eMedicine Specialties > Neurology > Electromyography and Nerve Conduction Studies

Ulnar Neuropathy: Follow-up

Author: Christina J Azevedo MD, Staff Physician, Department of Neurology, Dartmouth-Hitchcock Medical Center
Coauthor(s): Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Contributor Information and Disclosures

Updated: Dec 11, 2009

Follow-up

Prognosis

  • A motor amplitude of 10% of normal or a greatly reduced recruitment of motor units indicates a low likelihood of significant or full recovery.
  • Typically, nerves regenerate at a rate of 1 mm/d.
  • In some cases, regeneration is accompanied by pain and paresthesias, which are thought to be secondary to random ectopic impulse generation of affected nerves.
  • A diameter greater than 3.5 mm on the initial sonogram of the ulnar nerve at the elbow is associated with persistent symptoms or signs regardless of treatment (ie, conservative treatment or surgical treatment50 ).
  • The outcome does not correlate with clinical features at baseline or with the duration of symptoms prior to treatment.
  • The presence of motor conduction velocity slowing or pure conduction block across the elbow signifies a favorable outcome; these are considered independent prognostic factors51 .
  • A favorable surgical outcome is more likely for sensory function than for motor function; however, overall, a favorable outcome occurs in 85-95% of cases.
  • Unfavorable or poor surgical outcome is characterized by the following:
    • Age older than 50 years
    • Coexisting diabetes or other causes of peripheral polyneuropathy
    • Atrophy and ongoing denervation of ulnar-derived muscles
    • Absent ulnar sensory responses
    • Postoperative position of the ulnar nerve in relation to the medial epicondyle

Miscellaneous

Medicolegal Pitfalls

A number of medicolegal issues are related to ulnar neuropathy.

  • Diagnostic problems: When diagnostic problems occur, they often relate to the clinician’s failure to realize that the diagnosis of an ulnar neuropathy is difficult and requires great care. As noted in our discussion and as emphasized in numerous discussions on ulnar neuropathy, diagnosis and localization of this problem is more difficult than diagnosis of the more common carpal tunnel syndrome. Not uncommonly, precise localization cannot be achieved and the clinician should be aware when the data is not adequate to reliably state where the ulnar lesion is located. Problems can occur at virtually every step.
    • Failure to perform a thorough history and examination is probably the most important cause of mistakes in diagnosis. A thorough history and physical can usually tell the clinician the most important fact, ie, whether or not an ulnar neuropathy is likely to be present at all even though the precise localization cannot always be given.
    • During neurophysiological testing, the physician may fail to search for the Martin-Gruber anastomosis, a normal variant, thereby inaccurately diagnosing conduction block.
    • The examiner may fail to detect an ulnar neuropathy by failing to increase the sensitivity by testing the nerve conduction to the first dorsal interosseous (FDI)46 as well as to the abductor digiti minimi.
    • Another common error is testing only one nerve in the limb, thereby missing other potential conditions such as polyneuropathy.
    • In addition, the clinician may perform the electrodiagnostic52 tests at suboptimal limb temperatures (<30°C), leading to falsely prolonged latencies and increased amplitudes.
  • Problems related to treatment: An important pitfall in treatment is to lead the patient to believe that full recovery is to be expected in cases in which recovery is rather uncertain. Of course, few doctors today promise perfection and physicians often downplay the likelihood of complete recovery so as not to raise expectations unduly. Even so, many physicians, even neurologists and physiatrists, do not realize that an operation for ulnar entrapment has much less chance of a highly satisfactory result than an operation for carpal tunnel syndrome. The reasoning for this is unclear.
  • Postsurgical ulnar neuropathies: Finally, a surprisingly high rate of postsurgical neuropathies give rise to a considerable number of lawsuits. They appear to be most common after cardiac procedures. However, a study at the Mayo Clinic found a rate of 0.5% even after noncardiac procedures.53 Interestingly, however, many of the cases do not appear immediately after surgery. This suggests that the patients may traumatize the nerves in the postoperative period. Careful attention to protecting the ulnar nerve both during the surgery and postoperatively may cut the rate of such injuries and reduce the number of ensuing legal claims.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sandeep K Aggarwal, MD, to the development and writing of this article.



More on Ulnar Neuropathy

Overview: Ulnar Neuropathy
Differential Diagnoses & Workup: Ulnar Neuropathy
Treatment & Medication: Ulnar Neuropathy
Follow-up: Ulnar Neuropathy
Multimedia: Ulnar Neuropathy
References
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Further Reading

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Keywords

bicycle's neuropathy, cubital tunnel syndrome, Guyon canal syndrome, Guyon's canal syndrome, tardy ulnar palsy, ulnar palsy tarda

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Contributor Information and Disclosures

Author

Christina J Azevedo MD, Staff Physician, Department of Neurology, Dartmouth-Hitchcock Medical Center
Christina J Azevedo MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Stephen A Berman, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Paul E Barkhaus, MD, Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration Medical Center
Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Neil A Busis, MD, Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory, University of Pittsburgh Medical Center-Shadyside
Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

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