Early Symptom Aggravation Following Ulnar Nerve Transposition for Cubital Tunnel Syndrome: Incidence, Predictive Factors, and Threshold-Based Risk Stratification

Early Symptom Aggravation Following Ulnar Nerve Transposition for Cubital Tunnel Syndrome: Incidence, Predictive Factors, and Threshold-Based Risk Stratification | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early Symptom Aggravation Following Ulnar Nerve Transposition for Cubital Tunnel Syndrome: Incidence, Predictive Factors, and Threshold-Based Risk Stratification Tianyou Hu, Yujie Bian, Tao Zhou, Qiankun Wang, Hongxiang Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7075399/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Feb, 2026 Read the published version in Neurosurgical Review → Version 1 posted 13 You are reading this latest preprint version Abstract Background Early postoperative symptom aggravation is a clinically relevant yet underexplored phenomenon following anterior ulnar nerve transposition for cubital tunnel syndrome (CuTS). This study aimed to define its incidence, identify predictive factors, and establish a threshold-based risk stratification model. Methods We retrospectively reviewed 127 patients undergoing anterior subcutaneous transposition of the ulnar nerve between 2020 and 2023. Early symptom aggravation was defined as a postoperative deterioration in at least one clinical (VAS or PRUNE) or electrophysiological (CMAP or SNCV) indicator at two weeks post-surgery. Multivariate logistic regression and ROC curve analyses were performed to determine independent predictors and optimal thresholds. Results Early symptom aggravation occurred in 26.8% of patients. Multivariate analysis identified symptom duration (OR = 1.150, p < 0.00001) as a significant independent predictor. McGowan grade III showed a moderate association (OR = 3.224, p = 0.087). ROC analysis revealed excellent discriminative ability for symptom duration (AUC = 0.890) with an optimal threshold of 24.00 months (sensitivity 82.4%, specificity 86.2%). Other variables, including electrophysiological measures and demographics, demonstrated limited predictive value. Conclusion Symptom duration and preoperative McGowan grade are key risk factors for early symptom aggravation after CuTS surgery. A simple threshold-based model can aid in preoperative counseling and expectation management. These findings highlight the need for timely surgical intervention to minimize neural deterioration and improve short-term outcomes. Cubital tunnel syndrome、Ulnar nerve transposition、Early postoperative symptom aggravation、Risk stratification、Symptom duration Figures Figure 1 Figure 2 Figure 3 Introduction Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity, following carpal tunnel syndrome, and is characterized by chronic compression of the ulnar nerve at the elbow 1 , 2 . Patients typically present with numbness, paresthesia in the ulnar distribution, intrinsic hand muscle weakness, and progressive functional decline 3 , 4 . Surgical decompression remains the mainstay of treatment for moderate to severe cases, with anterior transposition of the ulnar nerve being one of the most widely performed techniques 5 , 6 . While most patients achieve favorable long-term outcomes, a subset experiences transient symptom aggravation shortly after surgery, manifesting as increased pain, sensory disturbances, or motor dysfunction 7 . This early postoperative symptom worsening may lead to patient anxiety, dissatisfaction, and confusion in clinical interpretation, sometimes being mistaken for surgical failure or recurrent nerve compression 8 . In other entrapment neuropathies, such as carpal tunnel syndrome, early postoperative symptom exacerbation has been reported and is often attributed to transient factors including postoperative edema, local ischemia, or nerve manipulation-induced neurapraxia 9 . Similar hypotheses have been proposed for CuTS, suggesting mechanisms such as postoperative inflammatory swelling, temporary traction injury during nerve mobilization, and dynamic instability of the transposed nerve 10 , 11 . However, these suppositions are primarily based on clinical impressions, and robust data remain lacking. Despite its potential clinical relevance, early symptom aggravation in CuTS has not been systematically defined or quantitatively studied 12 . In particular, there is a paucity of research examining the relationship between preoperative clinical or electrophysiological variables and the risk of early symptom worsening. Without clear definitions and predictive markers, clinicians face challenges in preoperative counseling and postoperative management, and patients may have unmet expectations regarding early recovery trajectories. In this retrospective cohort study, we aimed to systematically characterize early postoperative symptom aggravation in patients undergoing anterior subcutaneous transposition of the ulnar nerve. Using standardized clinical assessments and electrophysiological testing, we further sought to identify preoperative predictors associated with this phenomenon and to establish preliminary thresholds to aid in clinical risk stratification. Method Study Design and Patient Selection This retrospective cohort study was conducted at the Department of Orthopaedic Surgery, First Affiliated Hospital of Anhui Medical University. Patients diagnosed with cubital tunnel syndrome (CuTS) and treated with anterior ulnar nerve transposition between January 2020 and December 2023 were screened for eligibility. All surgeries were performed by a single senior surgeon to minimize technical variability. The diagnosis of CuTS was based on clinical symptoms (e.g., paresthesia in the ulnar nerve distribution, weakness of intrinsic hand muscles), physical examination, and electrophysiological studies. Inclusion criteria were: (1) confirmed diagnosis of CuTS, (2) failure of conservative management for at least three months, and (3) receipt of anterior ulnar nerve transposition as the primary surgical treatment. Exclusion criteria included: (1) prior surgery on the affected limb, (2) systemic neurological disorders (e.g., diabetes mellitus with peripheral neuropathy), (3) perioperative use of corticosteroids, and (4) incomplete clinical or follow-up data 5 , 13 . All patients were followed for a minimum of six months postoperatively. The study protocol was approved by the institutional ethics committee, and informed consent was obtained from all participants. Surgical Procedure and Postoperative Care All patients underwent open anterior subcutaneous transposition of the ulnar nerve under general anesthesia and tourniquet control. After a standard curvilinear incision centered over the medial epicondyle, the ulnar nerve was exposed, and compressive structures including Osborne’s ligament and the arcuate ligament of Osborne were released. The nerve was then mobilized and transposed anteriorly into a subcutaneous pocket, taking care to avoid torsion or undue tension. To maintain the new position of the nerve and reduce postoperative mobility-related strain, a fascial flap was fashioned from the flexor-pronator origin and sutured to the subcutaneous tissue, forming a soft-tissue sling. Two fixation methods were used sequentially across the cohort: traditional absorbable sutures buried under the skin, and percutaneous external suturing, in which sutures were passed through the skin surface to secure the flap. Postoperative care included limb elevation, elbow immobilization at 30–45° flexion for one week, and standardized physical therapy initiated after splint removal. No corticosteroids or anti-edema agents were administered perioperatively. Data Preprocessing and Encoding All patients with complete baseline clinical and electrophysiological data were included in the analysis. There were no missing values in the dataset at the time of statistical modeling. To maintain data consistency, specific rules were applied for handling incomplete entries where necessary during initial data collection. For the side of surgery, any missing or ambiguous entries were imputed as the right side, reflecting the dominant side distribution observed in the cohort 14 , 15 . For symptom duration (course), missing values were replaced with the cohort mean, ensuring minimal bias in central tendency measures. Categorical variables were encoded as binary indicators to facilitate statistical modeling. Sex was coded as 1 for male and 0 for female. The surgical side was coded as 1 for the right and 0 for the left. The McGowan classification, originally a three-level ordinal variable (Grades I–III), was dichotomized for analysis: Grades I and II were grouped as 0 (mild to moderate impairment), and Grade III was coded as 1 (severe impairment), based on established clinical thresholds for functional severity. Symptom duration (course) was treated as a continuous variable, measured in months. Preoperative clinical scores, including the Visual Analog Scale (VAS) and the Patient-Rated Ulnar Nerve Evaluation (PRUNE), were retained as continuous variables, as were electrophysiological measures such as compound muscle action potential (CMAP) amplitude and sensory nerve conduction velocity (SNCV). Definition of Outcome The primary outcome of this study was early postoperative symptom aggravation, which was operationally defined as a clinically relevant rebound in clinical evaluation or electrophysiological indicators compared to baseline measurements. Patients were classified as aggravated if they exhibited a deterioration in at least one of the following domains. For clinical evaluation indicators, aggravation was defined as an increase in the Visual Analog Scale (VAS) score or an increase in the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score. For electrophysiological indicators, it was defined as a decrease in compound muscle action potential (CMAP) amplitude or a decrease in sensory nerve conduction velocity (SNCV). Thresholds for defining rebound were determined based on clinically noticeable changes commonly observed in peripheral nerve decompression procedures and were adapted to reflect the postoperative recovery context specific to cubital tunnel syndrome. Statistical Analysis Descriptive Statistics Continuous variables were summarized as means and standard deviations (mean ± SD), while categorical variables were presented as frequencies and percentages. The distribution of continuous variables was assessed for normality using the Shapiro–Wilk test. Univariate Analysis For comparisons between the aggravated and non-aggravated groups, appropriate statistical tests were applied based on data distribution. Continuous variables were compared using independent samples t-tests for normally distributed data or Mann–Whitney U tests for non-normally distributed data. Categorical variables were compared using the chi-square test or Fisher’s exact test when expected cell counts were less than five. A p-value of < 0.05 was considered statistically significant. Multivariate Analysis To identify independent preoperative predictors of early postoperative symptom aggravation, multivariate logistic regression analysis was performed. Variables with clinical relevance and those achieving a p-value < 0.10 in univariate analysis were entered into the model. Stepwise selection procedures were applied to refine the model, retaining variables with significant contributions (p < 0.05). Categorical variables (sex, side, McGowan grade) were entered as binary variables, and continuous variables (age, BMI, course, CMAP, SNCV, VAS, PRUNE) were retained as continuous predictors. Variables exhibiting sparse distribution (e.g., sex, side) or high collinearity were excluded based on correlation analysis. The logistic regression model was reported with odds ratios (OR), 95% confidence intervals (CI), and p-values for each predictor. The model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test. Predictive Performance Assessment Receiver operating characteristic (ROC) curve analysis was performed for each preoperative variable to evaluate its