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

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

Video Transcription

These are more branches of the nerve that we'll preserve.  Now we're getting back down to a fascial plane again. It's there that we'll see the intermuscular septum. Do you have the Army, Navy's?  Yes, sir.  Thank you for watching!  You have a 4x4 there?  This little vein, of course.  So, we're actually releasing the  cubital tunnel proper. This is the nerve right below us, right there.  You have some longer forceps there.  There we go.  Thank you for watching!  Now that that's freed up from around the nerve, I can cauterize this part. You have the longer littlers too. Let's get you to switch hands there for us. So here's the nerve here.  It's these superficial sites of compression that I'm releasing now.  Just gently hold that so we don't pull that one too hard. This is the intermuscular septum that my scissors are pushing on right now.  It's a very tight band, and that will have to be divided. You can see the amount of release that you get simply by dividing this septum here.  So now, if that can be visualized, you can see how the nerve is actually pinched. This intermuscular septum is still pinching this, and this is where the arcade of strother  attaches to. And many times, we can actually push the nerve down to protect it and divide on top.  I tend to palpate up with a finger to make sure there's no other tight band that's left up there, and it appears to be released.  So now the nerve is coming down here, our intermuscular septum has been divided, I do tend to release the last little bit transversely to make sure there's no sharp edge that's  actually pushing on the nerve. Let's come down a little bit distally again. Now we have to make sure that we are going to release that tight band in the substance  of the muscle itself. So I'll use this end and then grab the medial epicondyle, and pull up on that a little, and grab these scissors here.  The fascia to the FCU is divided, and this is one of the leading edges right here that is very tight. Often times there's some larger veins that are right near this area.  The nerve is very sensitive so even just touching around it can result in contracture of the local muscles. There's a deep motor branch of the FCU that you  have to be careful about and preserve. The fascia to the FCU is almost T-shaped. Although it covers the fascia, there's a septum that goes down and it's part of  that septum that I think contracts the nerve distally.  And that's what we release. So now this is released down to that area there.  You can see the size of the nerve, which seems to be smaller here and more bulbous there,  indicating the site of compression was probably within the cubital tunnel itself, rather than distally.  I don't strip the entire nerve. I don't devascularize it and create an ischemic type of neuritis,  but enough to free up the nerve so that it's floating and there's no tight band that's notable on there.  There we go. And that's the release of the nerve. So this was an in situ release. Other techniques that I mentioned earlier were submuscular transposition, commonly used  at least in my practice for those that are more severe cases, recurrent cases. By more severe, they have permanent numbness or constant numbness.  They have wasting of the intrinsics. I just think it's a more severe compression that warrants a more aggressive surgery.  Otherwise, since patients do very well with the in situ, I haven't found the need to violate the flexor muscle mass to do a submuscular.  In situ release or in situ transposition, sorry, a subcutaneous transposition, again seems to be a little bit more aggressive than what's warranted in most cases of cubital tunnel.  Some of the other techniques utilized are smaller incisions and endoscopic techniques that I don't have a lot of experience with.  The branches of the medial umbrical nerve that we preserved are the more common, would be the most common site of complication if we've injured those or transected those.  Patients can get a painful neuroma in this area, or they get dysesthesias in the medial umbrical nerve distribution.  I don't like to manipulate the nerve too much at all. I just think that it's a very sensitive nerve and people can have a lot of pain and discomfort  afterwards as a result of that manipulation. So I like to touch it as little as possible. I use resorbable stitches here in this area because you can see the suture marks a lot  more frequently in this area than you can in other parts of the body. I just think it leaves a better scar. I'll need another one of these 4-0s for the subcuticular here.  So as you can see, decompression of the ulnar nerve at the cubital tunnel involves a small curvilinear incision on the medial aspect of the elbow and complete in situ release  is noted from all tight bands over the nerve. Guillain's canal release is a separate incision in the palm directly over the carpal tunnel  and the fibrous septum between the carpal tunnel and Guillain's canal is released. This resolves the double crush syndrome.

Video Summary

The video transcript describes a surgical procedure for decompressing the ulnar nerve at the cubital tunnel, commonly known as cubital tunnel release. The surgeon navigates through various fascial planes and anatomical structures to release tight bands and septa compressing the nerve, aiming to alleviate symptoms without causing further nerve damage. They take care to preserve branches of the medial umbrical nerve to avoid complications such as painful neuromas or dysesthesias. The procedure involves a small incision and careful manipulation to minimize postoperative pain. The surgeon prefers in situ release for most cases, only considering more aggressive techniques like submuscular transposition for severe, recurrent cases. Post-procedure, resorbable stitches are recommended to minimize visible scarring. The transcript also touches on related procedures like Guillain's canal release to address the double crush syndrome, emphasizing the precision and caution needed during surgery to ensure optimal outcomes and nerve preservation.

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

cubital tunnel release

ulnar nerve decompression

in situ release

double crush syndrome

nerve preservation