Cirugía de la neuropatía cubital por atrapamiento a nivel de codocomparación de la cirugía endoscópica vs cirugía a cielo abierto. Estudio clínico prospectivo randomizado

Résumé

Ulnar nerve entrapment at the elbow is, after carpal tunnel syndrome, the second compressive neuropathy in frequency. The surgical options that have been used for its treatment are simple or in situ decompression, nerve transposition (subcutaneous, submuscular and intramuscular) and medial epicondylectomy. Optimal surgical treatment continues to be a controversial issue, with no consensus regarding the best technique for this common pathology. Recently, a series of randomized and meta-analysis studies have concluded that in situ decompression of the ulnar nerve for ulnar nerve entrapment at the elbow presents clinical results comparable to the rest of the surgical techniques used for this purpose (subcutaneous, submuscular and intramuscular nerve transpositions), although with a lower rate of complications. Taken in light of the equivalent efficacy between simple in situ decompression and nerve transposition techniques, it seems prudent to choose the procedure with the lowest morbidity, and that is why in situ decompression of the ulnar nerve is currently considered the "gold standard" technique. The tendency to perform less extensive surgical exposures to reduce morbidity is accompanied by a tendency toward smaller incisions, appearing for this purpose minimally invasive endoscopic techniques more recently. It is well recognized that endoscopic techniques applied to carpal tunnel surgery have given very good long-term results with a very low complication rate. In contrast, published results about endoscopic decompression for ulnar nerve entrapment at the epitrochlear-olecranon groove are insufficient, case series are small, and studies do not include long-term follow-up results. This matter is probably so because only recently enough evidence has been gathered about the fact that simple decompression of the ulnar nerve offers equal or even better results than the anterior subcutaneous, intramuscular or submuscular transposition of the nerve. Even more important, the paucity of comparative analysis between endoscopic decompression and the classical open technique makes it difficult to draw conclusions about which technique is more appropriate for the decompression of the ulnar nerve at the elbow. Nowadays, based on evidence-based medicine, it has not been possible to elucidate which technique is better and which is safer and more appropriate depending on the particular cases. This thesis work, consisting of a prospective randomized study comparing two groups of patients with ulnar neuropathy at the elbow which are operated by open and endoscopic surgery respectively, tries to study whether endoscopic surgery for the treatment of ulnar nerve entrapment at the elbow offers more favorable results than open in situ decompression, which is nowadays considered the standard surgery and recommended for most of cases of ulnar nerve entrapment at the elbow. The analysis of the results of the study has not been able to demonstrate that endoscopic surgery offers better clinical results than open surgery for the treatment of ulnar entrapment neuropathy at the elbow. This fact agrees with the results of the other two prospective randomized studies which have appeared during the thesis work accomplishment. With both techniques significant improvements were obtained in motor and sensory conduction of the ulnar nerve at the level of the elbow with respect to the preoperative study, without observing statistically significant differences between the results of both groups. Endoscopic surgery was shown to be superior to open surgery in terms of early labor reincorporation, and in terms of less pain at the elbow six and twelve months after surgery. Although a statistically significant difference has not been demonstrated between the rate of complications of both groups, the number of complications was higher in the opensurgery group, especially related to hypesthesia and hypersensitivity at the scar. The study carried out in this thesis work shows favorable clinical results with minimally invasive endoscopic surgery, beyond it was not possible to find statistically significant differences compared to the classical open surgery technique. It is recommended, therefore, the continuation of this type of studies to increase the evidence of the results of endoscopic surgery and if endoscopic surgery offers true advantages over the classical open technique, which is currently the "gold standard" technique.