discriminative ability in predicting early symptom aggravation. The area under the curve (AUC) was calculated along with 95% confidence intervals. Optimal cutoff values were determined using the Youden index to maximize sensitivity and specificity. Special attention was given to symptom duration, for which a cutoff value of 24.00 months was identified, providing optimal discriminative performance. Correlation Analysis Spearman correlation coefficients were calculated to examine relationships between continuous variables. A correlation heatmap was generated to visualize inter-variable relationships and assess multicollinearity. Variables with a correlation coefficient (r) greater than 0.7 were considered to exhibit strong collinearity and were evaluated carefully during multivariate modeling. All statistical analyses were conducted using SPSS Statistics version 23.0 (IBM Corp., Armonk, NY, USA) and R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria). A two-sided p-value of < 0.05 was considered statistically significant for all analyses. Result A total of 127 patients who underwent anterior subcutaneous transposition of the ulnar nerve were included in the study. The cohort comprised 77 males (67.5%) and 37 females (32.5%), with a mean age of 52.86 ± 13.78 years. The mean symptom duration was 1.83 ± 2.85 years, and the mean body mass index (BMI) was 23.87 ± 3.17 kg/m². Surgical intervention was performed on the right side in 73.22% of patients and on the left side in 26.78%. Preoperative severity assessed using the McGowan classification showed that 18.1% of patients were classified as Grade I, 26.7% as Grade II, and 55.1% as Grade III. Among all patients, 34 (26.8%) met the criteria for early postoperative symptom aggravation and were categorized into the aggravation group, while the remaining 93 were classified into the non-aggravation group. Baseline characteristics of the entire cohort and the two subgroups are summarized in Table 1 . Table 1 Baseline Characteristics of Patients with Cubital Tunnel Syndrome Group Age(year)( \(\:\stackrel{-}{x}\pm\:s\) ) Sex (%) Course of disease(year)( \(\:\stackrel{-}{x}\pm\:s\) ) BMI(kg/m²)( \(\:\stackrel{-}{x}\pm\:s\) ) Left or right hand (%) McGowan (%) Male female left right Ⅰ Ⅱ Ⅲ All Patiences 52.86 ± 13.78 67.5 32.5 1.83 ± 2.85 23.87 ± 3.17 26.77 73.22 18.11 26.77 55.11 Aggravation Group 56.42 ± 12.14 79.4 20.6 4.03 ± 3.92 24.00 ± 3.18 26.47 73.52 0 23.52 76.47 At the 6-month postoperative follow-up, patients demonstrated significant improvements in both subjective and objective measures. The mean Visual Analog Scale (VAS) score decreased from 4.61 ± 1.01 preoperatively to 2.22 ± 1.16 (p = 0.0005), while the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score improved from 50.91 ± 10.04 to 30.08 ± 6.82 (p = 0.0006). Sensory recovery was reflected in the improvement of two-point discrimination (2PD) from 8.87 ± 1.89 mm to 5.80 ± 1.89 mm (p = 0.0032). Electrophysiological parameters showed marked improvements, with compound muscle action potential (CMAP) amplitude increasing from 1.79 ± 0.38 mV to 5.70 ± 0.76 mV (p = 0.0006), sensory nerve conduction velocity (SNCV) from 32.49 ± 6.41 m/s to 48.04 ± 5.22 m/s (p = 0.0004), and motor nerve conduction velocity (MNCV) from 32.92 ± 6.32 m/s to 48.20 ± 4.74 m/s (p = 0.0003). These long-term outcomes are detailed in Supplementary Table 1. At the 2-week postoperative evaluation, the majority of patients exhibited early signs of improvement. The mean VAS score decreased from 4.61 ± 1.01 to 3.89 ± 1.10 (p = 0.038), the PRUNE score decreased from 50.91 ± 10.04 to 46.86 ± 10.35 (p = 0.0027), and 2PD improved from 8.87 ± 1.89 mm to 8.33 ± 2.24 mm (p = 0.047). These short-term changes for the overall cohort are summarized in Supplementary Table 2. In contrast to the overall cohort, 34 patients (26.8%) exhibited significant deterioration within 2 weeks postoperatively and were categorized into the early symptom aggravation group. In this subgroup, the VAS score increased from 4.57 ± 1.00 to 4.21 ± 1.21 (p = 0.0186), and the PRUNE score increased from 51.96 ± 9.80 to 53.66 ± 9.27 (p = 0.0003). The 2PD worsened from 9.69 ± 1.07 mm to 10.75 ± 1.27 mm (p = 0.0002). Electrophysiological measures also showed deterioration, with CMAP decreasing from 1.77 ± 0.38 mV to 1.29 ± 0.28 mV (p = 0.0002), SNCV decreasing from 33.08 ± 6.18 m/s to 29.58 ± 5.55 m/s (p = 0.0002), and MNCV decreasing from 32.83 ± 5.56 m/s to 26.41 ± 4.62 m/s (p = 0.0002). The detailed changes in the overall cohort and in the aggravation subgroup are presented in Table 2 a, Table 2 b, Table 2 c, and Table 2 d. Table 2 a Comparison of Preoperative and Short-Term VAS, PRUNE, and Two-Point Discrimination in Patients with Symptom Aggravation( \(\:\stackrel{-}{x}\pm\:s\) )༈α = 0.05༉ VAS PRUNE Two-Point Discrimination(mm) pre 4.57 ± 1.00 51.96 ± 9.80 9.69 ± 1.07 post(short-term) 4.21 ± 1.21 53.66 ± 9.27 10.75 ± 1.27 S-W-p 0.0073/0.0588 0.4635/0.5421 0.0002/0.0033 SRT-p 0.0186 0.0003 0.0002 Table 2 b Comparison of Preoperative and Short-Term CMAP, SNCV, and MNCV in Patients with Symptom Aggravation( \(\:\stackrel{-}{x}\pm\:s\) )༈α = 0.05༉ CAMP SNCV MNCV pre 1.77 ± 0.38 33.08 ± 6.18 32.83 ± 5.56 post(short-term) 1.29 ± 0.28 29.58 ± 5.55 26.41 ± 4.62 S-W-p 0.3893/0.1168 0.2901/0.3673 0.5611/0.6112 SRT-p 0.0002 0.0002 0.0002 Multivariate logistic regression analysis was performed to identify preoperative predictors associated with early symptom aggravation. Among all considered variables, symptom duration and McGowan classification were retained in the final model. Symptom duration was independently associated with early aggravation, with an odds ratio (OR) of 1.150 per month increase (95% confidence interval [CI]: 1.080–1.225, p < 0.00001), indicating that each additional month of symptoms prior to surgery increased the odds of postoperative symptom aggravation by 15%. Severe McGowan grade (Grade III) was associated with an OR of 3.224 compared to less severe grades (95% CI: 0.843–12.339, p = 0.087). Although not reaching conventional statistical significance, this suggests a higher likelihood of early postoperative symptom worsening in patients with Grade III severity. Other variables, including sex (OR = 1.830, p = 0.402), side (OR = 0.224, p = 0.063), age (OR = 1.015 per year, p = 0.624), BMI (OR = 1.150 per unit, p = 0.195), CMAP (OR = 3.432, p = 0.679), MNCV (OR = 0.973, p = 0.602), VAS (OR = 0.544, p = 0.596), and PRUNE (OR = 0.997, p = 0.933), did not show significant associations and were excluded during stepwise regression. Full logistic regression results are presented in Table 3 . Table 3 Multivariate Logistic Regression Analysis of Preoperative Predictors for Early Symptom Aggravation After Ulnar Nerve Transposition Variable Coefficient OR 95% CI Lower 95% CI Upper p-value const -6.020 0.002 0.000 6.702 0.136 sex 0.604 1.830 0.445 7.533 0.402 side -1.495 0.224 0.046 1.086 0.063 mcgowan 1.171 3.224 0.843 12.339 0.087 age 0.015 1.015 0.955 1.079 0.624 bmi 0.140 1.150 0.931 1.421 0.195 course 0.140 1.150 1.080 1.225 1.23 × 10⁻⁵ CMAP 1.233 3.432 0.010 1180.634 0.679 MNCV -0.028 0.973 0.877 1.079 0.602 VAS -0.608 0.544 0.058 5.150 0.596 PRUNE -0.003 0.997 0.939 1.059 0.933 Abbreviations: OR, odds ratio; CI, confidence interval; p-value < 0.05 was considered statistically significant. Receiver operating characteristic (ROC) curve analysis demonstrated that symptom duration had the highest discriminative ability, with an area under the curve (AUC) of 0.890. The optimal cutoff value for symptom duration was 24.00 months, with a sensitivity of 82.4% and specificity of 86.2%. McGowan grade exhibited a moderate predictive ability with an AUC of 0.651, and age showed an AUC of 0.599. Other variables, including sex (AUC = 0.585), side (AUC = 0.501), BMI (AUC = 0.525), CMAP (AUC = 0.471), MNCV (AUC = 0.497), VAS (AUC = 0.467), and PRUNE (AUC = 0.537), displayed lower AUC values. The ROC curves of preoperative predictors are shown in Fig. 1 , and the AUC values and cutoff thresholds are detailed in Table 4 . Table 4 ROC Analysis of Preoperative Variables for Predicting Early Symptom Aggravation and Identification of Optimal Thresholds Variable AUC Best Threshold Sensitivity Specificity sex 0.585 1.00 0.794 0.375 side 0.501 1.00 0.765 0.238 mcgowan 0.651 1.00 0.765 0.538 age 0.599 57.00 0.618 0.600 bmi 0.525 24.48 0.529 0.650 course 0.890 24.00 0.824 0.862 CMAP 0.471 2.80 0.029 1.000 MNCV 0.497 25.60 0.971 0.125 VAS 0.467 3.00 1.000 0.012 PRUNE 0.537 51.00 0.647 0.462 Abbreviations: AUC, area under the curve; Best Threshold, cutoff value maximizing the Youden index; Sensitivity, true positive rate; Specificity, true negative rate. Receiver operating characteristic (ROC) curve analysis was conducted for each preoperative variable to evaluate their ability to discriminate between patients with and without early symptom aggravation. Symptom duration exhibited the highest discriminative ability, with an area under the curve (AUC) of 0.890. The optimal cutoff value for symptom duration was identified as 24.00 months, yielding a sensitivity of 82.4% and a specificity of 86.2%. McGowan grade demonstrated a moderate discriminative ability with an AUC of 0.651; the optimal threshold corresponded to Grade III classification, providing a sensitivity of 76.5% and specificity of 53.8%. Age had an AUC of 0.599, sex 0.585, side 0.501, BMI 0.525, CMAP 0.471, MNCV 0.497, VAS 0.467, and PRUNE 0.537, indicating limited discriminative abilities for these variables. The ROC curves for all preoperative predictors are shown in Fig. 1 , and the detailed AUC values, optimal thresholds, sensitivities, and specificities are summarized in Table 4 . Further analysis of the distribution patterns of preoperative variables between the aggravation and non-aggravation groups revealed distinct differences for symptom duration and McGowan grade. As shown in Fig. 2 A, patients in the aggravation group demonstrated a right-shifted distribution for symptom duration, with a higher proportion exceeding the 24-month cutoff. A similar pattern was observed for McGowan grade, with a larger fraction of patients in the aggravation group presenting with Grade III severity. The age distribution showed minor separation between groups but with considerable overlap. In contrast, non-predictive variables including CMAP, MNCV, VAS, PRUNE, sex, side, and BMI displayed largely overlapping distributions between the two groups, as illustrated in Fig. 2 B. Correlation analysis among the preoperative variables, presented in Fig. 3 , revealed a strong positive correlation between VAS and PRUNE scores (r = 0.965), indicating that higher preoperative pain was associated with worse upper extremity function. A moderate negative correlation was observed between CMAP and PRUNE scores (r = − 0.369), suggesting that lower motor conduction amplitude correlated with worse functional scores. No significant correlations exceeding r = 0.7 were observed between symptom duration, McGowan grade, or other variables, indicating an acceptable absence of multicollinearity among the main predictors used in the regression model. Discussion This study systematically evaluated the predictive value of preoperative clinical and electrophysiological variables for early symptom aggravation following anterior subcutaneous transposition of the ulnar nerve in patients with cubital tunnel syndrome 16 , 17 . The findings revealed that longer symptom duration and higher McGowan grade were significantly associated with an increased risk of early postoperative symptom worsening 18 . Electrophysiological and clinical scoring variables, including CMAP, MNCV, PRUNE, and VAS, demonstrated limited predictive value 19 . Demographic factors such as sex, BMI, side of surgery, and age were not significantly associated with early symptom aggravation 20 . These results provide new insights into risk stratification before surgery and suggest the importance of detailed preoperative assessment. Longer symptom duration emerged as the most significant independent predictor of early postoperative symptom