Pulsed radiofrequency lesioning of the axillary and suprascapular nerve in calcific tendinitis

Comparison of combined suprascapular and axillary nerve pulsed radiofrequency and nerve block for the treatment of primary frozen shoulder: a prospective cohort study

OBJECTIVES

To compare the effects of pulsed radiofrequency (PRF) and block of the suprascapular nerve (SSN) and axillary nerve (AN) in patients with primary frozen shoulder (FS).

METHODS

Patients with primary FS received PRF (Group P) or block (Group B). Shoulder pain during rest, activity and sleep was measured by a numerical rating scale (NRS), the Shoulder Pain and Disability Index (SPADI) was used to assess shoulder function and disability, and the passive range of motion (PROM) of the shoulder joint was measured by a digital inclinometer. Assessments were made at baseline and 2 weeks and 1, 3, and 6 months after the procedure.

RESULTS

Of the 74 patients, 63 were eventually included, and a total of 3 patients were lost to follow-up. Finally, 60 patients (30 in each group) completed the final analysis. There was a significant improvement in all outcome measures from baseline to 6 months after the procedure. Compared with those in group B, the NRS scores during activity and sleep in group P decreased more at 6 months after the procedure (p = 0.005 and 0.028). SPADI total scores were lower at 3 and 6 months after the procedure (p = 0.021 and 0.001). At different time after the procedure, most of the parameters of PROM improved more in group P than those in group B (flexion at 3 and 6 months, p = 0.042 and <0.001; abduction at 3 and 6 monthse, p = 0.001 and 0.001; extension at 3 and 6 months, p = 0.038 and 0.007, internal rotation at 6 months, p = 0.015; external rotation at 1, 3, and 6 months, p = 0.002, 0.002, and 0.001, respectively).

CONCLUSIONS

In patients with primary FS who completed both manipulation under anesthesia and intra-articular injections, PRF with SSN and AN appears to provide better pain relief, better PROM recovery, and more shoulder function improvement than nerve block treatment.

Axillary nerve: what anesthesiologists and pain physicians should know

Innervation of the shoulder joint is complex and remains poorly understood among regional anesthesiologists and chronic pain specialists. Current literature supports the important contribution of the axillary nerve to the total innervation of the shoulder, as well as its blockade for perioperative pain and denervation for chronic shoulder pain. However, a description of the entire course of the axillary nerve, the corresponding optimal targets, and the sonoanatomy pertinent to pain intervention is lacking. This educational article discusses in detail the functional anatomy and sonographic identification of possible windows for axillary nerve intervention. We discuss the contribution, extent, and type of innervation the axillary nerve provides to the shoulder joint, which is often misunderstood. Ultimately, this article serves to stimulate thoughts and ideas for future research in an area where literature is scarce.

Efficacy of pulsed radiofrequency on the suprascapular and axillary-circumflex nerve for shoulder pain: A randomised controlled trial

Background and Aims

Painful shoulder is one of the most frequent consultation causes. Multiple treatments have been described to relieve pain, restore range of motion and improve functionality.

Methods

This randomised clinical trial was conducted in 60 patients. The treatment group received combined pulsed radiofrequency (PRF) on suprascapular nerve (SN) and axillary-circumflex nerve (ACN). The control group received PRF on SN only. The primary outcome was pain intensity measured by the Numerical Rating Scale (NRS). The secondary outcomes were the Shoulder Pain and Disability Index (SPADI), the Constant-Murley range of motion scale and Disability of the Arm, Shoulder and Hand (DASH) scale. The patients were monitored at the baseline visit and at 1, 3, 6 and 9 months. A mixed ordinal regression model was estimated to evaluate the association between the study group and pain measured with NRS.

Results

A global decrease in pain at the end of the study was noted. The global baseline NRS was 8.4, and the global final NRS at 9 months of follow-up was 6.2. Combined PRF on SN and ACN was not associated with lower NRS pain scores compared to single SN PRF [odds ratio (OR) =1.04, 95% confidence interval (CI) 0.91-1.20, P = 0.507]. Secondary outcomes showed no significant differences: SPADI (OR = 1.04, 95% CI 0.92-1.18), Constant-Murley (OR = 1.01, 95% CI 0.90-1.14), DASH (OR = 1.04, 95% CI 0.92-1.17).

