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ARTICLES: R. Beekman, J. H.J. Wokke, M. C. Schoemaker, M. L. Lee, and L. H. Visser Ulnar neuropathy at the elbow: Follow-up and prognostic factors determining outcome Neurology 2004; 63: 1675-1680 [Abstract] [Full text] [PDF]

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Ulnar neuropathy at the elbow: Follow-up and prognostic factors determining outcome

Ronald HMA Bartels   (21 January 2005)

Reply to Bartels

Roy Beekman, J.H.J. Wokke, M.C. Schoemaker, M.L. Lee, L.H. Visser   (21 January 2005)

Ulnar neuropathy at the elbow: Follow-up and prognostic factors determining outcome 21 January 2005
Ronald HMA Bartels, University Medical Center St. Radboud Department of Neurosurgery, R. Postlaan 4, 6500 HB Nijmegen, The Netherlands Send Correspondence to journal: Re: Ulnar neuropathy at the elbow: Follow-up and prognostic factors determining outcome r.bartels{at}nch.umcn.nl Ronald HMA Bartels	I read the article by Beekman et al with great interest and want to make the following comments. [1] The conservative treatment is very minimal. A correct way of treating patients conservatively is described by Dellon. [2] It does include instructing the patient, modification of work and home environment, and splinting the arm during the night. Even periodical changes of work were suggested, as were nonsteroidal anti-inflammatory drugs in selected cases. They do not discuss what impact the loss of 18 % (15/84) of the patients might have on the results. The number of patients included in this study is of concern. Within this group, 15 subsamples were created without any statistical correction. The probability of obtaining significance by change is increased with every sub-analysis, and is, therefore, substantial in this study. While evaluating the predefined factors, they do not discriminate between not treated and surgically treated patients, except for the sonographic results. This is not correct. Globally, surgically treated patients have had a good outcome in 61 % of the patients whereas those of the not treated group only 35% and in the worse case 26%. In table 4, the authors represent the data on the sonographic results. In the surgical group differences were found. However, recalculation shows a 95% CI of (–0.05 – 0.64 for the mean difference between pre – and postoperatively for all arms, and a 95% CI of (-0.15 – 0.55) for the remission group. Considering the preoperative situation, a significant difference is found comparing the remission and the stable group (95% CI: 0.18 – 0.82). However, postoperatively no difference was found (95% CI: -0.10 – 0.50). In conclusion, the preoperative sonographic findings do not to predict any outcome. The authors pay attention to the finding of a thickened asymptomatic ulnar nerve at the contralateral side. They calculated a relative risk of 3.7. However, they fail to report the estimated 95% CI: 0.35 -37.8, indicating that there is absolutely no relation. They state that there is much debate about the efficacy and type of operation. Generally, a success rate of 70% is reported. [3] Therefore, the resistance against surgery is not correct. This study does not disclose that sonography is a valuable tool in the management of patients with ulnar neuropathy. Furthermore, the claim of the authors to be the first to show the role of electrodiagnostic data should be questioned. References 1. Beekman R, Wokke JHJ, Schoemaker MC, Lee ML, Visser LH. Ulnar neuropathy at the elbow. Neurology 2004; 63:1675-1680. 2. Dellon AL, Hament W, Gittelshon A. Nonoperative management of cubital tunnel syndrome: an 8-year prospective study [see comments]. Neurology 1993; 43(9):1673-1677. 3. Bartels RHMA, Menovsky T, van Overbeeke JJ, Verhagen WIM. Surgical management of ulnar nerve compression at the elbow: an analysis of the literature. J Neurosurg 1998; 89:722-727.
Reply to Bartels 21 January 2005
Roy Beekman, Atrium Medical Centre, Heerlen, The Netherlands PO Box 4446, 6401 CX Heerlen, The Netherlands, J.H.J. Wokke, M.C. Schoemaker, M.L. Lee, L.H. Visser Send Correspondence to journal: Re: Reply to Bartels r_beekman01{at}planet.nl Roy Beekman, et al.	We appreciate the interest of Bartels for our work [1], but disagree with most of the points that were raised: There are no prospective randomized studies for the subsequent conservative treatment measures mentioned. [2] However, we advised patients to incorporate the instructions described in our paper in home and work environment. The result section describes that the fifteen patients lost to follow-up were clinically not different from the others. Therefore this will not have much impact on the results. The primary conclusions of the study concerning the two patient groups (surgery vs. conservative treatment) were based on the full 69 patients for which follow-up was available. Secondary analyses were performed on patient subgroups and because of the nature of these evaluations, no statistical adjustments were considered necessary. Furthermore, prognostic factors were evaluated in a full multivariate model (simultaneous analysis) after initial univariate analyses. The primary clinical outcome was, of course, compared between the study arms and emphasized in the paper. However, a partial objective of this paper was to demonstrate the factors that predict outcome other than treatment approach. The analysis suggested here is overly simplistic. If the goal is to consider the relationship between pre- and post-treatment sonographic results across treatment arms, then the more meaningful approach is to use an analysis of covariance with terms for treatment arm and pre-treatment results, as well as a term for treatment-by-time interaction. We did not perform this analysis, since our interest was simply to evaluate each study arm. We did not claim any statistical meaningfulness for this relative risk. The paper quotes a sizable p-value, 0.55. This is tantamount to indicating a wide confidence interval. We disagree that there is substantial evidence to decide when and how to operate in ulnar neuropathy ath the elbow (UNE). The study mentioned here is an overview of the literature that contains no prospective randomized studies and mainly deals with different surgical techniques for UNE, not with the topic to operate or not to operate. [3] Only Eisen and Danon found that slowing of motor conduction below 41 m/s across the elbow predicted a greater likelihood of progression to motor deficits [4], but this was not found by Dellon et al. [2] No other electrodiagnostic parameters were evaluated in a prospective study in UNE. We sustain our conclusion that sonography is a useful tool in the management of patients with UNE, not only by improving the diagnostic accuracy of UNE [5], but also by providing prognostic information. [1] References 1. Beekman R, Wokke JHJ, Schoemaker MC, Lee ML, Visser LH. Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome. Neurology 2004; 63:1675-1680. 2. Dellon AL, Hament W, Gittelshon A. Nonoperative management of cubital tunnel syndrome: an 8-year prospective study. Neurology 1993; 43(9):1673-1677. 3. Bartels RHMA, Menovsky T, van Overbeeke JJ, Verhagen WIM. Surgical management of ulnar nerve compression at the elbow: an analysis of the literature. J Neurosurg 1998; 9: 722-727. 4. Eisen A, Danon J. The mild cubital tunnel syndrome. Its natural history and indications for surgical intervention. Neurology 1974; 24: 608 -613. 5. Beekman R, Schoemaker MC, van der Plas JPL, van den Berg LH, Franssen H, Wokke JHJ, Uitdehaag BMJ, Visser LH. The diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow. Neurology 2004; 62: 767-773.