Conclusions

In case you don’t want to read through the details, here are my conclusions about my ulnar decompression surgery for cubital tunnel syndrome:

• Surgery has helped me significantly and reduced my pain and symptoms.  But my symptoms have not disappeared completely, and I still have a few problems while using the computer.  However, at this point I feel surgery was definitely worth the pain and downtime.
   
• The surgery and recovery have been somewhat painful, but not much more painful than what I experienced on my bad days before surgery.
   
• Normal everyday tasks such as brushing my teeth and inserting contact lenses were very challenging after surgery with only the use of my weaker hand.  I was glad that I had practiced everyday activities using only my left hand for the few weeks before surgery.
   
• I returned to work five days after surgery, used my arm to type lightly two weeks after surgery, was typing at near-normal speed after four weeks, and at five weeks, I stopped taking pain medication for the first time in years.
   
• My recovery was a roller coaster experience, with 2-4 good days, followed by a bad day.  This pattern continued throughout my recovery and still continues after seven weeks.  I quickly learned that I had to be patient.
   
• It’s very important to get a doctor and surgery center that specializes in arm & nerve surgery and has extensive experience treating cubital tunnel syndrome.  I was fortunate to live near an excellent hand surgery center.

Week Before - Affairs in order

I got my affairs in order including my will and insurance.  Cubital tunnel surgery isn’t dangerous, but it involves general anaesthetic, and there is always a slight risk of complications when you are put to sleep.  I also finished any big jobs around the house that required two good arms: replaced a battery in the tractor, cut the lawn, chainsawed a tree, etc.

Day Before - Final preparations

I finished some final projects at work and around the house.  I paid the bills, called my family, and prepared for a few days off work.  Since I’m not allowed any food or drink after midnight, I had a second light supper around 11pm and drank a big glass of water as the clock struck midnight.

Surgery Day

I woke up thirsty but not nervous or anxious.  I stayed focused on the good chance that the surgery would reduce my pain.  I showered and shaved, then dressed in loose-fitting clothing: short-sleeved button-up-front shirt, sweat pants, tennis shoes, and no contact lenses. 

My wife drove me to the surgery center.  A nurse called me back before I even had a chance to open a magazine.  She showed me to a small dressing room, handed me a gown and told me to strip, put on the gown, and leave it untied in the back.  I brought a book to read in case I had to wait, but the nurse immediately took it and all my clothes and possessions and secured them in a locker.  She led me to the surgery room, which was fairly large and bright and had three operating areas separated by curtains.  I laid down on the operating table, and the nurse covered me with a heated blanket, which was nice in the cool room.  She also wrapped stimulator pads around my legs to promote blood circulation during surgery.

The nurse asked me a few questions, confirming who I was and what surgery I was to receive.  She used a pen to mark my right elbow where it was to be cut.  This gave me a certain level of relief, as I certainly didn’t want to wake up with a kidney removed or sex change operation!  Another nurse gave me a pill (can’t remember what it was for) and my first sip of water in 10 hours.  She also started me on a saline IV, inserting the needle in the back of my hand, which not pleasant.  The surgeon stopped by and gave me a few reassuring words.  After a few minutes, the anesthetist stopped by and told me it was time to go to sleep.  She hooked the knock-out juice to my IV and warned me that it would burn a little, which it did.  Within minutes I fell softly asleep…

CUT, SNIP, STITCH

When I awoke, the nurse was standing at the end of my bed, and she said, "Welcome back, Timm, please move your fingers for me."  All five digits working!  My arm was wrapped snugly in an ace bandage.  My elbow hurt a little, but the IV in the back of my other hand actually hurt more.  They removed the IV, eased me off the operating table, and handed me my clothes.  My wife was waiting for me when I emerged from the dressing room.  They sat me in a chair, went over post-op instructions with me (and made sure my wife understood them since my brain was still fuzzy), and then gave me a soda.

My wife drove me home and took care of me that day.  It’s important to have someone with you that entire first day.  She prepared my meals, cut my food, and attended to my needs.  I spent most of the day sleeping and relaxing.

Day After - Worst day of pain

I woke up in pain, and in spite of a liberal supply of prescribed codeine, I spent most of the day in significant pain.  Though honestly the pain was similar to what I had experienced on my bad days for the past few years, so I was somewhat used to it.  I spent most of the day resting, reading and watching TV. 

My wife had to work, so I was on my own, which was a bit of a struggle.  Not only was I down to one arm, but it was my weak arm.  Fortunately, during the past few weeks I had spent some time practicing my daily routine left-handed.  Nonetheless, many of the activities I take for granted were quite challenging with only my one weaker hand.  These include getting dressed, preparing meals, combing my hair, brushing and flossing my teeth, inserting and removing my contact lenses, shaving, bathing, itching, blowing my nose and wiping my butt.  Sorry to be explicit, but you don’t normally think about these things until it’s too late.  By the end of the day my left arm was exhausted, and so was I.