aggravation 21 . Multivariate logistic regression analysis revealed that each additional month of symptom duration increased the odds of early aggravation by 15% (odds ratio [OR] 1.150, 95% confidence interval [CI]: 1.080–1.225, p < 0.00001). Receiver operating characteristic (ROC) curve analysis further supported its predictive value, with an area under the curve (AUC) of 0.890, and an optimal cutoff of 24.00 months yielding a sensitivity of 82.4% and specificity of 86.2%. These findings indicate that a prolonged disease course significantly compromises postoperative recovery potential. Chronic compression of the ulnar nerve over an extended period can lead to progressive ischemia, perineural fibrosis, and irreversible axonal degeneration 11 , 22 . Histopathological studies have demonstrated that sustained mechanical compression impairs intraneural blood flow, increases endoneurial fluid pressure, and promotes fibrotic changes within the nerve, thereby hindering effective nerve regeneration even after decompression. Moreover, long-standing compression diminishes Schwann cell functionality, reduces axonal sprouting capability, and alters the microenvironment essential for nerve repair 23 , 24 . These pathophysiological changes are compounded over time, explaining why patients with symptom durations exceeding 24 months are at a significantly higher risk of early symptom aggravation 25 . Previous clinical studies have also correlated longer symptom duration with poorer postoperative functional outcomes in cubital tunnel syndrome, emphasizing the detrimental effects of delayed intervention 10 , 26 . Collectively, these results underscore the critical importance of early diagnosis and timely surgical decompression to optimize nerve recovery and minimize the risk of early postoperative symptom worsening in patients with cubital tunnel syndrome 27 , 28 . Higher McGowan grade was also associated with an increased likelihood of early postoperative symptom aggravation, although the association did not reach conventional statistical significance 29 . Multivariate logistic regression analysis showed an odds ratio (OR) of 3.224 for patients with Grade III severity compared to those with lower grades (95% confidence interval [CI]: 0.843–12.339, p = 0.087). Additionally, ROC analysis yielded an area under the curve (AUC) of 0.651 for McGowan grade, indicating moderate discriminative ability. The optimal threshold corresponded to the presence of Grade III, providing a sensitivity of 76.5% and a specificity of 53.8%. McGowan classification is a widely adopted clinical grading system for ulnar nerve dysfunction, categorizing patients based on the severity of intrinsic muscle atrophy and motor weakness 6 , 30 . Grade III is characterized by pronounced muscle wasting and marked motor impairment, reflecting advanced axonal loss and chronic denervation 31 . Patients presenting with Grade III severity are likely to have sustained extensive and possibly irreversible nerve injury, limiting their capacity for postoperative functional recovery. In the context of early postoperative assessment, these patients may exhibit persistent or even worsened symptoms despite adequate surgical decompression. Prior research has consistently demonstrated that higher preoperative McGowan grades are associated with poorer surgical outcomes, supporting the concept that the extent of preoperative functional impairment correlates with the nerve's regenerative potential 32 . Although McGowan grade did not independently predict early aggravation with high statistical certainty in this study, its moderate predictive value and established clinical relevance highlight the need for careful preoperative functional evaluation and counseling, particularly in patients presenting with severe preoperative deficits 33 . Among the electrophysiological indicators assessed, compound muscle action potential (CMAP) and motor nerve conduction velocity (MNCV) demonstrated limited predictive value for early postoperative symptom aggravation 34 , 35 . In multivariate logistic regression analysis, CMAP showed an odds ratio (OR) of 3.432 (p = 0.679), while MNCV had an OR of 0.973 (p = 0.602), indicating no significant associations. ROC analysis yielded AUC values of 0.471 for CMAP and 0.497 for MNCV, both suggesting poor discriminative ability. Although these electrophysiological measures were not significant predictors in this study, CMAP and MNCV remain important indicators of nerve integrity and function 36 . CMAP reflects the summated electrical activity of muscle fibers innervated by the stimulated nerve, and lower CMAP amplitudes are generally associated with greater axonal loss 37 . MNCV measures the speed of impulse conduction along motor fibers and may decrease in demyelinating conditions or with significant axonal degeneration 38 , 39 . The limited predictive value observed in this cohort may be due to the fact that early postoperative outcomes are influenced not only by the severity of preoperative axonal damage but also by factors such as the duration of compression and the timing of surgical intervention 5 . Nevertheless, these findings suggest that while CMAP and MNCV provide valuable baseline information regarding the degree of nerve injury, they may not reliably predict early postoperative symptom trajectories in isolation 40 . Among the clinical scoring measures, neither the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score nor the Visual Analog Scale (VAS) score demonstrated significant predictive value for early postoperative symptom aggravation 41 . Multivariate logistic regression showed an odds ratio (OR) of 0.997 for PRUNE (p = 0.933) and 0.544 for VAS (p = 0.596), indicating no significant associations. ROC analysis yielded an area under the curve (AUC) of 0.537 for PRUNE and 0.467 for VAS, both falling below the threshold commonly accepted for clinical utility 42 . Although these subjective measures did not predict early symptom worsening, they remain important indicators of patient-perceived disability and pain. The PRUNE score assesses upper extremity function specifically in patients with ulnar nerve dysfunction, and the VAS score captures pain intensity, which is a major symptom domain in cubital tunnel syndrome 43 . Interestingly, correlation analysis revealed a strong positive relationship between PRUNE and VAS scores (r = 0.965), suggesting that patients reporting higher pain levels also perceive greater functional impairment 44 . Despite this strong correlation, the lack of predictive utility may be attributed to the subjective nature of these assessments, which can be influenced by psychological and environmental factors independent of nerve recovery status 35 . These findings indicate that while PRUNE and VAS are useful for assessing clinical symptoms, they may not serve as reliable standalone predictors of early postoperative outcomes. Other demographic and baseline clinical variables, including sex, BMI, side of surgery, and age, did not show significant associations with early postoperative symptom aggravation in this study 31 , 45 . Logistic regression analysis revealed an odds ratio (OR) of 1.830 for sex (p = 0.402), suggesting no significant difference in aggravation risk between males and females 18 , 46 . BMI demonstrated an OR of 1.150 per unit increase (p = 0.195), and side of surgery showed an OR of 0.224 (p = 0.063), indicating a trend but no statistically meaningful relationship. Age exhibited an OR of 1.015 per year (p = 0.624). Receiver operating characteristic (ROC) analysis further confirmed the limited discriminative ability of these variables, with AUC values of 0.585 for sex, 0.525 for BMI, 0.501 for side, and 0.599 for age 47 . Previous studies investigating the role of demographic factors in surgical outcomes for cubital tunnel syndrome have yielded inconsistent results 48 – 50 . Some reports suggested that male patients might experience better nerve regeneration rates, potentially due to differences in hormonal influences or nerve fiber density, although conclusive evidence remains lacking. In terms of BMI, elevated body mass index has been proposed to negatively impact postoperative recovery through increased mechanical compression and impaired microcirculation around the nerve, yet large-scale studies have not consistently demonstrated a significant association 51 . Regarding the side of surgery, dominant hand involvement has been hypothesized to affect recovery trajectories, but most investigations found no substantial differences in outcomes based on surgical side 1 . As for age, it is generally accepted that advancing age is associated with diminished peripheral nerve regenerative capacity; however, the relationship between age and surgical outcomes is complex and may be influenced by comorbidities and baseline functional status 52 . This study evaluated whether demographic and baseline clinical variables predict early postoperative symptom aggravation following anterior subcutaneous transposition in cubital tunnel syndrome (CuTS). We found no significant associations for sex, BMI, surgical side, or age, aligning with prior research suggesting these factors have limited relevance in early outcomes. Given their low predictive value, emphasis should instead be placed on nerve injury severity and symptom duration—variables more closely linked to postoperative trajectories. Methodologically, this study benefitted from a standardized surgical approach by a single experienced surgeon, consistent pre- and postoperative evaluations, and fixed follow-up intervals at 2 weeks and 6 months. The focus on early postoperative symptom aggravation—a clinically important yet underexplored phenomenon—adds novelty and practical relevance to our findings. However, several limitations warrant mention. The single-center design and modest sample size may limit generalizability. Long-term outcomes beyond 6 months were not assessed. Subjective metrics like PRUNE and VAS, though informative, are vulnerable to reporting bias. Moreover, variables such as intraoperative nerve handling, rehabilitation adherence, and psychosocial status were not analyzed. Future large-scale, multicenter studies with extended follow-up are needed to validate and expand upon these findings. Conclusion In conclusion, this study demonstrates that early postoperative symptom aggravation is a relatively common but typically transient phenomenon following anterior ulnar nerve transposition for cubital tunnel syndrome. Symptom duration and McGowan grade emerged as the most robust preoperative predictors of early aggravation, reflecting underlying neural vulnerability and chronicity of compression. A simple risk stratification model based on these variables achieved excellent discriminative performance and offers a practical tool for preoperative counseling and postoperative management. Integrating objective clinical assessments with individualized risk profiling may enhance surgical decision-making, improve patient expectations, and prevent misinterpretation of early postoperative symptom fluctuations. Future research should focus on validating and expanding this predictive framework through larger, prospective, and multimodal studies to further optimize outcomes for patients undergoing CuTS surgery. Abbreviations AUC Area Under the Curve BMI Body Mass Index CI Confidence Interval CMAP Compound Muscle Action Potential CuTS Cubital Tunnel Syndrome MNCV Motor Nerve Conduction Velocity OR Odds Ratio PRUNE Patient-Rated Ulnar Nerve Evaluation ROC Receiver Operating Characteristic SD Standard Deviation SNCV Sensory Nerve Conduction Velocity VAS Visual Analog Scale 2PD Two-Point Discrimination Declarations Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (No. PJ2023-04-21). Consent to Participate Informed consent was obtained from all individual participants included in the study. Consent to Publish The authors affirm that human research participants provided informed consent for publication of anonymized clinical data. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Tianyou Hu, Tao Zhou, Hongxiang Zhou, Yvjie Bian, and Qiankun Wang. The first draft of the manuscript was written by Tianyou Hu, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Wade RG et al (2020) Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis. 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Ann Plast Surg 87:e1–e21. 10.1097/sap.0000000000002767 Sun J, Mao L, Wu X, Wang D, Chen Z (2024) Research progress on the diagnoses and rehabilitation for cubital tunnel syndrome: A narrative review. J Neurorestoratology 12:100116. 10.1016/j.jnrt.2024.100116 Khan M et al (2022) Soft tissue reconstruction of thumb: Classification of defects and standardization of treatment. Polski przeglad chirurgiczny 95:0. 10.5604/01.3001.0016.1601 Wood WA, Wood MA (2003) Decompression of peripheral nerves for diabetic neuropathy in the lower extremity. J foot ankle surgery: official publication Am Coll Foot Ankle Surg 42:268–275. 10.1016/s1067-2516(03)00313-2 Tang P, Hoellwarth JS, Chauhan A (2016) Recurrent Cubital Tunnel Syndrome: A Critical Analysis Review. JBJS reviews 4. 10.2106/jbjs.Rvw.O.00022 Choi PJ et al (2018) The Deep Fascia of the Forearm and the Ulnar Nerve: An Anatomical Study. Cureus 10, e2842. 10.7759/cureus.2842 Gaspar MP, Kane PM, Putthiwara D, Jacoby SM, Osterman AL (2016) Predicting Revision Following In Situ Ulnar Nerve Decompression for Patients With Idiopathic Cubital Tunnel Syndrome. J Hand Surg 41:427–435. 10.1016/j.jhsa.2015.12.012 Suzuki T et al (2017) Predictors of postoperative outcomes of cubital tunnel syndrome treatments using multiple logistic regression analysis. J Orthop science: official J Japanese Orthop Association 22:453–456. 10.1016/j.jos.2017.01.003 Aleem AW, Krogue JD, Calfee RP (2014) Outcomes of revision surgery for cubital tunnel syndrome. J Hand Surg 39:2141–2149. 10.1016/j.jhsa.2014.07.013 Asami A (2001) The evaluation of pre- and post-operative classification system for cubital tunnel syndrome. Hand surgery: Int J devoted hand Up limb Surg Relat Res : J Asia-Pacific Federation Soc Surg Hand 6:187–190. 10.1142/s0218810401000667 Florczynski MM, Kong L, Burns PB, Wang L, Chung KC (2023) Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve. J Hand Surg 48:28–36. 10.1016/j.jhsa.2022.10.008 Sprangers PN, van der Heijden EPA (2023) Protocol for Endoscopic Versus Open Cubital tunnel release (EVOCU): an open randomized controlled trial: EVOCU trial: Endoscopic Versus Open Cubital tunnel release. BMC Musculoskelet Disord 24:137. 10.1186/s12891-023-06234-y Power HA et al (2019) Compound Muscle Action Potential Amplitude Predicts the Severity of Cubital Tunnel Syndrome. J Bone Joint Surg Am Vol 101:730–738. 10.2106/jbjs.18.00554 Lee TY, Dy CJ, Ray WZ, Colorado BS, Brogan DM (2024) Gray-Scale and Power Doppler Ultrasound Findings Predictive of Cubital Tunnel Syndrome Severity. Hand (New York N Y) 19:392–399. 10.1177/15589447221127334 Qian Y, Bao B, Wei J, Song J, Zheng X (2024) Anterior transposition and positioning via helix sling method in cubital tunnel syndrome: An open-label, retrospective trial of maximum 5-year follow-up. Heliyon 10:e25177. 10.1016/j.heliyon.2024.e25177 Shibuya J, Takahara M, Satake H, Takagi M (2024) Subcutaneous Anterior Transposition With Modified Procedures to Prevent Recurrence Associated With the Transposed Ulnar Nerve. Tech Hand Up Extrem Surg 28:132–136. 10.1097/bth.0000000000000477 Liu Z, Jia ZR, Wang TT, Shi X, Liang W (2015) Preliminary study on the lesion location and prognosis of cubital tunnel syndrome by motor nerve conduction studies. Chin Med J 128:1165–1170. 10.4103/0366-6999.156100 Delancy MM, Kozusko SD, Franco MJ (2023) A 10-Year Update of Outcome Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature. Ann Plast Surg 91:363–369. 10.1097/sap.0000000000003637 Gallo L et al (2020) Reporting Outcomes and Outcome Measures in Cubital Tunnel Syndrome: A Systematic Review. J Hand Surg 45:707–728e709. 10.1016/j.jhsa.2020.04.001 Kortlever JTP, Somogyi JR, Ring D, Reichel LM, Vagner GA (2022) A Comparison of Nerve-Specific, Condition-Specific, and Upper Extremity-Specific Patient-Reported Outcome Measures in Patients With Carpal and Cubital Tunnel Syndrome. J Hand Surg 47:791. .e791-791.e710 Dabbagh A, Saeidi S, MacDermid JC (2022) Psychometric Properties of the Patient-Reported Outcome Measures for People With Ulnar Nerve Entrapment at the Elbow: A Systematic Review. Phys Ther 102. 10.1093/ptj/pzac103 Kong L et al (2018) Predictors of surgical outcomes after in situ ulnar nerve decompression for cubital tunnel syndrome. Ther Clin Risk Manag 14:69–74. 10.2147/tcrm.S155284 Roh YH, Kim S, Gong HS, Baek GH (2018) Clinical features affecting the patient-based outcome after minimal medial epicondylectomy for cubital tunnel syndrome. J Plast Reconstr aesthetic surgery: JPRAS 71:1446–1452. 10.1016/j.bjps.2018.05.038 Grisdela P Jr. et al (2023) Do Socioeconomic Factors Affect Symptom Duration and Disease Severity at Presentation for Cubital Tunnel Syndrome? Hand (New York, N.Y.) , 15589447231213386. 10.1177/15589447231213386 Węgiel A, Karauda P, Zielinska N, Tubbs RS, Olewnik Ł (2023) Radial nerve compression: anatomical perspective and clinical consequences. Neurosurg Rev 46:53. 10.1007/s10143-023-01944-2 Wolny T et al (2022) The Effects of Physiotherapy in the Treatment of Cubital Tunnel Syndrome: A Systematic Review. J Clin Med 11. 10.3390/jcm11144247 Ishii T et al (2018) Cubital tunnel syndrome caused by a very old chronic nonunion of the olecranon: a case report. J Shoulder Elbow Surg 27:e344–e347. 10.1016/j.jse.2018.07.009 Zhang D, Earp BE, Homer SH, Blazar P (2023) Factors Associated With Severity of Cubital Tunnel Syndrome at Presentation. Hand (New York, N.Y.) 18, 401–406. 10.1177/15589447211058821 Osei DA, Groves AP, Bommarito K, Ray WZ (2017) Cubital Tunnel Syndrome: Incidence and Demographics in a National Administrative Database. Neurosurgery 80, 417–420. 10.1093/neuros/nyw061 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7075399","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508072995,"identity":"5734f500-6cf5-4093-91ef-2d54cf4ddcf1","order_by":0,"name":"Tianyou Hu","email":"","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tianyou","middleName":"","lastName":"Hu","suffix":""},{"id":508072996,"identity":"3759f66f-6444-4290-8dea-b683c0abe483","order_by":1,"name":"Yujie Bian","email":"","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yujie","middleName":"","lastName":"Bian","suffix":""},{"id":508072997,"identity":"e857e056-8299-4679-a949-20c99224db65","order_by":2,"name":"Tao Zhou","email":"","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Zhou","suffix":""},{"id":508072998,"identity":"61951165-1294-47aa-89dc-f3e138693e0b","order_by":3,"name":"Qiankun Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qiankun","middleName":"","lastName":"Wang","suffix":""},{"id":508072999,"identity":"37bf2595-5f41-429b-af72-bf01b47f235a","order_by":4,"name":"Hongxiang Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDACCQYGZgYGGzl+9uYDBz78IF5LmrFkz7HEgzN7iNdyOHHDjRzjwxxsROiQn918TLqwDWTLmQ+HGXgY5PnFDuDXwjjnWJr0jDMgv/RuOFxgwWA4c3YCfi3MEjlm0jwVIFvObjg8g4chweA2AS1sYC0GYL88OMzDRoQWHogtYC0MxGmRkEhLtuY5Aw5kA2AgSxD2i/yM5IO3edvAUfn4w4cfNvL80gS0YNhKmvJRMApGwSgYBdgBACRXRCdL8OyCAAAAAElFTkSuQmCC","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":true,"prefix":"","firstName":"Hongxiang","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2025-07-08 13:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7075399/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7075399/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-025-03992-2","type":"published","date":"2026-02-19T15:57:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90801135,"identity":"43be0e10-fe7c-4465-b769-99f781a88328","added_by":"auto","created_at":"2025-09-08 10:13:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":248820,"visible":true,"origin":"","legend":"\u003cp\u003eROC Curves of Preoperative Predictors for Early Symptom Aggravation\u003c/p\u003e\n\u003cp\u003eReceiver operating characteristic (ROC) curves of preoperative variables for predicting early symptom aggravation. Variables include course (AUC = 0.890), mcgowan (AUC = 0.651), age (AUC = 0.599), sex (AUC = 0.585), side (AUC = 0.501), bmi (AUC = 0.525), CMAP (AUC = 0.471), MNCV (AUC = 0.497), VAS (AUC = 0.467), and PRUNE (AUC = 0.537).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7075399/v1/f2204eff74720e5c6d4949ec.png"},{"id":90801137,"identity":"940e6cc3-915a-49bd-bfa9-cb1569d6a86d","added_by":"auto","created_at":"2025-09-08 10:13:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":219552,"visible":true,"origin":"","legend":"\u003cp\u003eA Distribution Patterns of Typical Predictors by Group\u003c/p\u003e\n\u003cp\u003eDistribution density plots of typical predictors (course, mcgowan, and age) in the aggravated and non-aggravated groups. Red lines represent the aggravated group; blue lines represent the non-aggravated group.\u003c/p\u003e\n\u003cp\u003eB Distribution Patterns of Non-Predictive Variables by Group\u003c/p\u003e\n\u003cp\u003eDistribution density plots of non-predictive variables (CMAP, MNCV, VAS, PRUNE, sex, side, and bmi) in the aggravated and non-aggravated groups. Green lines indicate the aggravated group and light green lines indicate the non-aggravated group.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7075399/v1/a822e79ca933cdbd5ae5a77d.png"},{"id":90801943,"identity":"5afff088-c6f3-4064-8dde-065e35db409f","added_by":"auto","created_at":"2025-09-08 10:21:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":186190,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation Heatmap of Preoperative Variables\u003c/p\u003e\n\u003cp\u003eCorrelation matrix of preoperative variables included in model development. Moderate correlations were observed between PRUNE and VAS (r ≈ 0.96) and between PRUNE and CMAP (r ≈ –0.13).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7075399/v1/7798c065f0863d23355c0e93.png"},{"id":103251063,"identity":"d8b7e710-3607-44aa-bcf3-826ed39763e0","added_by":"auto","created_at":"2026-02-23 16:03:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1295521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7075399/v1/f375b5ec-7638-4c7f-b6ba-1898c3819451.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early Symptom Aggravation Following Ulnar Nerve Transposition for Cubital Tunnel Syndrome: Incidence, Predictive Factors, and Threshold-Based Risk Stratification","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity, following carpal tunnel syndrome, and is characterized by chronic compression of the ulnar nerve at the elbow\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Patients typically present with numbness, paresthesia in the ulnar distribution, intrinsic hand muscle weakness, and progressive functional decline\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Surgical decompression remains the mainstay of treatment for moderate to severe cases, with anterior transposition of the ulnar nerve being one of the most widely performed techniques\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. While most patients achieve favorable long-term outcomes, a subset experiences transient symptom aggravation shortly after surgery, manifesting as increased pain, sensory disturbances, or motor dysfunction\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. This early postoperative symptom worsening may lead to patient anxiety, dissatisfaction, and confusion in clinical interpretation, sometimes being mistaken for surgical failure or recurrent nerve compression\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn other entrapment neuropathies, such as carpal tunnel syndrome, early postoperative symptom exacerbation has been reported and is often attributed to transient factors including postoperative edema, local ischemia, or nerve manipulation-induced neurapraxia\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Similar hypotheses have been proposed for CuTS, suggesting mechanisms such as postoperative inflammatory swelling, temporary traction injury during nerve mobilization, and dynamic instability of the transposed nerve\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, these suppositions are primarily based on clinical impressions, and robust data remain lacking. Despite its potential clinical relevance, early symptom aggravation in CuTS has not been systematically defined or quantitatively studied\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In particular, there is a paucity of research examining the relationship between preoperative clinical or electrophysiological variables and the risk of early symptom worsening. Without clear definitions and predictive markers, clinicians face challenges in preoperative counseling and postoperative management, and patients may have unmet expectations regarding early recovery trajectories.