RESEARCH—HUMAN—CLINICAL TRIALS

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Postsurgical Electrical Stimulation Enhances
Recovery Following Surgery for Severe Cubital
Tunnel Syndrome: A Double-Blind Randomized
Controlled Trial
Hollie A. Power, MD, FRCSC∗
Michael J. Morhart, MD, MSc,
FRCSC∗
Jaret L. Olson, MD, FRCSC∗
K. Ming Chan, MD, FRCPC‡
∗
Division of Plastic Surgery, Department
of Surgery, Faculty of Medicine and Den-
tistry, University of Alberta, Edmonton,
Canada; ‡ Division of Physical Medicine
and Rehabilitation, Faculty of Medicine
and Dentistry, University of Alberta,
Edmonton, Canada
A preliminary report of this work was
presented at the American Society for
Peripheral Nerve Annual Meeting in
Scottsdale, Arizona, on January 16, 2016,
and at the Canadian Society of Plastic
Surgeons Annual Meeting in Ottawa,
Canada, on June 17, 2016.
Correspondence:
K. Ming Chan, MD, PRCPC,
Division of Physical Medicine and
Rehabilitation,
Faculty of Medicine and Dentistry,
5005 Katz Group Centre,
University of Alberta,
Edmonton, Canada T6G 2E1.
Email: ming.chan@ualberta.ca
BACKGROUND: Patients with severe cubital tunnel syndrome often have poor functional
recovery with conventional surgical treatment. Postsurgical electrical stimulation (PES) has
been shown to enhance axonal regeneration in animal and human studies.
OBJECTIVE: To determine if PES following surgery for severe cubital tunnel syndrome
would result in better outcomes compared to surgery alone.
METHODS: Patients with severe cubital tunnel syndrome in this randomized, double-
blind, placebo-controlled trial were randomized in a 1:2 ratio to the control or stimulation
groups. Control patients received cubital tunnel surgery and sham stimulation, whereas
patients in the stimulation group received 1-h of 20 Hz PES following surgery. Patients were
assessed by a blinded evaluator annually for 3 yr. The primary outcome was motor unit
number estimation (MUNE) and secondary outcomes were grip and key pinch strength
and McGowan grade and compound muscle action potential.
RESULTS: A total of 31 patients were enrolled: 11 received surgery alone and 20 received
surgery and PES. Three years following surgery, MUNE was significantly higher in the PES
group (176 ± 23, mean + SE) compared to controls (88 ± 11, P < .05). The mean gain
in key pinch strength in the PES group was almost 3 times greater than in the controls
(P < .05). Similarly, other functional and physiological outcomes showed significantly
greater improvements in the PES group.
CONCLUSION: PES enhanced muscle reinnervation and functional recovery following
surgery for severe cubital tunnel syndrome. It may be a clinically useful adjunct to surgery
for severe ulnar neuropathy, in which functional recovery with conventional treatment is
often suboptimal.
KEY WORDS: Cubital tunnel syndrome, Electrical stimulation, Functional outcomes, Nerve regeneration,
Randomized controlled trial, Surgery, Peripheral nerve regeneration
Neurosurgery 0:1–9, 2019 DOI:10.1093/neuros/nyz322 www.neurosurgery-online.com

Received, December 5, 2018.

Accepted, May 30, 2019.

C
ubital tunnel syndrome (CuTS) is the
Copyright 
C 2019 by the second most common compression
Congress of Neurological Surgeons neuropathy with an annual incidence
rate of 25 cases per 100 000.1 Severe cases can
ABBREVIATIONS: CMAP, compound muscle action
potential; CuTS, Cubital tunnel syndrome; MCID,
minimum clinically importance difference; MUNE,
motor unit number estimation; PES, Postsurgical
electrical stimulation; S-MUAP, surface-detected
motor unit action potential
Neurosurgery Speaks! Audio abstracts available for this
article at www.neurosurgery- online.com.
have a devastating impact on hand function
with profound weakness of the intrinsic muscles,
pain, and paresthesias. In patients with severe
axonal loss and symptoms that do not respond
to conservative therapy, surgical intervention
is advocated.2 However, despite appropriate
surgical management, suboptimal recovery of
hand function remains in a majority of patients
with severe CuTS.3
Although injured peripheral nerves have the
capacity to regenerate, the rate of nerve regener-
ation is slow and functional recovery following
proximal nerve injuries is often incomplete.4,5
This may be attributed to progressive decline

