Surgery for ulnar nerve compression at the elbow : Focusing on factors influencing outcome

Abstract: Ulnar nerve compression at the elbow (UNE) is a common peripheral nerve compression disorder in the upper limb. The literature regarding surgical outcome is inconclusive. This thesis aims to highlight various aspects of real-life settings for patients with UNE and to increase the understanding of underlying factors influencing the outcome of surgery.Patients undergoing surgery for UNE at a tertiary referral hospital were retrospectively evaluated (Linköping cohort; n=202). Comorbidity was extensive. Patients treated with simple decompression (SD) had a lower rate of complications than those with transposition surgery. Emerging neurogenic pain was the most common complication, with a two-fold risk for smokers. Scores from the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire revealed no differences between the surgical groups. Satisfaction with surgery was relatively low (53%), however only 8% stated that they would not go through the same surgical procedure again.Images from magnetic resonance imaging (MRI), performed in conjunction with surgery (Linköping cohort; 62 patients), were re-evaluated by a neuroradiologist. Spinal nerve root pathology contributing to the ulnar nerve (C8-Th1) was rare (1/62 patients), however, nerve root affections at other levels were common (26/62). No relation between cervical pathology and patient-reported outcome was seen.The Linköping cohort was combined with two cohorts from Region Skåne to evaluate time before return to work (RTW) after surgery for UNE (n=635 in total). RTW within 6 weeks was more common among older, SD and non-manual workers. Those who were unemployed were on sick leave longer than the rest of the population. Transposition of the ulnar nerve was the only predictor for prolonged RTW in the regression model.Patients with pain in conjunction with surgery were studied both in a retrospective observational study and in a qualitative study. Questionnaires obtained from the pain management clinic revealed a high prevalence of kinesiophobia, potential depression and/or anxiety, low life satisfaction and low overall health status. Patients with severe postoperative pain were younger and more often had bilateral surgery compared to the reference population. The narratives from the qualitative study revealed that chronic pain in conjunction with surgery for UNE affects most aspects of daily life and contributes to a heavy burden for the individual.In summary, patients surgically treated for UNE in a real-life setting constitute a heterogeneous population with wide variation in comorbidity and outcome of surgery. Pain after surgery can have a great impact on the individual and should be considered as an outcome. A biopsychosocial approach should be applied when treating patients with pain.

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