\u003c/p\u003e\u003cp\u003eIn this retrospective cohort study, we aimed to systematically characterize early postoperative symptom aggravation in patients undergoing anterior subcutaneous transposition of the ulnar nerve. Using standardized clinical assessments and electrophysiological testing, we further sought to identify preoperative predictors associated with this phenomenon and to establish preliminary thresholds to aid in clinical risk stratification.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Method","content":"\u003cp\u003eStudy Design and Patient Selection\u003c/p\u003e\u003cp\u003eThis retrospective cohort study was conducted at the Department of Orthopaedic Surgery, First Affiliated Hospital of Anhui Medical University. Patients diagnosed with cubital tunnel syndrome (CuTS) and treated with anterior ulnar nerve transposition between January 2020 and December 2023 were screened for eligibility. All surgeries were performed by a single senior surgeon to minimize technical variability. The diagnosis of CuTS was based on clinical symptoms (e.g., paresthesia in the ulnar nerve distribution, weakness of intrinsic hand muscles), physical examination, and electrophysiological studies.\u003c/p\u003e\u003cp\u003e Inclusion criteria were: (1) confirmed diagnosis of CuTS, (2) failure of conservative management for at least three months, and (3) receipt of anterior ulnar nerve transposition as the primary surgical treatment. Exclusion criteria included: (1) prior surgery on the affected limb, (2) systemic neurological disorders (e.g., diabetes mellitus with peripheral neuropathy), (3) perioperative use of corticosteroids, and (4) incomplete clinical or follow-up data\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. All patients were followed for a minimum of six months postoperatively. The study protocol was approved by the institutional ethics committee, and informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003eSurgical Procedure and Postoperative Care\u003c/p\u003e\u003cp\u003eAll patients underwent open anterior subcutaneous transposition of the ulnar nerve under general anesthesia and tourniquet control. After a standard curvilinear incision centered over the medial epicondyle, the ulnar nerve was exposed, and compressive structures including Osborne’s ligament and the arcuate ligament of Osborne were released. The nerve was then mobilized and transposed anteriorly into a subcutaneous pocket, taking care to avoid torsion or undue tension.\u003c/p\u003e\u003cp\u003eTo maintain the new position of the nerve and reduce postoperative mobility-related strain, a fascial flap was fashioned from the flexor-pronator origin and sutured to the subcutaneous tissue, forming a soft-tissue sling. Two fixation methods were used sequentially across the cohort: traditional absorbable sutures buried under the skin, and percutaneous external suturing, in which sutures were passed through the skin surface to secure the flap. Postoperative care included limb elevation, elbow immobilization at 30–45° flexion for one week, and standardized physical therapy initiated after splint removal. No corticosteroids or anti-edema agents were administered perioperatively.\u003c/p\u003e\u003cp\u003eData Preprocessing and Encoding\u003c/p\u003e\u003cp\u003eAll patients with complete baseline clinical and electrophysiological data were included in the analysis. There were no missing values in the dataset at the time of statistical modeling. To maintain data consistency, specific rules were applied for handling incomplete entries where necessary during initial data collection. For the side of surgery, any missing or ambiguous entries were imputed as the right side, reflecting the dominant side distribution observed in the cohort\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. For symptom duration (course), missing values were replaced with the cohort mean, ensuring minimal bias in central tendency measures.\u003c/p\u003e\u003cp\u003eCategorical variables were encoded as binary indicators to facilitate statistical modeling. Sex was coded as 1 for male and 0 for female. The surgical side was coded as 1 for the right and 0 for the left. The McGowan classification, originally a three-level ordinal variable (Grades I–III), was dichotomized for analysis: Grades I and II were grouped as 0 (mild to moderate impairment), and Grade III was coded as 1 (severe impairment), based on established clinical thresholds for functional severity.\u003c/p\u003e\u003cp\u003eSymptom duration (course) was treated as a continuous variable, measured in months. Preoperative clinical scores, including the Visual Analog Scale (VAS) and the Patient-Rated Ulnar Nerve Evaluation (PRUNE), were retained as continuous variables, as were electrophysiological measures such as compound muscle action potential (CMAP) amplitude and sensory nerve conduction velocity (SNCV).\u003c/p\u003e\u003cp\u003eDefinition of Outcome\u003c/p\u003e\u003cp\u003eThe primary outcome of this study was early postoperative symptom aggravation, which was operationally defined as a clinically relevant rebound in clinical evaluation or electrophysiological indicators compared to baseline measurements. Patients were classified as aggravated if they exhibited a deterioration in at least one of the following domains.\u003c/p\u003e\u003cp\u003eFor clinical evaluation indicators, aggravation was defined as an increase in the Visual Analog Scale (VAS) score or an increase in the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score. For electrophysiological indicators, it was defined as a decrease in compound muscle action potential (CMAP) amplitude or a decrease in sensory nerve conduction velocity (SNCV).\u003c/p\u003e\u003cp\u003eThresholds for defining rebound were determined based on clinically noticeable changes commonly observed in peripheral nerve decompression procedures and were adapted to reflect the postoperative recovery context specific to cubital tunnel syndrome.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive Statistics\u003c/p\u003e\u003cp\u003eContinuous variables were summarized as means and standard deviations (mean ± SD), while categorical variables were presented as frequencies and percentages. The distribution of continuous variables was assessed for normality using the Shapiro–Wilk test.\u003c/p\u003e\u003cp\u003eUnivariate Analysis\u003c/p\u003e\u003cp\u003eFor comparisons between the aggravated and non-aggravated groups, appropriate statistical tests were applied based on data distribution. Continuous variables were compared using independent samples t-tests for normally distributed data or Mann–Whitney U tests for non-normally distributed data. Categorical variables were compared using the chi-square test or Fisher’s exact test when expected cell counts were less than five. A p-value of \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eMultivariate Analysis\u003c/p\u003e\u003cp\u003eTo identify independent preoperative predictors of early postoperative symptom aggravation, multivariate logistic regression analysis was performed. Variables with clinical relevance and those achieving a p-value \u0026lt; 0.10 in univariate analysis were entered into the model. Stepwise selection procedures were applied to refine the model, retaining variables with significant contributions (p \u0026lt; 0.05). Categorical variables (sex, side, McGowan grade) were entered as binary variables, and continuous variables (age, BMI, course, CMAP, SNCV, VAS, PRUNE) were retained as continuous predictors. Variables exhibiting sparse distribution (e.g., sex, side) or high collinearity were excluded based on correlation analysis.\u003c/p\u003e\u003cp\u003eThe logistic regression model was reported with odds ratios (OR), 95% confidence intervals (CI), and p-values for each predictor. The model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test.\u003c/p\u003e\u003cp\u003ePredictive Performance Assessment\u003c/p\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve analysis was performed for each preoperative variable to evaluate its discriminative ability in predicting early symptom aggravation. The area under the curve (AUC) was calculated along with 95% confidence intervals. Optimal cutoff values were determined using the Youden index to maximize sensitivity and specificity. Special attention was given to symptom duration, for which a cutoff value of 24.00 months was identified, providing optimal discriminative performance.\u003c/p\u003e\u003cp\u003eCorrelation Analysis\u003c/p\u003e\u003cp\u003eSpearman correlation coefficients were calculated to examine relationships between continuous variables. A correlation heatmap was generated to visualize inter-variable relationships and assess multicollinearity. Variables with a correlation coefficient (r) greater than 0.7 were considered to exhibit strong collinearity and were evaluated carefully during multivariate modeling.\u003c/p\u003e\u003cp\u003eAll statistical analyses were conducted using SPSS Statistics version 23.0 (IBM Corp., Armonk, NY, USA) and R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria). A two-sided p-value of \u0026lt; 0.05 was considered statistically significant for all analyses.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 127 patients who underwent anterior subcutaneous transposition of the ulnar nerve were included in the study. The cohort comprised 77 males (67.5%) and 37 females (32.5%), with a mean age of 52.86 ± 13.78 years. The mean symptom duration was 1.83 ± 2.85 years, and the mean body mass index (BMI) was 23.87 ± 3.17 kg/m². Surgical intervention was performed on the right side in 73.22% of patients and on the left side in 26.78%. Preoperative severity assessed using the McGowan classification showed that 18.1% of patients were classified as Grade I, 26.7% as Grade II, and 55.1% as Grade III. Among all patients, 34 (26.8%) met the criteria for early postoperative symptom aggravation and were categorized into the aggravation group, while the remaining 93 were classified into the non-aggravation group. Baseline characteristics of the entire cohort and the two subgroups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics of Patients with Cubital Tunnel Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge(year)(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\pm\\:s\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eSex (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCourse of disease(year)(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\pm\\:s\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBMI(kg/m²)(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\pm\\:s\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eLeft or right hand (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003eMcGowan (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eleft\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eright\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eⅠ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eⅢ\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll Patiences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.86 ± 13.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e67.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.83 ± 2.