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POWER ET AL
in the distal nerve’s regenerative milieu to support growth.6 Brief
postsurgical electrical stimulation (PES) is a novel therapy that
has been shown to enhance peripheral nerve regeneration. In a
rat model of femoral nerve transection, 1 h of PES increased
regeneration-associated gene expression and accelerated both
motor and sensory axonal outgrowth.7-10 Similar effects were
seen in a rat model of demyelinating neuropathy.11 PES was also
efficacious in humans following carpal tunnel release, repair of
digital nerve laceration, and in reducing shoulder dysfunction
after oncologic neck dissection.12-14 Although motor reinner-
vation was significantly better in patients who received carpal
tunnel release and PES, we did not detect a significant functional
improvement compared to surgery alone. This is likely due to the
short regeneration distance and that fine dexterity can be compen-
sated for by the ulnar-innervated muscles. In contrast, the distance
to the intrinsic muscles is much longer in patients with CuTS.
Because the ulnar nerve plays a pivotal role in hand function,
successful reinnervation of the intrinsic muscles is critical.
Therefore, the goal of this study was to test the hypothesis that
PES following cubital tunnel surgery in patients with severe ulnar
neuropathy would result in improved intrinsic muscle reinner-
vation and functional recovery compared to surgery alone.
METHODS
This randomized, double-blind, placebo-controlled clinical trial was
approved by the Human Research Ethics Board at the University of
Alberta. All patients gave written informed consent. This trial was regis-
tered with the International Standard Randomized Controlled Trial
registry (trial no. 52307835).
Participants
Patients with severe CuTS were recruited from EMG laboratories
and plastic surgery clinics at the University of Alberta between 2007
and 2016. Patients who met the following inclusion criteria were
eligible: 1) age >18 yr, 2) signs and symptoms of severe CuTS (ie,
McGowan-Goldberg grade 3),15,16 3) needle EMG examination showing
evidence of chronic motor axonal loss and reduced recruitment in
the ulnar-innervated intrinsic hand muscles, and 4) electrophysio-
logic evidence of severe motor axonal loss with motor unit number
estimation (MUNE) greater than 2 standard deviations below the
normative mean.17 Although these patients with severe axonal loss also
had numbness and tingling affecting medial part of the hand, those
sensory symptoms were less troublesome and functionally less debili-
tating compared to hand weakness and digit deformity from marked
muscle wasting. Patients were excluded if they had concurrent nerve
injury, prior surgery for CuTS or coexisting neurologic conditions. After
inclusion, patients were randomized in a 1:2 ratio into the control or PES
groups using a computerized random number generator. The decision
for unequal allocation was made to maximize the recruitment rate and
to increase statistical power.18 Patients and evaluators were blinded to
treatment allocation.
Preoperative Assessment
Because the ulnar nerve plays a pivotal role in hand strength, we
focused on evaluating motor innervation. Power grip requires contraction
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of multiple flexor muscles in the forearm and hand, of which the
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ulnar-innervated muscles are a major contributor. Key pinch relies
primarily on the strength of the first dorsal interosseous and adductor
pollicis muscles. It is, therefore, a highly sensitive measure of intrinsic
hand muscle strength. Preoperative assessment included motor nerve
conduction study and MUNE of the hypothenar muscles. For functional
evaluation, we assessed grip strength using a Jamar dynamometer
(Sammons Preston Rolyan, Bolingbrook, Illinois) and key pinch strength
using a pinch gauge (B&L Engineering, Santa Ana, California). Because
inadvertent activation of the flexor pollicis longus muscle, innervated by
the anterior interosseous nerve, could have a major confounding impact
on the results, subjects were strictly instructed to keep the thumb straight
throughout the test.
Nerve Conduction Studies
Motor nerve conduction studies were performed on a Viking
Select EMG machine (Nicolet Biomedical, Minneapolis, Minnesota).
Maximum compound muscle action potential (CMAP) from the
hypothenar muscles was elicited by stimulating the ulnar nerve at the
wrist, below elbow, and above elbow sites. This was performed in accor-
dance with the American Association of Neuromuscular and Electrodi-
agnostic Medicine19 guidelines for ulnar neuropathy.
Motor Unit Number Estimation
MUNE is a research tool widely used to quantify motor unit loss and
track changes over time.20,21 It is a more sensitive measure of axonal
loss than motor nerve conduction study because the results are not
confounded by sprouting of terminal branches of the motor axons or
expansion of motor unit territory.17 It also allows direct comparisons
with data from animal studies where this is commonly measured.22-24
We chose to record from the hypothenar muscles, because the surface-
detected motor unit action potentials (S-MUAPs) are unlikely to be
contaminated by the median nerve innervated muscles located on the
lateral palm.25 In contrast, S-MUAPs recorded from the first dorsal
interosseous muscle are susceptible to contamination from the median
innervated thenar and lumbrical muscles that are in close proximity. This
would render the results highly unreliable.25
MUNE was performed on all patients using the multiple point
stimulation technique, one of the most widely used methods with
good reliability on an Advantage EMG machine (Neurosoft, Sterling,
Virginia).17,26 Briefly, disposable electrodes were placed over the
hypothenar muscle group to detect the maximal CMAP and S-MUAPs.
A ground electrode was placed on the dorsum of the hand and the
bandpass filter was set at 5 to 2000 Hz. The maximum CMAP was
evoked by stimulating the ulnar nerve at the wrist. S-MUAPs with the
lowest stimulus thresholds were elicited at multiple sites along the course
of the nerve that is accessible to surface stimulation. The peak-to-peak
amplitudes of 13 to 25 S-MUAPs were averaged using the “datapoint-by-
datapoint” averaging technique. The MUNE was calculated by dividing
the peak-to-peak amplitude of the maximum CMAP by the peak-to-peak
amplitude of the average S-MUAP.
Operative Technique and Post-Op Rehabilitation
All surgeries were performed under general anesthesia by one of 2
peripheral nerve surgeons (JLO or MJM). Under tourniquet-control,
a 10-cm incision was made over the ulnar nerve at the elbow. The
medial antebrachial cutaneous nerve was identified and protected. The
ulnar nerve was released at all common sites of compression around the
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 PES ENHANCES RECOVERY AFTER CUBITAL TUNNEL SURGERY

