Intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition

Abstract

The surgical management of cubital tunnel syndrome includes anterior transposition of the ulnar nerve. The success of all transposition procedures is dependent on placement of the nerve anterior to the medial epicondyle without tension. Fifteen cadaveric upper extremities underwent anterior transposition followed by anterior transposition with separation of the most proximal motor branches from the main ulnar nerve for a distance of 1, 2, and 3 cm. Proximal dissection of these motor branches achieved an average gain in distance from the epicondyle of 71%, with an average distance from the epicondyle of 3.6 cm. The intraneural topography of the ulnar nerve was studied in five additional cases. Cross-section analysis of the fascicular anatomy at 333 microns intervals along the length of the nerve with longitudinal reconstructions confirmed a safe dissection plane without interfascicular plexus formation. The most proximal motor branch in the forearm could be traced proximally an average of 6.7. cm within the nerve before interfascicular mingling occurred (range 6.0 to 7.5 cm). Thus, 6.0 cm represented the upper limit of safe proximal dissection in these nerves. Proximal separation may be performed without disruption of interfascicular plexus connections and will facilitate anterior transposition.