Conclusion

Combined PRF applied to SN and ACN was not superior to PRF applied to SN alone.

Accuracy of suprascapular notch cross-sectional area by MRI in the diagnosis of suprascapular nerve entrapment syndrome: a retrospective pilot study

BACKGROUND

Previous studies have demonstrated that morphological changes in the suprascapular notch are closely associated with suprascapular nerve entrapment syndrome (SNES). Thus, we hypothesized that the suprascapular notch cross-sectional area (SSNCSA) could be a good diagnostic parameter to assess SNES.

METHODS

We acquired suprascapular notch data from 10 patients with SNES and 10 healthy individuals who had undergone shoulder magnetic resonance imaging (S-MRI) and had no evidence of SNES. T2-weighted coronal magnetic resonance images were acquired from the shoulder. We analyzed the SSNCSA at the shoulder on S-MRI using our image-analysis program (INFINITT PACS). The SSNCSA was measured as the suprascapular notch, which was the most affected site in coronal S-MRI images.

RESULTS

The mean SSNCSA was 64.50 ± 8.93 mm2 in the control group and 44.94 ± 10.40 mm2 in the SNES group. Patients with SNES had significantly lower SSNCSA (P < 0.01) than those in the control group. Receiver operating curve analysis showed that the best cut-off of the SSNCSA was 57.49 mm2, with 80.0% sensitivity, 80.0% specificity, and an area under the curve of 0.92 (95% CI [0.79, 1.00]).

CONCLUSIONS

The SSNCSA was found to have acceptable diagnostic properties for detecting SNES. We hope that these results will help diagnose SNES objectively.

Ultrasound-guided continuous radiofrequency ablation of the suprascapular nerve for chronic shoulder pain secondary to osteoarthritis: a retrospective cohort study

OBJECTIVES

The objective of this study is to retrospectively evaluate the use of ultrasound-guided continuous radiofrequency (CRF) lesioning of the suprascapular nerve for treating chronic shoulder pain, due to osteoarthritis. We describe a modified distal and selective ablation technique in the spinoglenoid notch, with motor and sensory stimulation, which protects the motor branch of the nerve from ablation.

METHODS

A retrospective analysis was performed of patients, who underwent ultrasound-guided CRF lesioning of the suprascapular nerve from October 2013 to January 2020. During the procedure, the CRF electrode is placed in the spinoglenoid notch, at the distal suprascapular nerve capsular branch. Motor and sensory stimulations are used to confirm the position. CRF lesioning is applied up to three times, at 3 different points, for 1 min each time, at 80^° C.

RESULTS

In total, 127 first CRF suprascapular nerve lesioning procedures were performed on 101 patients with chronic shoulder pain secondary to osteoarthritis. One hundred nineteen diagnostic ultrasound-guided suprascapular nerve corticosteroid injections were performed prior to ablation. Mean pre-injection Visual Analogue Scale pain score (VAS) was 8.3, with post-injection VAS score of 4.4 at 24 h and 4.5 at 2 weeks. Mean pre-CRF lesioning VAS pain score was 7.7 with post-CRF lesioning VAS score of 4.4 at 24 h and 4.5 at 2 weeks.

CONCLUSIONS

Ultrasound-guided CRF lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic osteoarthritic shoulder pain, with repeat treatments infrequently required. It is associated with significant improvement in VAS pain scores.

KEY POINTS

• Ultrasound-guided continuous radiofrequency lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic shoulder pain in degenerative disease, with repeat treatments infrequently required. • The procedure is performed under ultrasound guidance, without the use of ionising radiation.