elbow. An in situ decompression was performed in the majority of cases.

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However, if the ulnar nerve subluxated with elbow flexion, a submus-
cular transposition was performed with myofascial flaps elevated from the
flexor-pronator mass. Although the study spanned over 10 yr, the same
surgeons performed all surgeries using the same techniques throughout
this time period. Local anesthesia was avoided because sodium-channel
blockade was previously shown to eliminate the effects of PES by
blocking propagation of action potentials to the neuronal cell body.7,10
Following surgery, all patients underwent identical rehabilitation therapy,
supervised by experienced therapists at the hand clinic.

Stimulation Protocol
Prior to skin closure, 2 sterile Teflon-coated stainless-steel electrodes
were placed transcutaneously immediately adjacent to the ulnar nerve
proximal to the site of compression (Figure 1A). These were secured
to the surgical dressing using tape (Figure 1B). In the postanesthesia
recovery unit, a research assistant who was not involved in outcome
assessments administered PES using a Grass SD9 stimulator (Grass
Technologies, Warwick, Rhode Island) (Figure 1C). The proximal wire
electrode was connected to the cathode and the distal to the anode.
Patients in the stimulation group received 1 h of PES as a continuous
20-Hz train of balanced biphasic pulses. The stimulation intensity was
set at the tolerance limit (<30 V, 0.1 ms pulse duration). Patients in
the control group received 5 s of similar-intensity PES before the stimu-
lator was turned off for the remainder of the hour. Because none of the
patients had previously received PES, it was difficult for them to guess
which group they had been randomized to. This was further aided by
sensory accommodation following repetitive stimulation and that the
patients were still groggy under the influence of general anesthetics and
opioid analgesics in the recovery unit. This method of blinding was used
successfully in a prior study.13 The stimulation electrodes were removed
and discarded at the end of the stimulation session.

