Mateusz Gładysz FESSH prep

FESSH prep Compressive neuropathies Cubital tunnel syndrome — concomitant proximal lesions and electrodiagnostic localisation

The double-crush hypothesis and ulnar neuropathy at the elbow

Last reviewed v1.0

FESSH-018Compressive neuropathies●●○ intermediate

The double-crush hypothesis (Upton and McComas, 1973) and ulnar neuropathy at the elbow

  1. 1.Wilbourn and Gilliatt's critical reanalysis concluded that the original double-crush dataset did not establish a causal interaction between proximal and distal nerve lesions.

  2. 2.Cervical radiculopathy and cubital tunnel syndrome can coexist, and concomitant proximal and distal lesions of the ulnar fibres should be sought when symptoms exceed those expected from either lesion alone.

  3. 3.Decompression of the ulnar nerve alone is sufficient to relieve symptoms in all patients with concurrent cervical and cubital ulnar-nerve compression.

  4. 4.Needle electromyography of the cervical paraspinal and non-ulnar C8/T1-innervated muscles, combined with focal motor conduction across the elbow, helps distinguish C8 radiculopathy from ulnar neuropathy at the elbow.

  5. 5.When patients have symptomatic compression at two anatomical sites along the ulnar nerve's course, addressing both lesions is likely to produce better functional outcomes than treating one site in isolation.

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Question ID
FESSH-018
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. Wilbourn and Gilliatt's critical reanalysis concluded that the original double-crush dataset did not establish a causal interaction between proximal and distal nerve lesions.

    True

    Wilbourn and Gilliatt re-examined the Upton–McComas data and subsequent supportive studies and concluded that coexisting cervical root and distal entrapment lesions occur, but evidence for a predisposing mechanism is lacking; co-occurrence is not synonymous with summation.

    • Wilbourn AJ, Gilliatt RW. Double-crush syndrome: a critical analysis. Neurology. 1997;49(1):21-29. PMID 9222165
    • Morgan G, Wilbourn AJ. Cervical radiculopathy and coexisting distal entrapment neuropathies: double-crush syndromes?. Neurology. 1998;50(1):78-83. PMID 9443461

  2. 2. Cervical radiculopathy and cubital tunnel syndrome can coexist, and concomitant proximal and distal lesions of the ulnar fibres should be sought when symptoms exceed those expected from either lesion alone.

    True

    Co-occurrence of cervical root pathology and ulnar-nerve compression at the elbow is reported in clinical series; whether the proximal lesion potentiates the distal one remains contested.

    • Wilbourn AJ, Gilliatt RW. Double-crush syndrome: a critical analysis. Neurology. 1997;49(1):21-29. PMID 9222165
    • Kane PM, Daniels AH, Akelman E. Double crush syndrome. J Am Acad Orthop Surg. 2015;23(9):558-562. PMID 26306807

  3. 3. Decompression of the ulnar nerve alone is sufficient to relieve symptoms in all patients with concurrent cervical and cubital ulnar-nerve compression.

    False

    Patients with concurrent cervical radiculopathy and cubital tunnel syndrome may not achieve full symptom relief from ulnar nerve decompression alone, although the optimal management of the proximal lesion is itself controversial.

    • Kane PM, Daniels AH, Akelman E. Double crush syndrome. J Am Acad Orthop Surg. 2015;23(9):558-562. PMID 26306807
    • Wilbourn AJ, Gilliatt RW. Double-crush syndrome: a critical analysis. Neurology. 1997;49(1):21-29. PMID 9222165

  4. 4. Needle electromyography of the cervical paraspinal and non-ulnar C8/T1-innervated muscles, combined with focal motor conduction across the elbow, helps distinguish C8 radiculopathy from ulnar neuropathy at the elbow.

    True

    Localisation of ulnar neuropathy at the elbow rests on focal slowing or conduction block across the elbow segment with normal C8/T1 non-ulnar muscles on EMG, whereas C8 radiculopathy typically shows denervation in non-ulnar C8/T1 muscles and may show paraspinal abnormalities.

    • American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in ulnar neuropathy at the elbow: summary statement. Muscle Nerve. 1999;22(3):408-411. PMID 10086904
    • Landau ME, Campbell WW. Clinical features and electrodiagnosis of ulnar neuropathies. Phys Med Rehabil Clin N Am. 2013;24(1):49-66. PMID 23177030

  5. 5. When patients have symptomatic compression at two anatomical sites along the ulnar nerve's course, addressing both lesions is likely to produce better functional outcomes than treating one site in isolation.

    True

    Series of patients with concurrent ulnar entrapment at the elbow and at Guyon's canal report better outcomes when both sites are decompressed; whether this principle extends to cervical-plus-distal lesions is uncertain.

    • Cohen BH, Gaspar MP, Daniels AH, Akelman E, Kane PM. Multifocal neuropathy: expanding the scope of double crush syndrome. J Hand Surg Am. 2016;41(12):1171-1175. PMID 27751780
    • Dy CJ, Mackinnon SE. Ulnar neuropathy: evaluation and management. Curr Rev Musculoskelet Med. 2016;9(2):178-184. PMID 27080868