding exercises, was equally effective in improving occupational activities and reducing pain at night. None of the conservative treatments improved muscle strength. In three RCTs, a total of 131 participants were treated by the surgical technique of simple decompression and 130 participants were treated by transposition of the nerve (submuscular or subcutaneous transposition). Meta-analysis found no significant difference between simple decompression and transposition of the ulnar nerve (subcutaneous or submuscular) in postoperative clinical and neurophysiological improvement. In another trial (47 participants) the authors compared medial epicondylectomy with anterior transposition and found no difference in clinical and neurophysiological outcomes. The available evidence is not sufficient to identify the best treatment of ulnar neuropathy at the elbow, on the basis of clinical, neurophysiological and imaging characteristics. However, in mild cases information on movements and positions to avoid may reduce subjective discomfort. Moreover, the results of our meta-analysis suggest that simple decompression surgery and decompression with transposition are equally effective. Decompression with transposition results in a higher number of deep and superficial wound infections.