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e23.87 ± 3.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e26.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e73.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e18.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e26.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e55.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAggravation Group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.42 ± 12.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e79.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.03 ± 3.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24.00 ± 3.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e26.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e73.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e23.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e76.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAt the 6-month postoperative follow-up, patients demonstrated significant improvements in both subjective and objective measures. The mean Visual Analog Scale (VAS) score decreased from 4.61 ± 1.01 preoperatively to 2.22 ± 1.16 (p = 0.0005), while the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score improved from 50.91 ± 10.04 to 30.08 ± 6.82 (p = 0.0006). Sensory recovery was reflected in the improvement of two-point discrimination (2PD) from 8.87 ± 1.89 mm to 5.80 ± 1.89 mm (p = 0.0032). Electrophysiological parameters showed marked improvements, with compound muscle action potential (CMAP) amplitude increasing from 1.79 ± 0.38 mV to 5.70 ± 0.76 mV (p = 0.0006), sensory nerve conduction velocity (SNCV) from 32.49 ± 6.41 m/s to 48.04 ± 5.22 m/s (p = 0.0004), and motor nerve conduction velocity (MNCV) from 32.92 ± 6.32 m/s to 48.20 ± 4.74 m/s (p = 0.0003). These long-term outcomes are detailed in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eAt the 2-week postoperative evaluation, the majority of patients exhibited early signs of improvement. The mean VAS score decreased from 4.61 ± 1.01 to 3.89 ± 1.10 (p = 0.038), the PRUNE score decreased from 50.91 ± 10.04 to 46.86 ± 10.35 (p = 0.0027), and 2PD improved from 8.87 ± 1.89 mm to 8.33 ± 2.24 mm (p = 0.047). These short-term changes for the overall cohort are summarized in Supplementary Table\u0026nbsp;2.\u003c/p\u003e\u003cp\u003eIn contrast to the overall cohort, 34 patients (26.8%) exhibited significant deterioration within 2 weeks postoperatively and were categorized into the early symptom aggravation group. In this subgroup, the VAS score increased from 4.57 ± 1.00 to 4.21 ± 1.21 (p = 0.0186), and the PRUNE score increased from 51.96 ± 9.80 to 53.66 ± 9.27 (p = 0.0003). The 2PD worsened from 9.69 ± 1.07 mm to 10.75 ± 1.27 mm (p = 0.0002). Electrophysiological measures also showed deterioration, with CMAP decreasing from 1.77 ± 0.38 mV to 1.29 ± 0.28 mV (p = 0.0002), SNCV decreasing from 33.08 ± 6.18 m/s to 29.58 ± 5.55 m/s (p = 0.0002), and MNCV decreasing from 32.83 ± 5.56 m/s to 26.41 ± 4.62 m/s (p = 0.0002). The detailed changes in the overall cohort and in the aggravation subgroup are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec, and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ea Comparison of Preoperative and Short-Term VAS, PRUNE, and Two-Point Discrimination in Patients with Symptom Aggravation(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\pm\\:s\\)\u003c/span\u003e\u003c/span\u003e)༈α = 0.05༉\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePRUNE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTwo-Point Discrimination(mm)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.57 ± 1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.96 ± 9.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.69 ± 1.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epost(short-term)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.21 ± 1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.66 ± 9.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.75 ± 1.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS-W-p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0073/0.0588\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.4635/0.5421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002/0.0033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSRT-p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0186\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb Comparison of Preoperative and Short-Term CMAP, SNCV, and MNCV in Patients with Symptom Aggravation(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\pm\\:s\\)\u003c/span\u003e\u003c/span\u003e)༈α = 0.05༉\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCAMP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSNCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMNCV\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.77 ± 0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.08 ± 6.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.83 ± 5.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epost(short-term)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.29 ± 0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.58 ± 5.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.41 ± 4.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS-W-p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.3893/0.1168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.2901/0.3673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5611/0.6112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSRT-p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMultivariate logistic regression analysis was performed to identify preoperative predictors associated with early symptom aggravation. Among all considered variables, symptom duration and McGowan classification were retained in the final model. Symptom duration was independently associated with early aggravation, with an odds ratio (OR) of 1.150 per month increase (95% confidence interval [CI]: 1.080–1.225, p \u0026lt; 0.00001), indicating that each additional month of symptoms prior to surgery increased the odds of postoperative symptom aggravation by 15%. Severe McGowan grade (Grade III) was associated with an OR of 3.224 compared to less severe grades (95% CI: 0.843–12.339, p = 0.087). Although not reaching conventional statistical significance, this suggests a higher likelihood of early postoperative symptom worsening in patients with Grade III severity. Other variables, including sex (OR = 1.830, p = 0.402), side (OR = 0.224, p = 0.063), age (OR = 1.015 per year, p = 0.624), BMI (OR = 1.150 per unit, p = 0.195), CMAP (OR = 3.432, p = 0.679), MNCV (OR = 0.973, p = 0.602), VAS (OR = 0.544, p = 0.596), and PRUNE (OR = 0.997, p = 0.933), did not show significant associations and were excluded during stepwise regression. Full logistic regression results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate Logistic Regression Analysis of Preoperative Predictors for Early Symptom Aggravation After Ulnar Nerve Transposition\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI Lower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI Upper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003econst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-6.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.604\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.830\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.445\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.533\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.402\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eside\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.086\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emcgowan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.843\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.339\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.955\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.624\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebmi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.931\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.195\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecourse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.080\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.23 × 10⁻⁵\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCMAP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1180.634\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.679\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMNCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.973\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.602\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.608\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRUNE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.997\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.939\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.933\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: OR, odds ratio; CI, confidence interval; p-value \u0026lt; 0.05 was considered statistically significant.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve analysis demonstrated that symptom duration had the highest discriminative ability, with an area under the curve (AUC) of 0.890. The optimal cutoff value for symptom duration was 24.00 months, with a sensitivity of 82.4% and specificity of 86.2%. McGowan grade exhibited a moderate predictive ability with an AUC of 0.651, and age showed an AUC of 0.599. Other variables, including sex (AUC = 0.585), side (AUC = 0.501), BMI (AUC = 0.525), CMAP (AUC = 0.471), MNCV (AUC = 0.497), VAS (AUC = 0.467), and PRUNE (AUC = 0.537), displayed lower AUC values. The ROC curves of preoperative predictors are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the AUC values and cutoff thresholds are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eROC Analysis of Preoperative Variables for Predicting Early Symptom Aggravation and Identification of Optimal Thresholds\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAUC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBest Threshold\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSensitivity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpecificity\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.585\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.794\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.375\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eside\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.765\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.238\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emcgowan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.651\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.765\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.538\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.599\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.618\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebmi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.650\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecourse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.890\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.824\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCMAP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.471\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMNCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.497\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.467\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRUNE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.537\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.647\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.462\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: AUC, area under the curve; Best Threshold, cutoff value maximizing the Youden index; Sensitivity, true positive rate; Specificity, true negative rate.