Partial Joint Denervation

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Partial joint denervation is the concept of preserving joint function and relieving joint pain by interrupting the neural pathway that transmits the pain message from the joint to the brain.

Traditional approaches to treating joint pain rely on musculoskeletal approaches to the joint itself and often require joint fusion or total replace ment arthroplasty. The concept of partial joint denervation offers the patient an outpatient, ambulatory operative approach that is join — sparing and rehabilitation-free. Establishing the validity of partial joint denervation requires 1) identifying the innervation of the specific joint through dissection because this information is not contained in anatomy texts, 2) defining a route to administer local anesthetic based on this new anatomic knowledge, 3) demonstrating that local anesthetics will relieve pain in patients in whom the musculoskeletal approach has failed, 4) planning a surgical approach to resect the nerve and interrupting the pain pathway, and 5) documenting the success of this approach with an appropriate patient population. This process must be repeated for each different joint.

Partial joint denervation was introduced by Dellon in a 1978 description of the innervation of the dorsal wrist capsule by the posterior interosseous nerve56 and in his description of the treatment of pain related to injury to that nerve in 1985.57 The innervation of the anterior wrist joint was described in 1984, and partial volar wrist denervation was then possible.58 Before this approach, total wrist denervation had been described and practiced in Europe but required 4 incisions and removal of 10 different nerve branches.59'60 The extension of the concept of partial joint denervation was then extended by Dellon to the knee joint.6163 Through 2000, the reported results for 344 patients treated with partial knee denervation (Table 5-4) are that 90% responded to a local anesthetic block with increased ambulation, stair climbing, kneeling, and reduced pain (improvement of at least 5 mm on a visual analog scale for pain).69 Causes for less-than-good results were related to

Table 5-4. Partial Joint Denervation: Relationship of Joint to its Innervation

Denervation

Painful Anatomic Site

Nerve Innervating Site

Described

Wrist, Dorsal

Posterior interosseous, 197856

Dellon, 198557

Wrist, Volar

anterior interosseous, 198458

Dellon, 198458

Knee

medial & lateral retinacular, 199461

Dellon, 199562

Sinus Tarsi

deep peroneal nerve, 200164

Dellon, 200265

Shoulder, Anterior

lateral thoracic, 199566

Dellon, 200367

Elbow, Lateral Epicondyle

Posterior brachial cutaneous nerve, 196283

DeJesus, 200484

Elbow, Medial Epicondyle

br. to medial epicondyle, 2 00485

Dellon, 200486

Temporomandibular Joint

auriculotemporal & br. of masseteric, 200368

Dellon, 200580

worker's compensation disability issues and drug addiction. Because of variability in the cutaneous nerves to the knee, about 10% of patients require a second operation to resect another cutaneous nerve, usually from the infrapatellar branch of the saphenous nerve. The experience with this procedure now exceeds 600 patients, and the results are similar (ALD, personal experience). This approach has been

Figure 5-5. The anterolateral ankle has a space described as the sinus tarsi that is illustrated in a) and b). In a), the deep peroneal nerve is shown innervating the extensor brevis muscle, and in b), the sinus tarsi is identified by the black arrow. In c), the deep peroneal nerve is shown innervating the sinus tarsi proximal to its extended to other joints (Table 5-4), and its extension to the lateral ankle and shoulder are described below.

O'Conner first described sinus tarsi syndrome in 1958.70 Lateral ankle (the sinus tarsi) pain is most commonly cause by an inversion sprain. The sinus tarsi are a space related to the bones of the anterolateral ankle (Figures 5-5a and 5-5b). The pain may be associated with a fracture innervating the brevis. Its terminal branch to the dorsal first webspace is also shown. In d), the deep peroneal nerve is resected through an approach in the lateral leg, to denervate the sinus tarsi.