Postoperative Outcome Assessment

In addition to routine postoperative follow-up, patients were assessed
annually for 3 yr. At each visit, motor nerve conduction study, MUNE,
grip, and key pinch strength were assessed by a blinded evaluator.
McGowan-Goldberg grade was assigned at the 3-yr follow-up visit.

Statistical Analysis
We used intention-to-treat analysis and for missing values, the last
available value was carried forward. Unless otherwise stated, all results
are reported as mean + standard error. Student t test and Fisher exact
test were used to compare differences in demographics. The Shapiro-
Wilk test of normality demonstrated that MUNE and CMAP ampli-
tudes were not normally distributed (P < .05), and therefore, nonpara-
metric statistics were used. Preoperative means for MUNE and CMAP
amplitudes between groups were compared using the Mann Whitney U-
test. Kruskal-Wallis rank test was done to evaluate postoperative changes
within each group. When a significant change was found, Wilcoxon
signed ranks test was used to determine which time point was signif-
icantly different from baseline and to compare the average between
groups at each postoperative time point. Grip and key pinch strength
were normally distributed (Shapiro-Wilk, P > .05) with homogenous
variance, and were therefore compared using Student t tests. Statistical
significance was set at P < .05. Stata 12 (StataCorp, College Station,
Texas) was used for analysis.
FIGURE 1. Experimental set up for brief PES. A, Electrode placement,
intraoperative view of the right arm. The black asterisk (∗ ) marks the
decompressed ulnar nerve, and the black arrows mark the stimulating
electrode wires that were lay immediately adjacent to the ulnar nerve
proximal to the site of compression. B, Electrode placement for stimulation
of the right arm in the postanesthesia recovery room. The proximal wire
electrode was connected to cathode (black), whereas the distal electrode
was connected to anode (red). C, The stimulator used (Grass SD9).
Sample Size Estimation
Because the main goal of this study was to evaluate the impact of
PES on muscle reinnervation, MUNE was used as the primary outcome
measure, as in published animal and human studies.7,12 Assuming a

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FIGURE 2. Clinical trial flow diagram.

difference in treatment effect of 26%, standard deviation of 30%, with

α = 0.05 and β = 0.20, a sufficiently powered study would require 20 TABLE 1. Baseline Patient Characteristics
participants.
Control Stimulation
group group P value

RESULTS Number of patients 11 20 –

Gender 8 males 15 males P = .90†
Thirty-six patients were assessed for study eligibility. A total Age, years ± SD 59 ± 12 54 ± 12 P = .35∧
of 5 were excluded: 2 patients had previous cubital tunnel Dominant hand 9 right (82%) 16 right (80%) P = .72†
surgery and 3 patients had coexisting neurologic conditions. Dominant limb affected 63% 48% P = .56†
Thirty-one patients were randomized into the control and stimu- Duration of symptoms, 419 ± 622 481 ± 380 P = .55∗
lation groups in a 1:2 ratio. Two patients in each group were days ± SD
Surgery type:
deceased. As per the intention-to-treat protocol, results at their
In Situ decompression 8 15 P = .89†
last follow-up were used for analysis. A total of 20 patients in Submuscular transposition 3 5
the stimulation group and 11 patients in the control group were
included in the final analysis (Figure 2). Each patient was followed
†
Fisher’s exact test; ∧ Paired t test; ∗ Mann-Whitney U test.

on average 3.1 ± 0.2 yr. Patient demographics are shown in

Table 1. The mean duration of symptoms prior to surgery was
similar between groups (control: 419 ± 622 d; stimulation:
481 ± 380 d; P = .55). There were no significant differences
in preoperative MUNEs, CMAP amplitudes, grip, or key pinch
strength (P > .10; Table 2).
Motor Unit Number Estimation
MUNE was used to establish the degree of denervation of
the hypothenar muscles preoperatively and to quantify reinner-
vation following surgery (Figure 3A). Preoperative MUNE was

