Putting Our Shoulder to the Wheel: Current Understanding and Gaps in Nerve Ablation for Chronic Shoulder Pain

Durable Shoulder Pain Relief and Avoidance of Surgery Up To 5 Years Following 60-Day PNS Treatment

INTRODUCTION

Shoulder pain can be a chronic, disabling condition resulting in major procedures like surgery that are invasive, costly, and pose significant risks to patients. Minimally invasive interventions that provide durable relief can improve outcomes while enabling patients to avoid accruing additional healthcare costs. The present survey study evaluated durability of pain relief in a real-world shoulder pain population following percutaneous 60-day peripheral nerve stimulation (PNS) treatment.

METHODS

A cross-sectional follow-up survey assessed follow-up outcomes among patients who received 60-day PNS for chronic shoulder pain. Outcomes included patient-reported percent pain relief, average and worst pain scores, and patient impression of change in quality of life, physical function, and sleep. Patients also reported other treatments and interventions used for their shoulder pain since the 60-day PNS treatment including changes in medication usage.

RESULTS

Among 489 survey participants (mean follow-up 21 months, range 6-60), 83% (405/489) reported no subsequent radiofrequency ablation, permanent implant, or surgery following 60-day PNS. Within this subset, 87% reported ongoing improvement in at least one domain at follow-up, including 71% who maintained ≥ 50% pain relief, and more than half who reported much or very much improved quality of life (61%), physical function (57%), or sleep (57%). Among those using PNS seeking to avoid surgery (n = 265), 81% reported no subsequent surgery, with 77% of those patients maintaining ≥ 50% pain relief. Outcomes were consistent across follow-up durations and shoulder pain etiologies.

CONCLUSIONS

This real-world evidence demonstrates that a large majority of responders to 60-day PNS may experience durable shoulder pain relief and other improvements, with benefits demonstrated up to 5 years post treatment. The low rate of progression to subsequent interventions including surgery suggests potential for healthcare economic benefit, supporting 60-day PNS as both a clinically effective and potentially economically advantageous approach for appropriate patients.

Management of post-arthroplasty pain: a narrative review of emerging interventional treatments

Total joint arthroplasties are one of the most common orthopedic procedures with over 1 million total hip and knee arthroplasties performed annually. While the majority of patients experience favorable long-term outcomes, a significant number of patients continue to report persistent pain more than 3 months post-arthroplasty that is unresponsive to conservative treatment. Although current treatment options may seem limited, there are a variety of innovative procedures for the management of post-arthroplasty pain with the overall goal of reducing pain and restoring function. In this review, we outline the work-up for persistent post-arthroplasty pain and provide a review of the literature on interventional treatment modalities consisting of intra-articular steroids, radiofrequency ablation, and neuromodulation for the management of chronic post-arthroplasty pain in the hip, knee, ankle, and shoulder.

Cooled Radiofrequency Ablation in Shoulder Pain: A Cohort study

OBJECTIVE

This study aims to evaluate the pain and clinical evolution of patients with shoulder pain with cooled radiofrequency ablation (CRFA).

METHODOLOGY

A cohort prospective study of patients with shoulder pain for >3 months. All patients included were treated with CRFA in the sensitive innervation around the shoulder (lateral pectoral, suprascapular nerve, axillary nerve), and were followed for 24 weeks. Pain was evaluated with the visual analog scale, while clinical evolution was evaluated with several scales of shoulder function.

RESULTS

Fifteen patients were included. All patients improved significantly the pain during the time of the study. The clinical function of the shoulder shows a significant improvement during the 24 weeks of follow-up.

CONCLUSIONS

CRFA is a medical procedure that helps to improve pain and function related to shoulder pain independently of the primary pathology in the shoulder.

Radiofrequency ablation of terminal sensory articular nerves before arthroscopic rotator cuff repair surgery improved early postoperative functional outcomes: A pilot study with 3 ​months follow-up

INTRODUCTION

Chronic shoulder pain caused by a rotator cuff tear is commonly treated with arthroscopic rotator cuff repair surgery (ARCR). However, ARCR may be associated with moderate-to-severe postoperative pain, and poorly controlled pain can result in delayed functional recovery and the development of frozen shoulder. Terminal sensory articular nerve radiofrequency ablation (RFA) has been shown to be clinically effective in patients with severe refractory shoulder pain from multiple etiologies. We aimed to investigate whether preoperative RFA would improve the postoperative pain and functional outcomes after ARCR.

METHODS

In this prospective pilot study, participants were randomized to receive fluoroscopic-guided terminal sensory articular nerve-cooled RFA (CRFA) (supraspinatus nerve, axillary nerve, lateral pectoral nerve) 1-5 days prior to elective ARCR as an intervention group compared to ARCR without prior RFA as a control group. Constant score (CS), American Shoulder and Elbow Surgeon score (ASES), and pain numerical rating score (NRS) were assessed at 1, 2, 3, 4, 5, and 6 weeks and 3 months following ARCR.