Day 2 - Pain is less

The second day after surgery started with a little less pain.  I took my first post-op shower, which required me to wrap my entire arm in a garbage bag and hold it above my head so it wouldn’t get wet.  This is easier than it sounds.  So was shampooing my hair, washing up with soap, and cleaning those hard-to-reach body parts, all a little more difficult with only one hand.  But mission accomplished; it’s not like I had anything else to do!  I spent most of the day resting.

Day 5 - First day back at work

I work at home, so fortunately I didn’t have to worry about getting dressed or driving to work on this Monday morning.  My arm was too sore to use, so I rested it on a pillow for most of the day, while using voice recognition and my left hand to work the computer.

Day 7 - First attempt to use my arm

I tried to use my right arm to type and move the mouse a few times.  Given that my arm was wrapped snugly in a bandage and couldn’t bend much, it was less touch typing and more of the Frankenstein stiff-arm hunt-and-peck method.  I didn’t type much because it still hurt too much.

Day 10 - Actually using my arm

It was my wife who noticed and pointed out to me that I was starting to use my sore arm a lot more.  I was opening and closing doors, clicking the TV remote, and even made my own sandwich.  But any activity that required me to bend my arm was still impossible, including flossing my teeth and inserting contact lenses.  I was still experiencing moderate pain at times, but today was my last day on Codeine, and I ended up with a few extra pills.

Day 12 - Typing with pain

Back at work, I attempted to start touch typing.  I could go for brief stretches of touch typing without pain — the first time in years.  But usually after a few minutes it would become too painful, and I had to resort to hunt-and-peck again.

Day 13 - Follow-up visit with surgeon

Today was the pre-scheduled follow-up visit with my surgeon.  The nurse removed my bandage and informed me that I had dissolvable stitches, so there were no stitches to remove.  Nice!  The surgeon inspected my incision and said it looked good.  He checked my arm movement and tested my hand strength.  He told me that I should begin using my arm as much as possible, and that I should work through the pain but of course stop if it becomes too severe.  He said I should expect 10% improvement per week with complete recovery in 2-3 months.

Day 14 - Typing without the bandage

This was my first day of typing without the ace bandage, and it really made a difference.  Now that I was able to hold my arm in the proper position and angle, I could type for longer stretches without pain.  It was also terrific to take a shower without wearing a garbage bag on my arm.  However, without the padding and protection from the ace bandage, my elbow was exposed to every little bump and scrape, and I found myself saying "ouch" many times throughout the day.

Day 16 - Another setback

Maybe I was typing too much that day, but I experienced a lot of pain and a surprising number of nerve shocks along my injured arm.  I could literally see my ulnar nerve pulsing at both my shoulder and forearm.  It was a freaky experience, but I was starting to get used to the up-and-down pattern of my recovery, so I stopped typing and hoped for a better day tomorrow.

Day 17 - A better day

And that’s what I got, a better day.  It helped that it was Saturday, so no typing, and hence, much less pain.

Day 19 - Still seeing improvement

I was able to touch type more with only limited pain.  I’m starting to regain some grip strength.

Day 21 - Good for most of the day, then bad

After about 7 hours of work my elbow was aching and sending electric shocks down my arm.  I had to stop working.

Day 26 - First day in years without pain medication

Today was my first work day in over three years that I did not take any pain medication, even an Advil. 

Day 27 - Another bad day

The pattern continues: I have 3-4 good days, followed by a bad day.  I had some pain and a few nerve shocks today, but I’ve come to accept these small setbacks as part of the recovery process.  My elbow was throbbing a bit, and I had to stop work late in the afternoon.

Day 28 - Glad I had surgery

I didn’t feel completely “fixed,” as I still had some pain, and the wound itself was still sensitive (my dog hit it and briefly sent me over the edge).  But I was definitely better than before surgery, and at many times I barely noticed any pain, which hasn’t happened in years.  The best part was that annoying “nerve irritation” was mostly gone.  Like when you hit your funny bone… not only do you feel pain, but also an irritating, tingling sensation.  My doctor said I would recover fully in a few months, so I still had some time to go.  But at this point, I was very glad I had the surgery.

Week 5 - Still improving

I started to skip my pain medication on a regular basis!  I was down to a couple Voltaren (a prescription NSAID) each day.  I still felt some pain, especially when using the computer, but nowhere near what it used to be.  I could touch type again at near-normal speed, though I still required a split keyboard and special mouse.

Week 6 - No more pain medication!