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve analysis was conducted for each preoperative variable to evaluate their ability to discriminate between patients with and without early symptom aggravation. Symptom duration exhibited the highest discriminative ability, with an area under the curve (AUC) of 0.890. The optimal cutoff value for symptom duration was identified as 24.00 months, yielding a sensitivity of 82.4% and a specificity of 86.2%. McGowan grade demonstrated a moderate discriminative ability with an AUC of 0.651; the optimal threshold corresponded to Grade III classification, providing a sensitivity of 76.5% and specificity of 53.8%. Age had an AUC of 0.599, sex 0.585, side 0.501, BMI 0.525, CMAP 0.471, MNCV 0.497, VAS 0.467, and PRUNE 0.537, indicating limited discriminative abilities for these variables. The ROC curves for all preoperative predictors are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the detailed AUC values, optimal thresholds, sensitivities, and specificities are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFurther analysis of the distribution patterns of preoperative variables between the aggravation and non-aggravation groups revealed distinct differences for symptom duration and McGowan grade. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, patients in the aggravation group demonstrated a right-shifted distribution for symptom duration, with a higher proportion exceeding the 24-month cutoff. A similar pattern was observed for McGowan grade, with a larger fraction of patients in the aggravation group presenting with Grade III severity. The age distribution showed minor separation between groups but with considerable overlap. In contrast, non-predictive variables including CMAP, MNCV, VAS, PRUNE, sex, side, and BMI displayed largely overlapping distributions between the two groups, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB. Correlation analysis among the preoperative variables, presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e, revealed a strong positive correlation between VAS and PRUNE scores (r = 0.965), indicating that higher preoperative pain was associated with worse upper extremity function. A moderate negative correlation was observed between CMAP and PRUNE scores (r = − 0.369), suggesting that lower motor conduction amplitude correlated with worse functional scores. No significant correlations exceeding r = 0.7 were observed between symptom duration, McGowan grade, or other variables, indicating an acceptable absence of multicollinearity among the main predictors used in the regression model.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study systematically evaluated the predictive value of preoperative clinical and electrophysiological variables for early symptom aggravation following anterior subcutaneous transposition of the ulnar nerve in patients with cubital tunnel syndrome\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The findings revealed that longer symptom duration and higher McGowan grade were significantly associated with an increased risk of early postoperative symptom worsening\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Electrophysiological and clinical scoring variables, including CMAP, MNCV, PRUNE, and VAS, demonstrated limited predictive value\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Demographic factors such as sex, BMI, side of surgery, and age were not significantly associated with early symptom aggravation\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. These results provide new insights into risk stratification before surgery and suggest the importance of detailed preoperative assessment.\u003c/p\u003e\u003cp\u003eLonger symptom duration emerged as the most significant independent predictor of early postoperative symptom aggravation\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Multivariate logistic regression analysis revealed that each additional month of symptom duration increased the odds of early aggravation by 15% (odds ratio [OR] 1.150, 95% confidence interval [CI]: 1.080\u0026ndash;1.225, p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001). Receiver operating characteristic (ROC) curve analysis further supported its predictive value, with an area under the curve (AUC) of 0.890, and an optimal cutoff of 24.00 months yielding a sensitivity of 82.4% and specificity of 86.2%. These findings indicate that a prolonged disease course significantly compromises postoperative recovery potential. Chronic compression of the ulnar nerve over an extended period can lead to progressive ischemia, perineural fibrosis, and irreversible axonal degeneration\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Histopathological studies have demonstrated that sustained mechanical compression impairs intraneural blood flow, increases endoneurial fluid pressure, and promotes fibrotic changes within the nerve, thereby hindering effective nerve regeneration even after decompression. Moreover, long-standing compression diminishes Schwann cell functionality, reduces axonal sprouting capability, and alters the microenvironment essential for nerve repair\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. These pathophysiological changes are compounded over time, explaining why patients with symptom durations exceeding 24 months are at a significantly higher risk of early symptom aggravation\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Previous clinical studies have also correlated longer symptom duration with poorer postoperative functional outcomes in cubital tunnel syndrome, emphasizing the detrimental effects of delayed intervention\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Collectively, these results underscore the critical importance of early diagnosis and timely surgical decompression to optimize nerve recovery and minimize the risk of early postoperative symptom worsening in patients with cubital tunnel syndrome\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHigher McGowan grade was also associated with an increased likelihood of early postoperative symptom aggravation, although the association did not reach conventional statistical significance\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Multivariate logistic regression analysis showed an odds ratio (OR) of 3.224 for patients with Grade III severity compared to those with lower grades (95% confidence interval [CI]: 0.843\u0026ndash;12.339, p\u0026thinsp;=\u0026thinsp;0.087). Additionally, ROC analysis yielded an area under the curve (AUC) of 0.651 for McGowan grade, indicating moderate discriminative ability. The optimal threshold corresponded to the presence of Grade III, providing a sensitivity of 76.5% and a specificity of 53.8%. McGowan classification is a widely adopted clinical grading system for ulnar nerve dysfunction, categorizing patients based on the severity of intrinsic muscle atrophy and motor weakness\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Grade III is characterized by pronounced muscle wasting and marked motor impairment, reflecting advanced axonal loss and chronic denervation\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Patients presenting with Grade III severity are likely to have sustained extensive and possibly irreversible nerve injury, limiting their capacity for postoperative functional recovery. In the context of early postoperative assessment, these patients may exhibit persistent or even worsened symptoms despite adequate surgical decompression. Prior research has consistently demonstrated that higher preoperative McGowan grades are associated with poorer surgical outcomes, supporting the concept that the extent of preoperative functional impairment correlates with the nerve's regenerative potential\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Although McGowan grade did not independently predict early aggravation with high statistical certainty in this study, its moderate predictive value and established clinical relevance highlight the need for careful preoperative functional evaluation and counseling, particularly in patients presenting with severe preoperative deficits\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAmong the electrophysiological indicators assessed, compound muscle action potential (CMAP) and motor nerve conduction velocity (MNCV) demonstrated limited predictive value for early postoperative symptom aggravation\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. In multivariate logistic regression analysis, CMAP showed an odds ratio (OR) of 3.432 (p\u0026thinsp;=\u0026thinsp;0.679), while MNCV had an OR of 0.973 (p\u0026thinsp;=\u0026thinsp;0.602), indicating no significant associations. ROC analysis yielded AUC values of 0.471 for CMAP and 0.497 for MNCV, both suggesting poor discriminative ability. Although these electrophysiological measures were not significant predictors in this study, CMAP and MNCV remain important indicators of nerve integrity and function\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. CMAP reflects the summated electrical activity of muscle fibers innervated by the stimulated nerve, and lower CMAP amplitudes are generally associated with greater axonal loss\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. MNCV measures the speed of impulse conduction along motor fibers and may decrease in demyelinating conditions or with significant axonal degeneration\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. The limited predictive value observed in this cohort may be due to the fact that early postoperative outcomes are influenced not only by the severity of preoperative axonal damage but also by factors such as the duration of compression and the timing of surgical intervention\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Nevertheless, these findings suggest that while CMAP and MNCV provide valuable baseline information regarding the degree of nerve injury, they may not reliably predict early postoperative symptom trajectories in isolation\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAmong the clinical scoring measures, neither the Patient-Rated Ulnar Nerve Evaluation (PRUNE) score nor the Visual Analog Scale (VAS) score demonstrated significant predictive value for early postoperative symptom aggravation\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Multivariate logistic regression showed an odds ratio (OR) of 0.997 for PRUNE (p\u0026thinsp;=\u0026thinsp;0.933) and 0.544 for VAS (p\u0026thinsp;=\u0026thinsp;0.596), indicating no significant associations. ROC analysis yielded an area under the curve (AUC) of 0.537 for PRUNE and 0.467 for VAS, both falling below the threshold commonly accepted for clinical utility\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Although these subjective measures did not predict early symptom worsening, they remain important indicators of patient-perceived disability and pain. The PRUNE score assesses upper extremity function specifically in patients with ulnar nerve dysfunction, and the VAS score captures pain intensity, which is a major symptom domain in cubital tunnel syndrome\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Interestingly, correlation analysis revealed a strong positive relationship between PRUNE and VAS scores (r\u0026thinsp;=\u0026thinsp;0.965), suggesting that patients reporting higher pain levels also perceive greater functional impairment\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Despite this strong correlation, the lack of predictive utility may be attributed to the subjective nature of these assessments, which can be influenced by psychological and environmental factors independent of nerve recovery status\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. These findings indicate that while PRUNE and VAS are useful for assessing clinical symptoms, they may not serve as reliable standalone predictors of early postoperative outcomes.