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 PES ENHANCES RECOVERY AFTER CUBITAL TUNNEL SURGERY

Motor Nerve Conduction Studies

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TABLE 2. Preoperative Values
At baseline, there was no significant difference in amplitudes
Control Stimulation of the maximum CAMP in the hypothenar muscles between the
group group P value stimulation and control groups (1.68 ± 0.41 vs 2.55 ± 0.53
mV; P = .67). In the stimulation group, the CMAP amplitudes
MUNE, number of 66 ± 13 34 ± 8 P = .10# showed gradual improvement that reached significance by 2 yr.
hypothenar motor units
At 3 yr, CMAP amplitudes were 4.46 ± 0.37 mV (P < .001).
CMAP amplitude, mV 2.55 ± 0.53 1.68 ± 0.41 P = .67#
Grip strength, kg 37.6 ± 4.3 34.1 ± 3.2 P = .91∧ In contrast, although there was a trend of increase in the control
Key pinch strength, kg 3.7 ± 0.9 3.3 ± 0.5 P = .97∧ group, it failed to reach significance by 3 yr (3.79 ± 0.76 mV;
P = .06) (Figure 3B).
MUNE: motor unit number estimation; # Mann-Whitney U test; ∧ Paired t test.

similar between groups (P = .10; Table 2). One year following
surgery, patients in the stimulation group demonstrated signif-
icant increases in MUNE (107 ± 11) compared to controls
(78 ± 6) (P < .05). By 3 yr postoperatively, stimulated
patients had more than double the number of motor units
compared to controls (178 ± 11 vs 88 ± 18; P < .05). In
contrast, patients in the control group failed to attain a signif-
icant increase in motor units by 3 y (66 ± 7 vs 88 ± 18;
P = .13).
Grip Strength
Preoperatively, there was no significant difference between
groups (P = .91; Table 2). Postoperatively, patients in the
stimulation group experienced a significant improvement in grip
strength from the first year onward (P < .001), whereas patients
in the control group failed to significantly improve their grip
strength even at 3 yr (P = .08) (Figure 4A).
A minimum clinically importance difference (MCID) in grip
strength, calculated based on 50% of the standard deviation
of the mean preoperative grip strength was 5.9 kg.27 Patients
in the control group had a mean improvement of 4.2 kg,

FIGURE 3. Motor reinnervation in the hypothenar muscles. A, Motor unit number estimates (MUNE) in the control group (left panel) compared
to subjects in the electrical stimulation (ES) group (right panel). B, Comparisons of maximum compound motor action potential (CMAP) amplitude
between the 2 groups with the same layout as in A. The black lines and grey bars represent mean ± SE at baseline. Asterisks (∗ ) represent statistical
significance (P < .05) postoperative improvements.

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FIGURE 4. Strength improvements in the hand. A, Postoperative changes in grip strength in the control group (left panel) compared to that in the
electrical stimulation (ES) group (right panel). B, Postoperative changes in key pinch strength between the 2 groups. Layout is the same as in A. The
black lines and grey bars represent mean ± SE at baseline. Asterisks (∗ ) represent statistically significant (P < .05) postoperative improvement.

whereas patients in the stimulation group had an improvement of McGowan-Goldberg Grading

8.1 kg at 3 yr. Thus, patients in the stimulation group had a
clinically important improvement in grip strength by 3 yr from
surgery.
Key Pinch Strength
At baseline, there was no significant difference between groups
(P = .97; Table 2). Patients in the control group failed to
show a statistically significant improvement in pinch strength
at all time points (P > .1), whereas patients in the stimulation
group had a significant improvement at all 3 postoperative visits
(P < .001; Figure 4B). The mean gain in key pinch strength in
the stimulation group was almost 3 times of that in the control
group.
Using the same calculation as grip strength, the MCID for key
pinch strength was 1.1 kg. Patients in the control group had an
improvement of 0.67 kg, whereas those in the stimulation group
had an improvement of 1.9 kg at 3 yr, representing a clinically
important difference for the patients that received PES.
Using the McGowan-Goldberg grading system at final follow-
up, 3 of 11 patients (25%) in the control group attained grade
2, and 3 of 11 (25%) attained grade 1. In contrast, 8 of 20
patients (40%) in the stimulation group attained grade 2, and
7 of 20 (35%) attained grade 1, which represents a significant
improvement over the control group (P < .05).
Complications
There were no postoperative complications and no adverse
events observed with our stimulation protocol.
DISCUSSION
In this clinical trial, we found that patients with severe CuTS
who underwent a single 1-h session of PES had faster muscle
reinnervation, significantly more functional motor units, and
improved grip and key pinch strength compared to controls. This
is reflected clinically by improvement in the McGowan-Goldberg
grade.

