The Treatment of the Cubital Tunnel Syndrome Using the Anterior Transposition Surgical Technique

Introduction: The paper aims to present the advantages and disadvantages related to using the anterior transposition technique for the treatment of the cubital tunnel syndrome. Materials and Methods: The study presents the surgical treatment of a 58 years old woman. The therapeutic protocol included the decompression of the ulnar nerve at the level of the elbow, followed by the anterior transposition, the new position being maintained by anchoring in a fascial sling. Results: The electromyographic evaluation performed 12 months after the surgical intervention indicated that the parameters of motor nerve conduction were within normal limits on all segments, normal sensory velocities from the V fi nger, orthodromic and from the dorsal branch, sign of a very good postoperative recovery. Conclusions: Anterior transposition of the ulnar nerve may be a fi rm solution for the treatment of the compressive ulnar neuropathies located at the level of the elbow.


ORIGINAL PAPER
anterior transposition and the maintenance of the new anatomical relationships through the creation of an anterior fascial sling ( Figure 1).
Th e closure of the postoperative wound was performed by an intradermal suture, a special attention being given to the atraumatic manipulation of the wound edges, as well as the dissected fascia structures, an attitude that signifi cantly contributes to the improvement of the postoperative aesthetic aspect (Figure 2).
Th e surgery was performed using general anesthesia, the total duration of the procedure being 90 minutes. Th e patient was discharged after 2 days in the process of healing with the recommendation of administering B-complex vitamins for 30 days after the surgical intervention. Th e postoperative monitoring period was 2 years, the patient being reassessed every 4 months.

RESULTS
Following the surgical treatment the local evolution was favorable, the sutures being removed 14 days after the intervention. Th e intensity of the symptomatology diminished progressively, the patient appreciating the complete recovery approximately 45 days after the surgical treatment. Objectively, the result of the surgery was appreciated by performing an electromyography

INTRODUCTION
Compressive neuropathies are frequently identifi ed in advanced stages because of nonspecifi c symptoms which can often create diffi culties in establishing the diagnosis. Nevertheless performing the electromyogram is an essential element that contributes to establishing the diagnosis 1 , representing the primary factor that determines the surgical protocol.
Th e issue of compression neuropathies is a topical subject in the context in which an increasing number of people perform their professional activity in front of computers. Th e repeated movements necessary for the input of data in the operating systems and the fi xed positions maintained for long periods of time are also elements that contribute to the onset of these diseases and at the same time are aggravating factors for the patients with genetic predisposition related to the development of this type of diseases 2 .

MATERIALS AND METHODS
Th e paper presents the case of a 58 years old patient admitted at the 'Bagdasar-Arseni' Emergency Clinical Hospital for the treatment of left cubital tunnel syndrome. Th e patient had paresthesia in the fi ngers IV and V, the symptomatology being installed about 2 years before the admittance to the hospital. Performing the electromyography revealed the electrophysiological aspect compatible with the chronic neuropathy of the left ulnar nerve, predominantly sensitive proximal to the Guyon canal. Th e electrophysiological changes identifi ed were the main factors that established the surgical indication.
Th e therapeutic protocol included the decompression of the ulnar nerve at the level of the elbow, its

DISCUSSION
Th e increased incidence of compressive neuropathies requires particular attention from the medical professionals dedicated to the diagnosis and treatment of these conditions [3][4][5][6] . Unfortunately, the defi ciencies of the screening systems and the relatively unspecifi c symptomatology contribute to the delay in establishing the diagnosis, the patients benefi ting from the surgical treatment in severe forms, frequently after more than 5 years from the appearance of the fi rst signs of the neurological impairment [7][8][9][10] .
Th e essential therapeutic element is the decompression which contributes signifi cantly to the recovery of the aff ected nerve structures [11][12][13] . In order to maintain long-term results, the transposition of nerves into positions that do not expose to risk is an extremely important aspect 14 .
Conducting in-depth studies on the objective analysis related to the results of the surgical treatment is often diffi cult, because of the patients' reluctance to perform an additional investigation (EMG) under the condition of remitted symptomatology. Th erefore, most studies are based on the subjective assessment of the surgical results according to the questionnaires that assess the patients' degree of satisfaction.

CONCLUSIONS
Th e decompression and transposition of the ulnar nerve can be a fi rm solution for the treatment of cubital tunnel syndrome (at the level of the elbow), associated with a signifi cant improvement in the velocity of the nerve impulses (objectifi ed through EMG), as well as with a high degree of patient satisfaction related to the postoperative result.
Regarding the aesthetic result, performing the surgery by atraumatic manipulation of the involved anatomical structures, rigorous hemostasis and performing an intradermal suture are all elements that contribute to minimizing the size of the scar with a major impact on increasing the level of the patient satisfaction.
Compliance with ethics requirements: Th e authors declare no confl ict of interest regarding this article. Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law. Informed consent was obtained from all the patients included in the study.