Masseter Muscle Rigidity

Figure 5-5. The anterolateral ankle has a space described as the sinus tarsi that is illustrated in a) and b). In a), the deep peroneal nerve is shown innervating the extensor brevis muscle, and in b), the sinus tarsi is identified by the black arrow. In c), the deep peroneal nerve is shown innervating the sinus tarsi proximal to its innervating the brevis. Its terminal branch to the dorsal first webspace is also shown. In d), the deep peroneal nerve is resected through an approach in the lateral leg, to denervate the sinus tarsi.

or dislocation, but it is always associated with a tear of the ligaments to the joints in this space. When traditional non-operative treatment for sinus tarsi syndrome fails, and pain becomes recalcitrant, surgical options usually involved evacuating the contents of the sinus tarsi (sometimes referred to as a "clean out"), a subtalar joint arthrodesis, or a subtalar joint arthroscopy.7173

The innervation of the sinus tarsi was described in 2001 as being from the deep peroneal nerve, with the branch(es) arising just proximal to the ankle in 100% of people (Figure 5-5c), and with additional innervation coming from the sural nerve in about 20% of people.64 The evaluation of these patients requires previous foot and ankle consultation to be sure that all musculoskeletal sources of pain have been treated and that the ankle is strong. This evaluation includes being sure that there are no bone fragments in the subtalar joint. First, nerve blocks with local anesthetic must be done for the deep peroneal nerve proximal to the ankle, and then, if there is still pain with ambulation, the sural nerve should be blocked. Although the first patient reported excellent pain relief after partial resection of the deep peroneal nerve just above the ankle, which preserved function in the extensor brevis muscle and the distal dorsal foot skin,65 in a larger series, some patients did not experience relief. The current recommendation is to resect the entire deep peroneal nerve through the anterolateral lower leg (Figure

Figure 5-6. Characteristics of recovery from different surgeries for sinus tarsi syndrome.

Figure 5-7. Innervation of the anterior shoulder capsule from a branch of the lateral pectoral nerve (arrow). Because this nerve crosses the coracoid, it is the site for a nerve block.

5-5d),74 as described for the treatment of dorsal foot neuromas.75 Results obtained with partial resection of the deep peroneal nerve were excellent in 4 patients, good in 2, and poor in 1, in contrast to the results of traditional therapy, which were excellent in 6 and poor in 1 (Figure 5-6).74 The one failure in this last group of patients involved a complex regional pain syndrome.

Anterior shoulder pain is the most common symptom of failed orthopedic approaches to treating impingement syndrome and rotator cuff tears. Shoulder pain limits movement of the shoulder, the ability to perform activities of daily living, and many work activities, in particular work requiring the overhead use of the hand.

Over the past 25 years, open or arthroscopic approaches to correct shoulder pain has left about 20% of patients with anterior shoulder pain.76 79 In 1967, a description of the innervation of the anterior shoulder capsule from a branch of the lateral thoracic nerve (Figure 5-7)67 suggested that this nerve could be blocked by local anesthetic injection on the surface of the coracoid (Figures 5-8a and 5-8b). Before the block, the patient's pain is measured with a visual analog scale, and the range of painless shoulder motion is identified. The nerve is then blocked, taking care not to inject too deeply to the coracoid, to prevent blocking the brachial plexus and injuring the lung. If the block is successful, within 10 minutes the patient's pain will diminish and range of motion of the shoulder will improve (Figures 5-8c and 5-8d).

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Figure 5-6. Characteristics of recovery from different surgeries for sinus tarsi syndrome.

Figure 5-8. Technique for nerve block of the anterior shoulder capsule. a) Identifying the coracoid as a site of pain and b) doing the nerve block. c) The site before surgery and d) after a successful block, establishing that this nerve was the source of shoulder pain.

PARTIAL ANTERIOR SHOULDER DENERVATION RESULTS:

BEFORE BLOCK

AFTER BLOCK

Figure 5-8. Technique for nerve block of the anterior shoulder capsule. a) Identifying the coracoid as a site of pain and b) doing the nerve block. c) The site before surgery and d) after a successful block, establishing that this nerve was the source of shoulder pain.

