The Hague, The Netherlands
To the Editor:
We read with great interest the article on open vs endoscopic decompression of the ulnar nerve by Dützmann et al1 comparing the results from open surgical ulnar nerve release to retractor-endoscopic decompression of the ulnar nerve.
In this paper, open decompression is performed by a 6 to 8 cm long incision around the medial epicondyle. The endoscopic technique consists of an incision of 1.5 to 2 cm made directly on the sulcus, this is as large as needed to introduce the retractor of the endoscope. Results from this study showed no significant differences on long-term outcome evaluation. However, on short term the endoscopic technique resulted in slightly better results in postoperative recovery and return to full activity. With the endoscopic decompression 65% of the patients were pain-free after three days, this was 49% in patients operated with the open technique.
The authors state that the endoscopic approach has the advantage of a small skin incision and minimal tissue trauma, with faster recovery and gaining full functionality over the open surgical decompression. The disadvantage of this technique is the limited exposure, with possible contusion of the ulnar nerve while introducing the retractor and endoscope and also the relative limited possibility for hemostasis. Because of the greater length of nerve decompression (compared to the open decompression), there is bigger chance of subluxation of the ulnar nerve. The endoscopic technique also requires a learning curve, with endoscopic instrumentation needing time to prepare.
In our view, a small variation to the open surgical technique combines the advantages of both the open and the endoscopic decompression. This is simply achieved by changing the positioning of the arm of the patient, giving the surgeon better view over the course of the nerve. The patient is placed in the supine position with the arm backwards in a leg-rest (Figure 1A-B). A classical but small incision of 2 to 3 cm is made over the course of the ulnar nerve in the sulcus (Figure 1C-D). The nerve is then identified and decompressed and is dissected along his path while the soft tissue is held up with a small Weitlaner retractor. In this way, the surgeon has an optimal view along the nerve in both directions just by changing his direction of view (Figure 2). Compare this to a referee in a football game standing on a corner of the field having both the backline and sideline under vision. By this method the nerve can be dissected over a length of 10 cm proximally and distally.
The duration of surgery in this positioning takes from skin to skin approximately 15 minutes. This is considerably less than operating time given in above stated article (27, 7 ± 13, 7 min and 29, 6 ± 8, 4 min for the open and endoscopic technique respectively).
This positioning gives the opportunity to perform a mini-invasive open ulnar nerve decompression with a small incision, comparable to endoscopic incisions leading to small and less painful scars. Since trauma to the tissue is minimalized, the recovery period is decreased as well. A disadvantage of this technique is that no ulnar nerve transposition can be performed due to the small incision.
In our opinion the technique described here is a small but simple and effective variation of the well-known open surgical technique for decompression of the ulnar nerve combining the advantages of both the open and endoscopic techniques.
The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.
1. Dützmann S, Martin KD, Sobottka S, et al.. Open vs retractor-endoscopic in situ decompression of the ulnar nerve in cubital tunnel syndrome: a retrospective cohort study. Neurosurgery. 2013;72(4):605–616; discussion 614-616.