Effect of ultrasound-guided pulsed radiofrequency on intercostal neuralgia after lung cancer surgery: A retrospective study

This retrospective study investigated the effect of ultrasound-guided pulsed radiofrequency (UGPRF) on intercostal neuralgia (ICN) after lung cancer surgery (LCS).This retrospective observational study analyzed the outcome data of UGPRF on ICN in 80 patients with LCS. All those patients were allocated into a treatment group (n = 40) and a control group (n = 40). All patient data were collected between January 2018 and November 2019. The primary outcome was pain intensity (measured by numerical rating scale, NRS). The secondary outcomes were sleep quality (measured by Pittsburgh Sleep Quality Index, PSQI), anesthetic consumption, and treatment-related adverse events.After treatment, patients in the treatment group showed better outcomes in NRS (P < .01), PSQI (P < .01), and anesthetic consumption (P < .01), than patients in the control group. No treatment-related adverse events were documented in both groups in this study.The results of this study found that UGPRF may benefit patients for pain relief of ICN after LCS.

A systematic review and meta-analysis of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain

BACKGROUND AND OBJECTIVE

Studies have reported relief of chronic shoulder pain with non-ablative pulsed neuromodulatory (pRF) or ablative radiofrequency (aRF) procedures on innervation of the shoulder joint but interpretation of these reports is hampered by inconsistent indications, anatomic targets and follow-up. This systematic review was conducted to synthesize the existing literature on procedures employing pRF or aRF for treating chronic shoulder pain.

DATABASES AND DATA TREATMENT

MEDLINE and other medical literature databases were reviewed up to 31 December 2019 for publications on pRF or aRF procedures on shoulder joint innervation to relieve chronic pain. Data on analgesic and functional outcomes measured at any time point following the interventions were extracted. Existing knowledge on innervation of the shoulder joint with relevance to RF procedures was also synthesized.

RESULTS

In all, 42 publications, 7 randomized controlled trials (RCTs) and 35 observational studies, case series or reports were identified. Thirty-six of these publications were on pRF procedure and 29 of these reported procedures exclusively targeting the suprascapular nerve. A meta-analysis of the seven RCTs evaluating pRF indicated no analgesic benefit or functional improvement with this treatment over conventional medical management. Case series and reports on aRF indicate a potential for analgesic benefit but the quality of this evidence was low.

CONCLUSIONS

RF treatments targeting the sensory innervation of the shoulder joint affected by degenerative conditions have the potential to reduce pain but the current evidence does not suggest analgesic or functional benefit (GRADE certainty of evidence-low). Studies of high methodological quality are required to further investigate the role of these interventions.

SIGNIFICANCE

This is a comprehensive review of literature on pulsed (non-ablative) and ablative radiofrequency (RF) procedures for chronic shoulder pain. The systematic review and meta-analysis of 7 trials found that pulsed RF for chronic shoulder pain provided similar analgesia and functional improvement as conservative medical management at three months after the procedures. The case series and reports on ablative RF for shoulder pain indicate possible analgesic benefit but their quality was low. This review highlights the need for studies of a high quality on ablative RF treatments for chronic shoulder pain.

Adaptation of an Ultrasound-Guided Technique for Pulsed Radiofrequency on Axillary and Suprascapular Nerves in the Treatment of Shoulder Pain

BACKGROUND

It has been estimated that 20% of the general population will suffer shoulder pain throughout their lives, with a prevalence that can reach up to 50%. The suprascapular nerve (SSN) provides sensation for the posterior and superior regions of the glenohumeral joint, whereas the anterior and inferior zones and the skin are innervated mostly by the axillary nerve. Pulsed radiofrequency on the SSN has been proposed as a therapeutic option in chronic shoulder pain. Axillary nerve block has been proposed in the context of surgical analgesia as an adjuvant to SSN block.

INTERVENTIONS

Ultrasound (US)-guided techniques target the nerve selectively, minimizing patients' and physicians' exposure to harmful radiation while increasing success rates by better needle placement. We perform both US-guided techniques with the patient in a lateral decubitus position with the affected shoulder on the upper side.

OBJECTIVE

The aim of this report is to describe the adaptation of a US-guided technique that targets both the suprascapular and axillary nerves for the treatment of painful shoulder syndrome. The simultaneous pulsed radiofrequency on the suprascapular and axillary nerves for the treatment of the chronic condition of shoulder pain has been scarcely studied, with very few references in the literature.

CONCLUSIONS

By adapting an approach developed in acute pain management, we can safely deliver pulsed radiofrequency to the suprascapular and axillary nerves for the treatment of shoulder pain.