I went the entire week without pain medication.  I still felt a low-grade elbow pain, especially when using a computer.  But it wasn’t enough for me to take any pain pills.  It’s also possible that I’ve built up a higher pain threshold after three years of moderate to severe pain.

Week 7 - Today - Much better but not "fixed" yet

The problem with eliminating one pain is then you can feel any other pain that you may have.  Whether it’s arthritis or simply 25+ years of excessive computer use, I now feel slight pain in my fingers, wrist and both elbows.  But at least it’s not that annoying nerve pain from my cubital tunnel syndrome, and nowhere near the intensity I had before surgery.

I still cannot use a regular mouse for more than a few minutes without pain and shocks in my operated elbow.  I must still use a split keyboard, hold my arm as close to handshake position as possible, and continue to use good ergonomics and assistive technologies to reduce my repetitive motion while using the computer.  My operated arm still suffers from reduced strength and loss of dexterity.

But I’m no longer in severe pain.  My arm doesn’t throb and pulse at night and consume my thoughts while watching TV.  I don’t constantly think about my sore elbow.  I no longer get into a pain-driven foul mood.

So after seven weeks, count me as one of those patients whose condition was "significantly improved but not fixed" by cubital tunnel surgery.  Hopefully I will continue to improve over time.  My case seems to mirror the anecdotal evidence on the Web: surgery helps but does not completely cure cure cubital tunnel syndrome, especially if you return to the activities that caused you pain in the first place.

Special Thanks

Surgery is often a painful and stressful experience.  But several people helped me get through my cubital tunnel treatment, surgery and recovery.  First I’d like to thank my wife Theresa for taking care of me and picking up my slack while I was down.  And for her terrific health insurance, which reduced a four-figure bill down to about the cost of a night out at the movies.  I’d also like to thank my mother, family and friends for their wonderful support and prayers.  And finally I’d like thank my doctor, Dr. Thomas Kiefhaber from Cincinnati Hand Surgery Specialists, for helping me for years with conservative treatment, and for his excellent and professional job performing my ulnar decompression surgery.

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Given the state of medicine these days, with busy doctors, bureaucratic HMOs and complex injuries, it’s important that you affect your own medical care.  You should conduct your own research about CuTS on the Web, be open and honest and explicit with the doctor about your symptoms and concerns, and be sure to ask lots of questions. 

Inspired by posts in our Cubital Tunnel Forums (here and here), following are 10 questions you should ask your doctor about your cubital tunnel syndrome:

1. What is your experience with CuTS?  How many surgeries have you performed and what is your success rate?
   CuTS is less common than carpal tunnel syndrome, and therefore many doctors lack experience with CuTS.  However, CuTS is a serious affliction that requires a specialist who has significant experience and success treating CuTS and who is familiar with the latest CuTS studies and surgery techniques. 
    
2. Which test(s) do you recommend?
   There are many tests for CuTS.  Studies show that MCV tests (motor nerve conduction velocity) that indicate "decreased velocity" across the ulnar nerve are quite effective in diagnosing cubital tunnel syndrome.  Other tests include 2-point discrimination (testing whether you can distinguish between one or two pin pricks on your finger), ability to cross index and middle fingers, grip and pinch strength, and EMG (electromyograph) tests.
     
3. How severe is my condition?
   There are numerous medical scales to describe the severity of CuTS.  My favorite scale is also the simplest: mild, moderate or severe.  With severe CuTS, you can no longer do your job, your fingers may bend in toward your palm, and you may lose all sensation in your ring and little fingers.
     
4. Where in my arm is the problem occurring?  Elbow, wrist, and/or shoulder?
   CuTS pain can appear in both the elbow and ring & little fingers.  The problem is caused by a pinching of the ulnar nerve, which starts in your neck, runs along your shoulder, around your elbow, through your wrist and into your hand.  Pinching or compression of that nerve anywhere along its path can result in pain and discomfort.  It’s important your doctor knows where the problem originates in order to treat you properly.
    
5. What is the cause of my CuTS?
   There are many causes of cubital tunnel syndrome: direct injury, sports, sleeping on bent elbows, computer use, repetitive motion, cysts and bone spurs.  Be sure to share with your doctor the activities you do that cause you pain.  Remember that even with treatment or surgery, your CuTS may not go away completely if you continue the activities that caused your CuTS in the first place.
     
6. Which treatment(s) do you recommend?  Physical therapy, night splints, medication, surgery?
   Conservative treatment is recommended first for mild to moderate CuTS.  This include splints to keep your elbow straight while sleeping, a change in your work or play habits that caused your CuTS, Advil or prescription NSAIDs to help relieve pain, and special exercises or physical therapy to help relieve pressure on your ulnar nerve.  Patients with severe CuTS typically require surgery immediately.
    
