Surgery Spotlight: Release of Guyon's Canal and Cubital Tunnel: Part I-Surgery Spotlight: Release of Guyon's Canal and Cubital Tunnel: Part I

Surgery Spotlight: Release of Guyon's Canal and Cubital Tunnel: Part I

Video Transcription

Hi, I'm Mike Neumeister from Southern Illinois University School of Medicine. This case involves release of the cubital tunnel and Guillain's Canal for a double  crush syndrome of the ulnar nerve. The Guillain's Canal release, this young lady has already had a carpal tunnel release in the past.  Using that same incision, actually, it's extended slightly. I make a hockey stick type of incision towards the distal end of that Guillain's Canal because  it helps me identify the neurovascular bundle as it leaves Guillain's Canal. As you know, the Guillain's Canal is actually formed, the floor of Guillain's Canal is the  roof of the carpal tunnel. So the ligament comes down and dives underneath the neurovascular bundle.  There's a fibrous septum that distinguishes both compartments, carpal tunnel and Guillain's Canal, and we will go through that fibrous septum to release the Guillain's Canal.  It's not uncommon, or it's not common, to actually have entrapment of the Guillain's Canal, and really the physical findings will help delineate the exact site of compression.  So in this particular lady, she had a TINAL sign at Guillain's Canal, as well as a positive provocative compression test, or Durkin's type of test. So I release the carpal tunnel.  In this case, it's a re-do. I think the secret to this part of the procedure is traction and counter-traction.  So I use SEND retractors that are pulled rather aggressively to allow for good exposure.  I don't think there's a routine case reason to actually go beyond the wrist crease at all. So there's our median nerve that's down below there.  So from your direction there, do you have a rag now? You may want to hold your head back just a little there.  So rather than myself as the primary surgeon actually reaching backwards or changing sides, I think it's important to do this part of the procedure forehand.  So the assistant can often release this more proximal site.  That test really shows that there's still a portion or a band that's pushing on the nerve. And so as he passes the scissors from the proximal forearm into the palm, you can see  underneath the skin that it still had a tight band over the nerve itself. That looks a lot better.  So as we can see here, actually, you may end up releasing from your side there with a 15 neurovascular bundle.  I'll get you to hold this one here. It's right here. This is why I perform this hockey stick, because I can fully see this area.  There's the artery as it's leaving the Guillain's canal, and this is the edge, the distal edge of Guillain's canal there. The nerve itself is a little more ulnar to that.  But here's our artery. This is the septum, if this is our median nerve right here. The septum that compartmentalizes Guillain's canal is right here.  So we're going to release this septum now.  This can be done either with the scissors or the knife.  If we actually go distally where that end of that is, we can start dividing there.  It's important to get the more proximal aspect of the Guion's canal. There's often a tight band right at this proximal site.  Although we've released the entire septum, if we don't look more proximally, you may actually miss an important site of compression.  Same thing with the scissor test there, with that underneath the skin. So the scissors have gone up to this point right there, Guion's canal starts about there.  As he pulls back, you can see that there's no tight band. If there was, as his scissors went in distally and he pulled back, you'd get a tight upward  rise in the scissors, and we didn't see that. My retractor goes all the way back. So this is now completely released.  What you can see from the distal end is, this is actually a small blood vessel, difficult to see, but there's a little blood vessel that's servicing this part of the palm.  As I release my retractor, it actually shows there's no compression of the nerve on that site. If there was, then I would actually just cauterize that, or clip that little vessel.  There's no need to at this point. One last item to just kind of free up some of that scar tissue around the nerve, so I'll  grab it from this direction there, just to show that our median nerve is free too.  And there's her median nerve, and then the ulnar nerve is beside her artery and below it.  Sorry.  Do you have the nylon suture for us?  Yes. Okay.  After the suturing, the dressing is a simple dressing of a non-adherent first layer, such as Adaptic or Xeriform, and then the Fluffs and Acrylics. We don't use a splint.  The same is true for just a simple carpal tunnel release.  And we'll have the patients remove the dressing in about two days' time, put a simple Band-Aid on this, and other than limiting the amount of lifting they do with this, there's actually not a lot of restriction.  Okay.  And we'll pick up the curlings.  Alright, so now we'll move on to the cubital tunnel, which is at the elbow here. So the cubital tunnel, actually mark out the medial epicondyle, which is right about there,  which means the cubital tunnel will have the nerve that kind of travels in this direction like that.  So in this particular case, she had a Tenell's and a positive compression test right at the cubital tunnel.  Other sites might be Osborne's band or the leading edge at FCU, or a more distal band within the substance of the FCU muscle. That needs to be looked at.  These other two areas need to be released, the roof of the cubital tunnel, and then the arcade of struthers as it progresses more proximally.  The intermuscular septum is where we'll find the nerve, just on the posterior aspect of that septum itself.  The important part here are the medial antebrachial nerve branches that course right through this incision site here.  So we'll spread, once we get through a layer of fat, we'll spread the tissue to identify those nerves and make sure that we don't injure those to prevent neuromas or dysesthesias  in the medial antebrachial nerve distribution. So because I think the incision's more comfortable, I actually make the incision slightly anterior to the medial epicondyle.  That'll be the course that we take. I don't think the incision needs to be quite that long, so it'll kind of go from that distance to there.  Underneath the tissues, I'll continue to release to that area and up into this area as well. Now I'll take the 15 blade.  Thank you for watching!  The nerves are deeper than this first layer of fat, and if anything, there's actually superficial veins that might be in the way here.  But this first part can be cauterized to deal with small bleeding that may occur. Now we'll start to spread through this.  We'll use retraction and counter traction to open up the tissue planes.  And there's numerous different ways to treat the cubital tunnel. This is just a fibrous band. We're going to do an in situ release in this particular case.  This, in my experience, has worked as well as a submuscular transposition, subcutaneous transposition. Here's a nerve here.  And I don't have current experience with the endoscopic technique. So the spreading technique was meant to preserve some of the structures, particularly the branches  of the medial and the brachial nerve.  And we can start to see some of these branches coming through there. The fascia that we see at the base of the wound here is actually the fascia of the flexor carpi ulnaris.  All the flexor origins are at the site of the medial pecundum.

Video Summary

Dr. Mike Neumeister from Southern Illinois University School of Medicine presents a surgical procedure for a patient with double crush syndrome affecting the ulnar nerve. The patient previously had a carpal tunnel release. In this case, a modified incision extends slightly to perform a Guillain's Canal release. He explains the importance of identifying neurovascular bundles and the fibrous septum dividing carpal tunnel and Guillain's Canal. He emphasizes the need for careful examination for nerve compression and specific surgical techniques like traction and counter-traction for successful release. Attention is also given to the cubital tunnel at the elbow, where different release techniques are discussed, focusing on preserving structures like the medial antebrachial nerve to avoid neuromas. The procedure concludes with careful suturing and application of a simple dressing, advising minimal restriction post-surgery for the patient.

Asset Caption

Michael W. Neumeister, MD demonstrates release of Guyon's Canal and the cubital tunnel for a double crush syndrome of the ulnar nerve.

Surgeon

Michael W. Neumeister, MD This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Hand

Nerve

Michael W. Neumeister MD; Memben

double crush syndrome

ulnar nerve

Guillain's Canal release

neurovascular bundles

cubital tunnel