RESULTS

Twenty-one participants were enrolled in this study, including 11 in the control group and 10 in the cooled RFA group. The cooled RFA group showed statistically significantly better CS and ASES both at 6 weeks and 3 months. The two groups showed no differences in pain outcomes at all time points. No intervention-related complications were noted.

CONCLUSION

Cooled RFA of the terminal sensory articular branches of the supraspinatus, axillary, and lateral pectoral nerves performed 1-5 days prior to elective ARCR as part of a multimodal postoperative pain management regimen can improve functional outcomes as early as 6 weeks.

LEVEL OF EVIDENCE

III.

Shoulder terminal sensory articular nerve radiofrequency ablation for nonsurgical refractory shoulder pain due to rotator cuff pathology and osteoarthritis: a technical note

BACKGROUND

Given the high prevalence of chronic shoulder pain and encouraging early results of terminal sensory articular branch radiofrequency ablation to treat shoulder pain, research is warranted to refine the procedural technique on the basis of updated neuroanatomic knowledge with the goal of further improving patient outcomes.

OBJECTIVE

We describe an updated radiofrequency ablation protocol that accounts for varied locations of the terminal sensory articular branches of the suprascapular, axillary, subscapular, and lateral pectoral nerves within individual patients.

DESIGN

Technical note.

METHODS

Cadaveric studies delineating the sensory innervation of the shoulder joint were reviewed, and a more comprehensive radiofrequency ablation protocol is proposed relative to historical descriptions.

CONCLUSIONS

The proposed radiofrequency ablation protocol, which is based on neuroanatomic dissections of the shoulder joint, will provide a safe means of more complete sensory denervation and potentially improve clinical outcomes compared with historical descriptions, the efficacy of the new protocol must be confirmed in prospective studies.

Phenolysis for Advanced Shoulder Osteoarthritis: A Case Series of a Novel Ultrasound-Guided Approach to Anterior and Posterior Glenohumeral Articular Nerve Branches

INTRODUCTION

The shoulder is one of the joints most affected by osteoarthritis, with a prevalence of almost 20% in adults over 65 years of age. Various treatments have been proposed to control osteoarthritis pain, including radiofrequency, pulsed and thermal, and recently cryoanalgesia. We propose in this series of cases a new approach to analgesic therapy with chemical denervation with phenol.

MATERIALS AND METHOD

Patients who underwent phenolysis for shoulder osteoarthritis at our institutions in Italy and Australia between August 2022 and May 2023 were included. All patients included in our report provided written consent for publication. This chemical neurolysis technique consisted of two injections. First, the anterior shoulder capsule was denervated by a modified deep SHAC (Shoulder Anterior Capsule) approach to cover the anterior terminal articular branches of the axillary nerve, lateral pectoral nerve, and subscapularis nerve. Second, the posterior shoulder capsule was denervated by a posterior glenoid approach to cover the terminal articular branches of the suprascapular nerve (SSN).  Results: We included a total of 11 patients in this case series. Ten of 11 patients were affected by shoulder osteoarthritis, of which three had rotator cuff tendinopathy and three had full-thickness cuff tears. One patient had chronic subluxation of a shoulder prosthesis. After treatment, all patients significantly reduced pain immediately after treatment and, two weeks later, recovered joint movement and improved quality of life. No adverse events or loss of motor function following treatment.

CONCLUSION

We presented a novel chemical approach to shoulder denervation, which was shown to be another effective way of improving pain and function in advanced glenohumeral arthritis.

Interventional Therapies for Osteoarthritis: An Update

Osteoarthritis (OA) is one of the most common diseases worldwide and is expected to increase in incidence as the age of the general population rises. Both oral medications, such as NSAIDs, and surgical treatments used for OA management have limitations. Demand is rising for minimally invasive techniques such as intraarticular injections and percutaneous interventions for use in place of or in conjunction with oral medications and surgical therapies, and the past 2 decades have seen a rapid expanse in both pharmacologic and nonpharmacologic minimally invasive OA treatments. Image guidance with fluoroscopy, CT, or ultrasound is often used in conjunction with these procedures to achieve precise treatment localization to achieve maximal therapeutic effect. The choice of modality used for image guidance is often influenced by clinician experience, patient characteristics, and equipment availability. This article reviews the mechanisms of action, contraindications, complications, and efficacy of conventional and developing minimally invasive OA treatments. The minimally invasive treatment options described in this Review include therapeutic injections such as antiinflammatory agents, viscosupplements, and biologics, as well as nonpharmacologic treatments of subchondroplasty, nerve ablation, genicular artery embolization, intraarticular pulsed radiofrequency therapy, and MRI-guided focused ultrasound therapy.