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Comparisons to Other Studies
Based on previous reports, patients with severe CuTS (ie,
McGowan-Goldberg grade 3) have meaningful motor recovery
following surgical treatment in only 50% of cases.3,28,29 Although
patients in our control group showed comparable improvement,
those in the PES group did significantly better. This is further
supported by quantitative electrophysiologic and functional
outcomes. Patients in our control group failed to attain a
significant increase in MUNE even 3 yr from surgery. In
contrast, patients that received PES improved markedly by 3 yr.
Functionally, this corresponded with significantly better grip and
key pinch strength in stimulated patients.
In a recent study by Bruder et al30 (2017), they found that
CuTS patients with shorter symptom duration (210 ± 300 d)
had greater recovery of muscle bulk compared to those with long
symptom duration (780 ± 990 d) after surgery. In contrast, we
did not find a significant correlation between MUNE increase
(r = 0.26; P = .33) or pinch strength gain (r = 0.28; P = .30)
and symptom duration in our subjects in the stimulation group.
One potential explanation for this is that patients in the study of
Bruder et al30 were only followed for 6 mo after surgery; a time
that is far too short for reinnervation to occur in the intrinsic
hand muscles. Therefore, findings between the 2 studies may not
be directly comparable.
Correlation with Animal Studies and Mechanism of
Action
One hour of 20 Hz PES accelerated axon outgrowth and
facilitated earlier target reinnervation in animal models of nerve
injury including rats,7-10,31 mice,32,33 and in humans following
digital nerve transection,13 carpal tunnel release,12 oncologic neck
dissection,14 and now cubital tunnel decompression. Interest-
ingly, 1 h of 20 Hz PES in rats produced the same beneficial results
as week-long continuous stimulation in motor nerves,7 whereas
stimulation durations longer than 1 h (ie, 3 h, 7 d, and 14 d)
were harmful for regenerating sensory nerves.10
PES promotes regeneration by activating molecular pathways
within Schwann cells, surrounding inflammatory cells and the
cell body of neurons. It increases production of neurotrophins,
including BDNF, NT-3, and NT-4/5,33-35 causing increased
intracellular cyclic AMP levels,36 enhanced regeneration-
associated gene expression, and production of cytoskeletal
assembly proteins.37 For a more extensive review on the mecha-
nisms of PES, the reader is referred to Gordon and English38
(2015).
The chronic compressive axonal injury seen in CuTS likely
impairs the ability of motor axons to regenerate after the
compression is released. The diminished capacity for axonal
regeneration in chronic axotomy was reduced up to 66% in a rat
model of chronically axotomized tibial nerve.39,40 Thus, it is not
surprising that patients in our control group failed to demonstrate
a significant improvement in hypothenar reinnervation even
3 yr after surgery. Remarkably, patients that underwent PES had
NEUROSURGERY
PES ENHANCES RECOVERY AFTER CUBITAL TUNNEL SURGERY
double the number of functional hypothenar motor units by
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3 yr. This provides evidence that chronically injured motor axons
retain the ability to regenerate and that this can be augmented
with PES.
Limitations
A limitation of our study is the lack of objective assessment
of pain and sensation. The reason for this is that the most debil-
itating symptom of severe CuTS is muscle atrophy and loss of
hand strength. We have previously shown that PES promotes
sensory nerve regeneration in ulnar-innervated digital nerves,13
and assume the same would be true for the sensory changes in
patients with CuTS.
Second, this is a single-center study with relatively small sample
size. Realizing the potential limitation on statistical power, we
elected to use unequal treatment allocation. This helped to
increase recruitment and statistical power.18 To increase the gener-
alizability of our findings, a large multicenter study including
patients with different disease severity will be needed.
Lastly, another potential limitation is that 2 different surgical
techniques were used to decompress the ulnar nerve at the elbow.
Although the majority of our patients had an in Situ decom-
pression, a small number of patients with ulnar nerve instability