\u003c/p\u003e\u003cp\u003eOther demographic and baseline clinical variables, including sex, BMI, side of surgery, and age, did not show significant associations with early postoperative symptom aggravation in this study\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Logistic regression analysis revealed an odds ratio (OR) of 1.830 for sex (p\u0026thinsp;=\u0026thinsp;0.402), suggesting no significant difference in aggravation risk between males and females\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. BMI demonstrated an OR of 1.150 per unit increase (p\u0026thinsp;=\u0026thinsp;0.195), and side of surgery showed an OR of 0.224 (p\u0026thinsp;=\u0026thinsp;0.063), indicating a trend but no statistically meaningful relationship. Age exhibited an OR of 1.015 per year (p\u0026thinsp;=\u0026thinsp;0.624). Receiver operating characteristic (ROC) analysis further confirmed the limited discriminative ability of these variables, with AUC values of 0.585 for sex, 0.525 for BMI, 0.501 for side, and 0.599 for age\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePrevious studies investigating the role of demographic factors in surgical outcomes for cubital tunnel syndrome have yielded inconsistent results\u003csup\u003e\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Some reports suggested that male patients might experience better nerve regeneration rates, potentially due to differences in hormonal influences or nerve fiber density, although conclusive evidence remains lacking. In terms of BMI, elevated body mass index has been proposed to negatively impact postoperative recovery through increased mechanical compression and impaired microcirculation around the nerve, yet large-scale studies have not consistently demonstrated a significant association\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Regarding the side of surgery, dominant hand involvement has been hypothesized to affect recovery trajectories, but most investigations found no substantial differences in outcomes based on surgical side\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. As for age, it is generally accepted that advancing age is associated with diminished peripheral nerve regenerative capacity; however, the relationship between age and surgical outcomes is complex and may be influenced by comorbidities and baseline functional status\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study evaluated whether demographic and baseline clinical variables predict early postoperative symptom aggravation following anterior subcutaneous transposition in cubital tunnel syndrome (CuTS). We found no significant associations for sex, BMI, surgical side, or age, aligning with prior research suggesting these factors have limited relevance in early outcomes. Given their low predictive value, emphasis should instead be placed on nerve injury severity and symptom duration\u0026mdash;variables more closely linked to postoperative trajectories.\u003c/p\u003e\u003cp\u003eMethodologically, this study benefitted from a standardized surgical approach by a single experienced surgeon, consistent pre- and postoperative evaluations, and fixed follow-up intervals at 2 weeks and 6 months. The focus on early postoperative symptom aggravation\u0026mdash;a clinically important yet underexplored phenomenon\u0026mdash;adds novelty and practical relevance to our findings.\u003c/p\u003e\u003cp\u003eHowever, several limitations warrant mention. The single-center design and modest sample size may limit generalizability. Long-term outcomes beyond 6 months were not assessed. Subjective metrics like PRUNE and VAS, though informative, are vulnerable to reporting bias. Moreover, variables such as intraoperative nerve handling, rehabilitation adherence, and psychosocial status were not analyzed. Future large-scale, multicenter studies with extended follow-up are needed to validate and expand upon these findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrates that early postoperative symptom aggravation is a relatively common but typically transient phenomenon following anterior ulnar nerve transposition for cubital tunnel syndrome. Symptom duration and McGowan grade emerged as the most robust preoperative predictors of early aggravation, reflecting underlying neural vulnerability and chronicity of compression. A simple risk stratification model based on these variables achieved excellent discriminative performance and offers a practical tool for preoperative counseling and postoperative management. Integrating objective clinical assessments with individualized risk profiling may enhance surgical decision-making, improve patient expectations, and prevent misinterpretation of early postoperative symptom fluctuations. Future research should focus on validating and expanding this predictive framework through larger, prospective, and multimodal studies to further optimize outcomes for patients undergoing CuTS surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAUC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArea Under the Curve\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCMAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCompound Muscle Action Potential\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCuTS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCubital Tunnel Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMNCV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMotor Nerve Conduction Velocity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRUNE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient-Rated Ulnar Nerve Evaluation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReceiver Operating Characteristic\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSNCV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSensory Nerve Conduction Velocity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analog Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e2PD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTwo-Point Discrimination\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics Approval\u003c/h2\u003e\u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (No. PJ2023-04-21).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent to Participate\u003c/h2\u003e\u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication of anonymized clinical data.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003cp\u003eCompeting Interests\u003c/p\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Tianyou Hu, Tao Zhou, Hongxiang Zhou, Yvjie Bian, and Qiankun Wang. The first draft of the manuscript was written by Tianyou Hu, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWade RG et al (2020) Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis. JAMA Netw open 3:e2024352. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2020.24352\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2020.24352\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAssmus H et al (2011) Cubital tunnel syndrome - a review and management guidelines. 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J Shoulder Elbow Surg 27:e344\u0026ndash;e347. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jse.2018.07.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jse.2018.07.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang D, Earp BE, Homer SH, Blazar P (2023) Factors Associated With Severity of Cubital Tunnel Syndrome at Presentation. \u003cem\u003eHand (New York, N.Y.)\u003c/em\u003e 18, 401\u0026ndash;406. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/15589447211058821\u003c/span\u003e\u003cspan address=\"10.1177/15589447211058821\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsei DA, Groves AP, Bommarito K, Ray WZ (2017) Cubital Tunnel Syndrome: Incidence and Demographics in a National Administrative Database. \u003cem\u003eNeurosurgery\u003c/em\u003e 80, 417\u0026ndash;420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/neuros/nyw061\u003c/span\u003e\u003cspan address=\"10.1093/neuros/nyw061\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cubital tunnel syndrome、Ulnar nerve transposition、Early postoperative symptom aggravation、Risk stratification、Symptom duration","lastPublishedDoi":"10.21203/rs.3.rs-7075399/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7075399/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEarly postoperative symptom aggravation is a clinically relevant yet underexplored phenomenon following anterior ulnar nerve transposition for cubital tunnel syndrome (CuTS). This study aimed to define its incidence, identify predictive factors, and establish a threshold-based risk stratification model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed 127 patients undergoing anterior subcutaneous transposition of the ulnar nerve between 2020 and 2023. Early symptom aggravation was defined as a postoperative deterioration in at least one clinical (VAS or PRUNE) or electrophysiological (CMAP or SNCV) indicator at two weeks post-surgery. Multivariate logistic regression and ROC curve analyses were performed to determine independent predictors and optimal thresholds.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEarly symptom aggravation occurred in 26.8% of patients. Multivariate analysis identified symptom duration (OR\u0026thinsp;=\u0026thinsp;1.150, p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001) as a significant independent predictor. McGowan grade III showed a moderate association (OR\u0026thinsp;=\u0026thinsp;3.224, p\u0026thinsp;=\u0026thinsp;0.087). ROC analysis revealed excellent discriminative ability for symptom duration (AUC\u0026thinsp;=\u0026thinsp;0.890) with an optimal threshold of 24.00 months (sensitivity 82.4%, specificity 86.2%). Other variables, including electrophysiological measures and demographics, demonstrated limited predictive value.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSymptom duration and preoperative McGowan grade are key risk factors for early symptom aggravation after CuTS surgery. A simple threshold-based model can aid in preoperative counseling and expectation management. These findings highlight the need for timely surgical intervention to minimize neural deterioration and improve short-term outcomes.\u003c/p\u003e","manuscriptTitle":"Early Symptom Aggravation Following Ulnar Nerve Transposition for Cubital Tunnel Syndrome: Incidence, Predictive Factors, and Threshold-Based Risk Stratification","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:13:25","doi":"10.21203/rs.3.rs-7075399/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-09T15:47:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T08:00:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-14T11:16:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231708438684035261552155151559093730294","date":"2025-10-14T09:58:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T19:15:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T22:30:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45639011633271389944826429404219744602","date":"2025-10-09T11:05:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203025296024174001357371291846766929265","date":"2025-10-08T22:15:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116011634326092174675020364550133317277","date":"2025-10-07T16:36:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T07:36:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T07:35:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T14:46:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2025-07-08T13:26:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bf23b93f-84a1-431f-a2f3-f917cd05d46c","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:01:02+00:00","versionOfRecord":{"articleIdentity":"rs-7075399","link":"https://doi.org/10.1007/s10143-025-03992-2","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2026-02-19 15:57:35","publishedOnDateReadable":"February 19th, 2026"},"versionCreatedAt":"2025-09-08 10:13:25","video":"","vorDoi":"10.1007/s10143-025-03992-2","vorDoiUrl":"https://doi.org/10.1007/s10143-025-03992-2","workflowStages":[]},"version":"v1","identity":"rs-7075399","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7075399","identity":"rs-7075399","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}