Residual impairment in the range of motion may remain as a result of adhesive capsulitis. If the denervation procedure is successful, subsequent surgery can improve the range of motion of the "frozen shoulder." The incision is made over the coracoid, and the pectoralis muscle is split longitudinally (Figure 5-9a). Loup magnification and bipolar coagulation is used. The vessels in the loose areolar tissue just deep to the pectoralis and immediately over the coracoid

Figure 5-9. Intra-operative view of a nerve to the anterior shoulder capsule. a) The incision on the right shoulder of a patient who had a previous open-shoulder surgery. b) A nerve to the anterior shoulder capsule adjacent to vessels.

Figure 5-9. Intra-operative view of a nerve to the anterior shoulder capsule. a) The incision on the right shoulder of a patient who had a previous open-shoulder surgery. b) A nerve to the anterior shoulder capsule adjacent to vessels.

are inspected, and any nerve within this tissue is excised, often requiring excision of one of the veins as well (Figure 5-9b). Then, the coracoid is approached, and the origin of the biceps and coracobrachialis inspected. A second branch of the nerve may be present at this level, measuring less than 1.0 mm. A 2-cm segment is resected. Marcaine is placed into this area. If there is any question about the nerve being a motor branch to the pectoralis, intra-operative stimulation is used. The nerve typically can be traced directly to the shoulder capsule, but it is resected over the coracoid.

The results in the first group of 12 patients treated with this technique were reported in

2003, to the Argentinian Hand Surgery Society meeting (Figure 5-10).67 The mean age of the 8 men and 4 women was 37.5 years (range 29 to 54 years). The mechanism of injury was work-related in 7. The mean time from injury to shoulder denervation was 2.5 years (range: 0.5 to 7.0 years). To be eligible for the procedure, each patient had to have at least 5 points on the pain scale and required an increase in range of motion. At a mean of 1.2 years after anterior shoulder denervation, 8 patients had excellent results and 4 had good results. Mean VAS pain scores dropped from 8.5 to 1.8, and mean range of motion, pain-free, increased from 0° to 60° to 1° to 100°.

Elbow joint pain must be distinguished from medial and lateral humeral epicondylar pain. Although the innervation of the elbow joint was described more than half a century ago,80 and total elbow denervation was described more than 40 years ago,81,82 partial elbow joint denervation has not been described, nor has isolated denervation of either the medial or lateral humeral epicondyle. Kaplan and Wilhelm did describe denervation of the lateral humeral epicondylitis, but Kaplan81 clearly denervated only branches of the radial nerve at the radial-humeral joint, whereas Wilhelm82 did this as well, plus denervating muscles innervated at the epicondyle. He also included the posterior brachial cutaneous nerve (nervus cutaneous antebrachii dorsalis) in perhaps his first description of this procedure in German, in 1962.83

In 2004, isolated denervation of the lateral humeral epicondyle by resecting the branches of the posterior cutaneous nerve of the arm and forearm was described at the American Association of Hand Surgery meeting.84 The innervation of the medial humeral epicondyle was described in 2005 at the American Society for Peripheral Nerve. This nerve was noted during resection of the medial intermuscular septum duringsubmus-cular transposition of the ulnar nerve. Cadaver dissections revealed that it originates from the radial nerve in the axilla in all cases, with one case having a contribution from the ulnar nerve in the axilla as well. This nerve can be resected at the insertion of the medial intermuscular septum into the medial epicondyle for the treatment of medial epicondylitis ("golfer's elbow").85-86

Temporomandibular joint (TMJ) pain is another example of debilitating joint pain.

Figure 5-10. Results of anterior shoulder denervation. A typical patient preoperative^ and 6 months after surgery, showing increased range of motion.