7. If I do not see improvement from my treatment, what are the next steps?
   Based on anecdotal evidence on the Web, it appears that conservative treatment works only about half the time, and the other half eventually requires surgery.  This is true especially for CuTS caused by long-term repetitive motion at work or in sports.  Be sure to give conservative treatment time to work, but don’t wait to long or allow your symptoms to become severe.  The more severe your symptoms before surgery, the less likely that surgery will be completely successful.
    
8. If I require surgery, which surgical method do you recommend?
   There are three main types of cubital tunnel surgery: decompression, transposition, and medial epicondylectomy.  The success rate is roughly the same for all three types: about 70% of patients see improvement, 20% see little or no improvement, and 10% may get worse.  But there are big differences in the severity of the procedures.  With decompression, you can typically return to work in about a week and see full recovery in two months.  With transposition, your arm is immobilized for 2-4 weeks, and full recovery can take 6 months or more.  Many doctors are unaware of recent studies that show decompression is the preferred method for mild-to-moderate CuTS.  If your symptoms are not severe but your doctor is recommending transposition, be sure to question why.
     
9. What are the pros and cons of having surgery?
   Although not life threatening, CuTS can certainly have a significant negative impact on your job and overall well-being.  But CuTS surgery is no walk in the park either.  Although CuTS surgery helps many people, it is not 100% effective, and as with any surgery that puts you to sleep with a general anestetic, CuTS surgery carries some risks.
    
10. When can I return to work and play?
    As mentioned in #8, the type of CuTS surgery you have has a significant effect on your downtime.  Be sure you understand how long your arm will be immobilized, when you can start using your arm for light-duty work, and when you can expect to return to work or play at full force.  Note that complete recovery from CuTS surgery may take as long as 6 months.
     

Remember that it’s your responsibility to ensure that you have an experienced, attentive doctor who has all the information he or she needs to treat your cubital tunnel syndrome.  Good luck, and if you have any questions, you are welcome to ask them in our forums.

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Note: In spite of trends found in these studies, each case of cubital tunnel syndrome is unique. Do not rely solely on this website, any other website, or your family doctor. Please see a hand doctor or surgeon, and get a second opinion if you have any doubts.

Following are some unofficial conclusions from cubital tunnel syndrome studies and patient experiences:

• There are many causes of cubital tunnel syndrome: injury, cysts, sleeping on bent elbow, sports, computer use, and other repetitive motion activities.
• MCV tests that indicate “decreased velocity” across the ulnar nerve are useful to diagnose cubital tunnel syndrome.
• If you cannot solve your cubital tunnel syndrome with conservative treatment, you should seek surgery.
• But don’t wait too long to seek surgery.  The worse your condition before surgery, the less chance for a complete recovery.
• The success rate is roughly the same for the three major types of cubital tunnel surgery — decompression, transposition, and medial epicondylectomy.  About 70% of patients see improvement, 20% see little or no improvement, and 10% may get worse.
• Ulnar nerve decompression is the preferred method of surgery for patients with mild to moderate symptoms.  It is typically not effective for subsequent surgeries on the same arm.
• Anterior subcutaneous transposition is the preferred method of surgery for patients with severe symptoms or for subsequent surgeries on the same arm.
• Recovery time depends on the surgical method.  Decompression patients can begin light use of their arm in 1-2 weeks, heavy use in 2-4 weeks.  Transposition patients must immobilize their arm for 2-4 weeks, then perform physical therapy for another 1-3 months.
• Most patients recover fully within six months, but complete recovery may take years.
• Cubital tunnel symptoms and pain may return over time, especially if the patient resumes the activities that caused the problem in the first place.

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Following are typical guidelines for patients undergoing cubital tunnel surgery such as anterior subcutaneous transposition, ulnar decompression, and medial epicondylectomy.  These guidelines are for information only and may not apply to your specific case.  If your surgeon or hospital has not provided you with specific surgery-day guidelines, please ask for them.

• No food or drink after midnight the night before surgery
• You may brush your teeth and rinse with mouthwash, but do not swallow any liquids
• Do not use breath mints or chewing gum
• Take a shower or bath the night before or morning of your surgery
• Do not wear contact lenses; if you wear glasses, bring a case
• Leave all valuables at home
• No jewelry on the arm that will have surgery
• Wear a loose-fitting, button-up front shirt that will fit over your cast or brace
• Avoid tight pants or other clothing that will be difficult to put on after surgery
• If cold outside, bring a large coat that you can put over your back
• Bring a pillow in the car to support your arm on the ride home
• Bring your insurance card and credit card
• Bring a copy of your pre-operation examination form
• Someone must bring you to the hospital, remain there during your surgery, and drive you home afterward
• Relax and remember that cubital tunnel surgery should bring you relief

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