required submuscular transposition. There has been much debate
as to which surgical technique yields the best outcome in CuTS.
Gervasio et al29 (2005) compared in Situ decompression with
submuscular transposition in a randomized controlled trial of 70
patients with severe CuTS and found no difference in outcomes
between the 2 procedures. Similarly, a Cochrane systematic review
involving 430 patients failed to find a significant difference in
outcomes between the 2 procedures.41 Other studies also failed
to find a consistent difference between the 2 techniques.2,42,43
A subgroup analysis of outcomes in our study could not be
meaningfully interpreted because of the small number of patients
that underwent transposition. However, based on the literature
above, we do not believe the type of surgery significantly impacted
our outcomes.
Feasibility in the Clinical Setting
The stimulation equipment is inexpensive (stimulator $2400
USD, implantable electrodes $5-$10 USD) and requires minimal
training to operate. In a previous study, we demonstrated that it
adds minimal operative time to implant the electrodes.13 The 1-h
treatment can easily be administered in the recovery room, day
surgery unit, or clinic. A potential barrier to clinical implemen-
tation is the requirement for surgery to be done under general
anesthesia. Given the recent trend towards “wide-awake surgery,”
the use of local anesthesia is becoming increasingly desirable.
However, this issue can likely be circumvented by stimulating
the nerve well proximal to the field of local anesthesia. In the
case of the ulnar nerve proximal to the elbow, ultrasound-guided
placement of a needle stimulating electrode could be utilized.
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POWER ET AL
CONCLUSION
We have demonstrated that a single 1-h session of PES
enhances reinnervation of the intrinsic muscles in severe CuTS
and results in improved functional recovery beyond that seen with
surgery alone. We propose that PES is a clinically useful adjunct
to surgical treatment for severe ulnar neuropathy, in which
motor functional recovery with conventional treatment is often
suboptimal.
Disclosures
This research was funded by the Canadian Institutes of Health Research grant
no. RMF82496. The authors have no personal, financial, or institutional interest
in any of the drugs, materials, or devices described in this article.
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Acknowledgments
We would like to thank Dr Matthew Curran, Dr Joshua Wong, Mahsa Mackie,
and Cheryl Pilipchuk for their assistance in data collection.
Neurosurgery Speaks! Audio abstracts available for this article at www.neurosurgery-
online.com.
COMMENT
T he authors have presented an important study in which they
performed a randomized, double-blind, sham stimulation control
trial of post-surgical electrical stimulation (PES) in patients with severe
ulnar nerve entrapment neuropathy at the elbow. Despite the relatively
NEUROSURGERY
PES ENHANCES RECOVERY AFTER CUBITAL TUNNEL SURGERY
small numbers, they were able to demonstrate a statistically significant
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improvement in motor unit number estimation (MUNE) and functional
motor recovery. The outcomes for sensation and pain were not studied.
Patients with advanced ulnar entrapment neuropathy comprise a notori-
ously frustrating group for nerve surgeons, with a large percentage
of patients not showing clinically meaningful improvement with any
surgical procedure. This relatively simple intervention holds promise
for greater recovery in these patients. It will be important to study this
technique in patients with milder entrapment neuropathies to see if this
benefit is still seen. Many of these simple decompression procedures are
performed with local anesthesia. The authors do point out that local
anesthesia renders this stimulation useless, unless the electrodes are placed
far proximal to the field. This could be done percutaneously with the use
of ultrasound guidance. Do we know that that electrode placement would
work as well? It is likely it will, but perhaps this question requires another
study to prove that. The authors are to be congratulated for pursuing this
intervention from the laboratory through well-conducted clinical trials,
for the benefit of our patients.
Eric L. Zager
Philadelphia, Pennsylvania
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