Figure 5-10. Results of anterior shoulder denervation. A typical patient preoperative^ and 6 months after surgery, showing increased range of motion.

Although TMJ pain is taught traditionally to be related to dental malocclusion, it if often considered to be part of the symptom complex in brachial plexus compression, in the thoracic inlet (thoracic outlet syndrome) and cervical sprain. The TMJ can be the center of referred pain from the cervical plexus, as in the two clinical examples given above, from the maxillary sinusitis (infraorbital nerve), or from third molar problems (superior and inferior alveolar nerves). This referral pattern is best understood by relating it to the recent iteration of the many earlier papers that describe the innervation of the TMJ, from branches of the trigeminal nerve division V2, the mandibular nerve. The lateral aspect of the TMJ is innervated by the auriculotemporal nerve before it pierces the temporal fascia to innervate the preauricular and temporal region. The medial aspect of the TMJ is innervated by a branch from the nerve that innervates the masseter muscle just before that nerves crosses between the coronoid and condylar processes, at the mandibular notch.68 Additional medial innervation may come from the nerve to the lateral pterygoid muscle.68

Despite extensive protocols for managing TMJ pain, if they fail, endoscopic or open procedures attempt to tighten the ligaments of the TMJ or to reshape or reconstruct the joint itself. These procedures classically give immediate relief, but pain recurs in 3 to 6 months. Much of this success is likely related to completely denervating the TMJ, and the recurring pain is caused by reinnervation of the joint or true neuroma formation.

On January 28,2005, the first attempt to dener-vate the TMJ was performed (Figure 5-lla) in a patient who had three previous procedures, two endoscopic and one open.87A preauricular incision was made, and the upper portion of the mandibular ramus was approached, using a dilute epinephrine solution to control bleeding and intraoperative electrical stimulation to identify the facial nerve branches (Figure 5-llb). The auriculotemporal nerve moves from posterior to anterior across this portion of the mandible and may be identified at this point (Figure 5-11b) and followed to the lateral TMJ capsule, and resected (Figure 5-llc). A branch to the eustachian tube can be identified and should also be resected because this branch may create referred or neuromatous pain in the external auditory meatus (which it did in this patient, preventing her from wearing her hearing aid). The branch from the nerve to the masseter is difficult to identify, but it was approached in this patient by extending the incision toward the mandibular

Figure 5-11. Denervation of the temporomandibular joint (TMJ). a) Preoperative view of the TMJ outlined with innervation, from the auriculotemporal nerve to the lateral and the masseteric nerve to the medial side of the joint capsule. b) Intra-operative view, with the blue vessel loop on a facial nerve branch (note nerve stimulator in use) and white vessel loop on branch of auriculotemporal

Figure 5-11. Denervation of the temporomandibular joint (TMJ). a) Preoperative view of the TMJ outlined with innervation, from the auriculotemporal nerve to the lateral and the masseteric nerve to the medial side of the joint capsule. b) Intra-operative view, with the blue vessel loop on a facial nerve branch (note nerve stimulator in use) and white vessel loop on branch of auriculotemporal nerve. c) After resection of the auriculotemporal nerve, its proximal end is placed deep to the mandibular ramus (dark hole and arrow). The specimen is lying on the cheek skin. d) The branch of the masseteric nerve to the joint capsule is approached by elevating the masseter from the mandibular ramus (white area) and then grasping the nerve with a right-angle clamp, reaching behind the condyle.

angle, elevating the masseter from the mandible, and dissecting superiorly towards the notch. In this location, a right angle clamp can be placed posteriorly, and the innervation of the medial TMJ can be disrupted (Figure 5-llc). It may be that only a partial, lateral TMJ denervation is needed for most patients with intractable TMJ pain.

For plastic surgery, the concept of partial joint denervation opens a new area for patient care, permitting relief of pain and restoration of function throughout the body for those with joint pain.

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