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Atrophy after surgery: Ulnar cubital tunnel decompression.

Sometime early this year, as I stood up after working for several hours at my desk, I realized that the pinkie and ring fingers (but especially the pinkie) on my left hand (I am right handed) were clawed and felt somewhat numb. Except for some mild discomfort/numbness on the tip of my thumb and index fingers (and only occasionally on my pinkie) during the previous months, I had basically not experienced any other symptoms in my left hand. After performing a nerve conduction study and a clinical needle study, a neurologist determined that the ulnar nerve in my left arm was compressed inside the cubital tunnel, and he seemed to disbelieve my story of the time frame and symptoms up to the clawing of my fingers (apparently because of the condition of my hand). The neurologist basically told me that I needed surgery but that my expectations for recovering the full use of my left hand should be limited and, in fact, I might have no recovery at all. He then referred me to a surgeon who performed a decompression of the cubital tunnel (but no transposition of the ulnar nerve). The surgeon expressed considerably more optimism than the neurologist. Prior to the surgery, the surgeon approximated that I had a 60% chance of a recovery of full use of my left hand, but that any recovery was likely to take at least 8 or 9 months. After the surgery the surgeon informed me that the damage to the ulnar nerve was less than he expected. I believe that the surgery resulted in an almost immediate lessening of the discomfort that I felt. However, 4 or 5 weeks after the surgery I had not noticed any significant lessening of the numbness in my hand or any improvement in the use of my hand. While I suspect that the lack of improvement at that point was to be expected, I noticed that the muscles in between my index finger and the thumb had appeared to have shrunk or atrophied significantly. I returned to the surgeon last week to have him address my concerns, but he basically told me that there was nothing I could do. He told me to be patient, and that I might not have any significant recovery at all. In addition, the surgeon basically provided no guidance as to my inquiries about the benefits of exercise, therapy, braces, gloves, etc. So, of course, I am concerned as to what to do and how, if possible at all, to stop or reverse the atrophy, in addition to regaining the normal use of my hand. Is it possible that that my ulnar nerve remains compressed and damaged in the Guyan canal of my left hand? I would appreciate any insight anyone can give me, whether as to what I might do or as to the type of professional I should go to for additional help.
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replied July 9th, 2012
Especially eHealthy

The first dorsal interosseous muscle in the last muscle innervated by the ulnar nerve, and as such is usually the one tested manually for ulnar nerve function. This muscle sits on the radial side (thumb side) of the index finger metacarpal. If you make a "peace sign" or "victory sign" with your index and middle finger, the 1st DI is the muscle that moves the index finger away from the middle finger.

When there is no information getting to this muscle via the ulnar nerve, it will atrophy. This is noted as a hollow appearing on the radial side of the index finger, in the web space. When this muscle atrophies, it is pretty obvious.

The ulnar nerve can be compressed in many places, but the two most common are in the cubital tunnel and at Guyon's canal. When the neurologist did the electrical studies, he should have checked out both of these regions. So, compression at Guyon's canal should have been ruled out. You can always contact the neurologist (or check the study) to make sure.

A double crush syndrome does occur (compression of the same nerve at two or more points), and is often the reason that a release fails. So, it is worth checking with the neurologist to make sure.

Unfortunately, the palsies that seem to come on very quickly and very significantly seem to do the worst, for some reason. The neurologist could also look at the electrical studies, and can usually tell how badly the nerve has been injured. So, the neurologist may have been more pessimistic than the surgeon because of that. The surgeon can actually look at the nerve, to see if its blood supply is still intact, if the nerve has changed in appearance, etc, and have a different assessment. But, usually, time will tell the true story.

It is possible to get post release electrical studies, but they usually have to be delayed a minimum of six weeks and preferably 3 months after the release. If they are done earlier than that, the nerve really hasn’t had enough time to change, so the results are worth much. But, it is something to possibly do in the near future.

As to other treatments for ulnar nerve palsies. You must keep all of your finger and wrist joints supple, with full range of motion. This may require that you use your other hand to help put the fingers and wrist through full ranges of motion. If the joints become stiff, even if the nerve did start working again, the muscles would not be able to move ankylosed joints. (Just like a rusted mechanical joint. Cables won’t move it if it is rusted shut.)

If you have significant hyperextension of the ulnar two MCPJ (metacarpal phalangeal joints, or the big knuckles in the hand), this will prevent the use of the hand. But, if you were put in a metacarpal bar brace (also called a lumbrical bar), to bring the MCPJs down, the fingers will function better at the PIPJs (proximal interphalangeal joints). This is basically an ulnar nerve palsy splint.

If the nerve does not come back, and you have problems using the hand, there are tendon transfers which can be performed. These take sacrificable tendons from muscles that do work and transfer them to make up for the functions that are deficient. These never make a “normal” hand, but can provide for a significant improvement in function. But, this is a ways down the road. You are not at that point yet.

So, you should contact the neurologist and make sure that the nerve was assessed at Guyon’s canal. You may need to have post-release electrical studies conducted. The neurologist can tell you when the optimal time would be for that.

You should probably be assessed by an occupational therapist, to see if bracing for an ulnar nerve palsy would increase your function. The occupational therapists are usually trained in hand therapy. Physical therapists usually are not specifically trained in the hand, as it is a specialized area in therapy.

But, you do need to keep the joints on that hand supple, with full range of motion.

Again, sorry about your condition. Hope that your nerve does start to wake up. Good luck.
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replied October 19th, 2013
ulnar nerve damage
My c8 nerve root was compressed, due to a herniated disk. I am recovering from neck surgery where a microdiscectomy was preformed. I'm 8 days post op and my symptoms are worse then before the surgery. The numbness and pressure I feel in my hand are so very uncomfortable. Atrophy had begun before the surgery, and it continues. My neurosurgeon said I may require additional surgery, thru the front of my neck and preform a fusion! Going from bad to worse. I'm so confused and don't know what to do
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