Evaluation of suprascapular nerve radiofrequency ablation protocols: 3D cadaveric needle placement study

BACKGROUND AND OBJECTIVES

Image-guided intervention of the suprascapular nerve is a reported treatment to manage chronic shoulder joint pain. The suprascapular nerve is conventionally targeted at the suprascapular notch; however, targeting of its branches, the medial and lateral trunks, which are given off just posterior to the notch has not been considered. Since the lateral trunk supplies the posterior supraspinatus and articular branches to the glenohumeral joint capsule, while the medial trunk provides motor innervation to the anterior region, it may be possible to preserve some supraspinatus activation if the medial trunk is spared. The main objective was to investigate whether midpoint between suprascapular and spinoglenoid notches is the optimal target to capture articular branches of lateral trunk while sparing medial trunk.

METHODS

In 10 specimens, using ultrasound guidance, one 17 G needle was placed at the suprascapular notch and a second at midpoint between suprascapular and spinoglenoid notches. The trunks and needles were exposed in the supraspinous fossa, digitized and modeled in 3D. Lesion volumes were added to the models to asses medial and lateral trunk capture rates. Mean distance of needle tips to origin of medial trunk was compared.

RESULTS

Conventional notch technique captured both lateral and medial trunks, whereas a midpoint technique captured only lateral trunk. Mean distance of needles from the origin of medial trunk was 5.10±1.41 mm (notch technique) and 14.99±5.53 mm (midpoint technique).

CONCLUSIONS

The findings suggest that the midpoint technique could spare medial trunk of suprascapular nerve, while capturing lateral trunk and articular branches. Further clinical investigation is required.

Radiofrequency Ablation for Management of Shoulder Pain

PURPOSE OF REVIEW

The treatment options for the management of shoulder pain are broad but evolving process. Modalities for controlling shoulder pain have commonly focused on pharmacotherapy, physical therapy, rehabilitation, and invasive procedures (surgical procedures, surgical, intra-articular steroid injections, many times, being sub-optimal). The use of radiofrequency ablation (RFA) for managing shoulder pain is on the rise. Our review investigated the evidence for the use of RFA in the management of shoulder pain.

RECENT FINDINGS

In our investigation, a review of the literature was conducted using Medline, PubMed, and Cochrane Database of Systematic Reviews from 1966 to 2018. Our study included RCTs, open non-randomized control studies, prospective studies, retrospective studies, case series, and case reports. We limited our search to patients with chronic shoulder pathologies. Our initial search identified 96 articles for initial review. This was narrowed down to 31 articles, which met our inclusion criteria, with only 18 articles remaining after our exclusion criteria was applied. This systematic review suggests that shoulder RFA may provide a safe and significant benefit in the management of chronic shoulder pain. There were a few high-quality RCTs included in our study, which supports the findings of several case reports and case series.

Quantitative analysis of the distal, lateral, and posterior articular branches of the axillary nerve to the shoulder: implications for intervention

INTRODUCTION

The terminal sensory branches innervating the shoulder joint are potential therapeutic targets for the treatment of shoulder pain. This cadaveric study investigated in detail the anatomic pathway of the posterior terminal sensory branch of the axillary nerve (AN) and its relationship to nearby anatomic structures for applications, such as nerve block or ablation of the shoulder joint.

METHODS

For this study, nine shoulders were dissected. Following dissection, methylene blue was used to stain the pathway of the terminal sensory branches of the AN to provide a visual relationship to the nearby bony structures. A transparent grid was overlaid on the humeral head to provide further detailed information regarding the innervation to the shoulder joint.

RESULTS

Eight of the nine shoulders displayed terminal sensory branches of the AN. The terminal sensory branches of the AN innervated the posterolateral head of the humerus and shoulder capsule and were deep and distal to the motor branches innervating the deltoid muscle and teres minor muscle. All terminal branches dissected innervated the shoulder capsule at the posteroinferior-lateral aspect of the greater tuberosity of the humerus. All specimens displayed innervation to the shoulder joint in the lateral most 25% and inferior most 37.5% before methylene blue staining.

