Treatment of ulnar neuritis and early ulnar paralysis.

In the last 2 decades , reconstructive surgery for the deformities associated with leprosy has come into its own. However, surgery can rarely restore full range of movement or bring back lost sensation . In spite of sulphones and other antileprosy drugs, neuritis sometimes super­ venes, with resulting deformities and trophic ulceration. Many workers have tried to relieve the pain of ulnar neuritis with drugs, and others have attempted different surgical procedures with the same intention . Various operative tech­ niques are described such as: external neurolysis, neurolysis combined with longitudinal incision of the epineurium, endoneurolysis and fascicular neurolysis . Most of the serious disabilities occurring in leprosy are the consequence of damage to mixed nerve trunks . Such damage is usually associated with swelling of the nerve, and secondary ischaemia may be the immediate factor causing damage by compression. The surgical procedure of choice at the Leprosy Centre , Polambakkam, is external neurolysis . The patients were selected at random . Those with bilateral neuritis (mostly acute) , those whose nerves were less enlarged or with hands with slight degrees of paresis or paralysis were kept as controls, as were also some others with unilateral neuritis . Full records were kept of duration of pain, sensory charting (with nylon No . 5 ) , motor power of muscles, and the patients' own state­ ments concerning ability to work ; all these were noted before and after treatment . The operative technique was as follows (Figs . 1 to 3 ) : An incision of about 3 inches was made over the ulnar groove . Mter dissection of the superficial tissues , the ulnar nerve was identified and its fascial roof divided. The dis­ section was continued distally to the point where the nerve dips between the 2 heads of the flexor carpi ulnaris . The fibrous arch was divided completely, and then excised in order to prevent further adhesions . No tourniquet was used, and care was taken not to infiltrate the nerve or to incise its sheath . The following observations were made at operation: The nerves were enlarged proximal to the arch and compressed at the arch itself. The arch was thickened . The nerve was white proximally, but distal to the arch it was yellowish . Shortly after decom­ pression, the vasa nervorum on the antero-Iateral aspect of the nerve could be seen filling up . The patient volunteered that he experienced relief of pain soon after division of the fibrous arch . Mter the operation, the paralysed hands were immobilised in the lumbrical position for 3 to 4 weeks. Mter the removal of plaster, massage and exercise of the hands were en­ couraged. Tables 1 and 2 give the analysis of the treatment and control groups .