UNETREAT: Treatment for Ulnar Neuropathy at the Elbow
Study Details
Study Description
Brief Summary
The purpose of the study is to investigate utility and appropriateness of treatment interventions taking into account the presumed mechanisms of two main varieties of ulnar neuropathy at the elbow (UNE). The investigators hypothesize that in patients with UNE under the humeroulnar aponeurosis (HUA) surgical HUA release (simple decompression) is superior to conservative treatment. By contrast, in patients with UNE at the retroepicondylar (RTC) groove surgical HUA release (simple decompression) should not be superior to conservative treatment.
Condition or Disease | Intervention/Treatment | Phase |
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N/A |
Detailed Description
Ulnar neuropathy at the elbow (UNE) is the second most common focal neuropathy with annual incidence rate of 21 per 100.000. Therefore, in Slovenia UNE each year affects approximately 420 and in Europe 156.000 patients. In previous publications evidence was presented that idiopathic UNE consists of two conditions occurring 2-5 cm apart. In the first condition, affecting about 15% of UNE patients, the ulnar nerve is entrapped 2-3 cm distal to the medial epicondyle (ME) under the humeroulnar aponeurosis (HUA), i.e., in the cubital tunnel. In the second condition, affecting the majority (about 85%) of patients, the lesion is located at the ME or up to 4 cm proximally in the retroepicondylar (RTC) groove. As no anatomical structure constricting the ulnar nerve is usually found in that segment, the most probable cause of UNE at this location is extrinsic ulnar nerve compression against the underlying bone. The investigators believe that these two groups of UNE patients need different therapeutic approaches: (1) surgical release for ulnar nerve entrapment distal to ME and (2) conservative treatment for extrinsic nerve compression in the RTC groove. The efficiency of this therapeutic approach was already evaluated and significant clinical improvement was found in 80% of UNE patients. However, the design of that study did not enable to obtain an indisputable evidence that outcome was a result of treatment approach. It is still possible that improvement observed in patient population was a consequence of natural history rather than therapy. To resolve this problem a properly designed randomized control trial is needed. The investigators believe such trial would prevent numerous unnecessary and delayed operations in UNE patients.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: UNE at HUA_HUA release Patients with UNE under the HUA randomly distributed for simple decompression of the ulnar nerve. Patients will also receive pictured recommendations with descriptions, which limb positions should be avoided. Control neurological examination will be performed every 3 months and identical protocol as at the time of diagnostic evaluation at 1 year follow-up. |
Procedure: Simple decompression of the ulnar nerve
Surgical HUA release 2-3 cm distal to medial epicondyle with minimal-incision technique .
Behavioral: Conservative treatment
Patients will be given pictured recommendations with descriptions, which limb positions should be avoided.
|
Active Comparator: UNE at HUA_conservative treatment Patients with UNE under the HUA randomly distributed for conservative treatment. Patients will receive pictured recommendations with descriptions, which limb positions should be avoided. In order to prevent deterioration in conservatively treated group of patients with UNE at HUA control neurological examination will be performed every 3 months. Criteria for surgical HUA release will be clinical deterioration or lack of clinical improvement after 12 months. Prior to surgical HUA release and at 1 year follow-up identical protocol as at the time of diagnostic evaluation will be performed. |
Behavioral: Conservative treatment
Patients will be given pictured recommendations with descriptions, which limb positions should be avoided.
|
Experimental: UNE at RTC_HUA release Patients with UNE in the RTC groove randomly distributed for simple decompression of the ulnar nerve. Patients will also receive pictured recommendations with descriptions, which limb positions should be avoided. At 1 year follow-up identical protocol as at the time of diagnostic evaluation will be performed. |
Procedure: Simple decompression of the ulnar nerve
Surgical HUA release 2-3 cm distal to medial epicondyle with minimal-incision technique .
Behavioral: Conservative treatment
Patients will be given pictured recommendations with descriptions, which limb positions should be avoided.
|
Active Comparator: UNE at RTC_conservative treatment Patients with UNE in the RTC groove randomly distributed for conservative treatment. Patients will receive pictured recommendations with descriptions, which limb positions should be avoided. At 1 year follow-up identical protocol as at the time of diagnostic evaluation will be performed. |
Behavioral: Conservative treatment
Patients will be given pictured recommendations with descriptions, which limb positions should be avoided.