CONCLUSION

The terminal sensory branches of the AN consistently innervate the inferior and lateral aspects of the posterior humeral head and shoulder capsule. These nerves are easily accessible and would provide a practical target for nerve block or ablation to relieve shoulder pain without compromising motor integrity.

Innervation of the Long Head of the Triceps Brachii in Humans-A Fresh Look

The triceps brachii muscle occupies the posterior compartment of the arm in humans and has three heads. The lateral and medial heads originate from the humerus and the long head arises from the infraglenoid tubercle of the scapula. All heads form a common tendon that inserts onto the olecranon and the deep antebrachial fascia on each side of it. Each head receives its own motor branch, which all are thought to originate from the radial nerve. However, several studies reported that the motor branch of the long head of the triceps (LHT) arises from the axillary nerve or the posterior cord. Here, we dissected 27 triceps in 15 cadavers to analyze the innervation of the LHT and found only radial innervation, which contradicts those studies. We examined studies reporting that the motor branch to the LHT in humans does not arise from the radial nerve as well as studies of the triceps in primates. Occasional variations of the innervation of skeletal muscles are normal, but a change of principal motor innervation from radial to axillary nerve has important implications. This is because the axillary nerve is often involved during shoulder injuries. The precise identification of the prevalence of axillary versus radial innervation is therefore clinically relevant for surgery, nerve drafting, and occupational and physical therapy. We conclude that the primary motor branch to the LHT arises from the radial nerve but axillary/posterior cord innervations occur occasionally. We suggest the development of a standard methodology for further studies. Anat Rec, 301:473-483, 2018. © 2018 Wiley Periodicals, Inc.

Comparative study of anatomical landmark-guided versus ultrasound-guided suprascapular nerve block in chronic shoulder pain

Background:

Suprascapular nerve block (SSNB) is an effective method for the treatment of shoulder disorders. The present study was conducted to evaluate and compare the effectiveness of SSNB under ultrasonographic guidance with anatomical landmark-guided (LMG) technique in the treatment of chronic shoulder pain.

Materials and Methods:

A total of fifty patients with shoulder pain were enrolled in the present prospective randomized study. Patients in Group I (n = 25) received SSNB using the anatomical LMG as technique described by Dangoisse, in whom a total of 6 ml of drug (5 ml of 0.25% bupivacaine and 40 mg methylprednisolone) was injected. Group II patients (n = 25) were given SSNB using the ultrasound guidance with the same amount of drug. Pain was measured using visual analog scale (VAS), range of motion and Shoulder Pain and Disability Index (SPADI) were recorded. Observations were recorded before the block, immediately after the block, and 1 and 4 weeks after the block.

Results:

There was no statistically significant difference between the VAS score, range of motion and SPADI before the procedure (P > 0.05) in both the groups. Both the groups showed statistically similar improvement of VAS, range of motion and SPADI at 4-week (P > 0.05) follow-up. In Group I, VAS decreased from baseline value of 6.64 ± 1.50–2.04 ± 0.94 at 4 weeks (P < 0.001). In Group II, the VAS decreased from 6.92 ± 1.00 to 1.84 ± 1.03 at 4 weeks (P < 0.01).

Conclusion:

In our study, both the techniques have produced comparable relief of pain, improvement in shoulder movement, and decreased SPADI 4 weeks after the block.

Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: two case reports

Tarsal tunnel syndrome (TTS) is a compression neuropathy that results from entrapment of the posterior tibial nerve or its branches. TTS may be treated either by conservative measures, including physical therapy, medications, and steroid injections, or by surgical decompression. Despite a variety of treatments, a few cases of TTS will relapse, and many cases of recurrent TTS will require re-operation. Pulsed radiofrequency (PRF) is known to have a number of advantages for pain management, particularly as this technique does not cause neural compromise such as motor weakness. Here, we report a new application of ultrasound-guided PRF in two cases of intractable TTS. Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief. We applied ultrasound-guided PRF to the affected posterior tibial nerve in each patient, and both had significantly reduced pain intensity scores and analgesic requirements without any complications. Ultrasound-guided PRF for intractable TTS relieved severe foot pain. It may supersede surgery as a reliable treatment for intractable TTS.