|
Outcome Measures
Primary Outcome Measures
- Improvement/remission [2 years]
Primary outcome of the study will be percentage of patients with at least moderate symptoms improvement or complete remission
Secondary Outcome Measures
- UNE symptoms [2 years]
Percentage of patients without UNE symptoms or with minimal UNE symptoms
Other Outcome Measures
- Muscle wasting_subjective [2 years]
Percentage of patients without hand muscle wasting
- Muscle wasting_objective [2 years]
Cross section area of the first dorsal interosseous (FDI) muscle measured by ultrasonography (US)
- Muscles strength_subjective [2 years]
Percentage of patients with near normal (4+/5 on MRC) or normal (5/5 on MRC) ulnar hand muscles strength
- Muscles strength_objective [2 years]
Improvement in strength of the first dorsal interosseous (FDI) muscle as measured by dynamometer (microFET2)
- Ulnar_CMAP_AMP [2 years]
Increase in amplitude (AMP) of the ulnar compound muscle action potential (CMAP)
- Ulnar_MNCV [2 years]
Increase of motor nerve conduction velocity (MNCV) in the most affected 2 cm segment
Eligibility Criteria
Criteria
Inclusion Criteria:
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continuous numbness or paresthesias in the 5th finger,
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weakness of the ulnar-innervated muscles or hand clumsiness.
Exclusion Criteria:
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previous elbow fracture or surgery,
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polyneuropathy, symptoms of polyneuropathy, conditions causing polyneuropathy (e.g., diabetes) or multiple mononeuropathy,
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motor neuron disorders (e.g., monomelic amyotrophy, amyotrophic lateral sclerosis - ALS).
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | University Medical Center Ljubljana, Department of Neurology, Institute of Clinical Neurophysiology | Ljubljana | Slovenia | 1000 |
Sponsors and Collaborators
- University Medical Centre Ljubljana
- Slovenian Research Agency
Investigators
- Principal Investigator: Simon Podnar, MD, DSc, Department of Neurology, University Medical Center Ljubljana
Study Documents (Full-Text)
None provided.More Information
Publications
- Leis AA, Smith BE, Kosiorek HE, Omejec G, Podnar S. Complete dislocation of the ulnar nerve at the elbow: a protective effect against neuropathy? Muscle Nerve. 2017 Aug;56(2):242-246. doi: 10.1002/mus.25483. Epub 2017 Jan 4.
- Omejec G, Božikov K, Podnar S. Validation of preoperative nerve conduction studies by intraoperative studies in patients with ulnar neuropathy at the elbow. Clin Neurophysiol. 2016 Dec;127(12):3499-3505. doi: 10.1016/j.clinph.2016.09.018. Epub 2016 Oct 13.
- Omejec G, Podnar S. Long-term outcomes in patients with ulnar neuropathy at the elbow treated according to the presumed aetiology. Clin Neurophysiol. 2018 Aug;129(8):1763-1769. doi: 10.1016/j.clinph.2018.04.753. Epub 2018 Jun 1.
- Omejec G, Podnar S. Neurologic examination and instrument-based measurements in the evaluation of ulnar neuropathy at the elbow. Muscle Nerve. 2018 Jun;57(6):951-957. doi: 10.1002/mus.26046. Epub 2018 Jan 23.
- Omejec G, Podnar S. Normative values for short-segment nerve conduction studies and ultrasonography of the ulnar nerve at the elbow. Muscle Nerve. 2015 Mar;51(3):370-7. doi: 10.1002/mus.24328. Epub 2015 Jan 10.
- Omejec G, Podnar S. Precise localization of ulnar neuropathy at the elbow. Clin Neurophysiol. 2015 Dec;126(12):2390-6. doi: 10.1016/j.clinph.2015.01.023. Epub 2015 Feb 14.
- Omejec G, Podnar S. Proposal for electrodiagnostic evaluation of patients with suspected ulnar neuropathy at the elbow. Clin Neurophysiol. 2016 Apr;127(4):1961-7. doi: 10.1016/j.clinph.2016.01.011. Epub 2016 Jan 28.
- Omejec G, Podnar S. What causes ulnar neuropathy at the elbow? Clin Neurophysiol. 2016 Jan;127(1):919-924. doi: 10.1016/j.clinph.2015.05.027. Epub 2015 Jun 17.
- Omejec G, Žgur T, Podnar S. Can neurologic examination predict pathophysiology of ulnar neuropathy at the elbow? Clin Neurophysiol. 2016 Oct;127(10):3259-64. doi: 10.1016/j.clinph.2016.08.002. Epub 2016 Aug 9.
- Omejec G, Žgur T, Podnar S. Diagnostic accuracy of ultrasonographic and nerve conduction studies in ulnar neuropathy at the elbow. Clin Neurophysiol. 2015 Sep;126(9):1797-804. doi: 10.1016/j.clinph.2014.12.001. Epub 2014 Dec 8.
- Podnar S, Omejec G, Bodor M. Nerve conduction velocity and cross-sectional area in ulnar neuropathy at the elbow. Muscle Nerve. 2017 Dec;56(6):E65-E72. doi: 10.1002/mus.25655. Epub 2017 Apr 15.
- Simon NG. Treatment of ulnar neuropathy at the elbow - An ongoing conundrum. Clin Neurophysiol. 2018 Aug;129(8):1716-1717. doi: 10.1016/j.clinph.2018.06.006. Epub 2018 Jun 18.
- UNE Treatment