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Targeted Relief: A Cadaveric Study of Ultrasound-Guided Quad-Nerve Denervation
Olachi Oleru, MD
1, Bryan Ganter, MD
1, Peter Strang, PA-C
1, Pooja Dhupati, MPH
2, Shirley Lowmaster, MS
1; Shelley S. Noland, MD
1(1)Mayo Clinic, Phoenix, AZ, (2)University of Arizona College of Medicine Phoenix, Phoenix, AZ
Background
Surgical denervation of the wrist is gaining popularity as a treatment option for wrist osteoarthritis.
1 However, for patients who cannot or choose not to undergo surgery, therapeutic options are more limited. Chemical denervation has existed as a minimally invasive method for treating both motor and sensory disease in a wide variety of patients and pathologies.
2,3 This, however, has not yet been applied clinically to the small joints of the upper extremity. This study aims to determine the feasibility of minimally invasive denervation for the treatment of wrist osteoarthritis.
Methods and Materials
Under ultrasound guidance, 2.5cc of a mixture of phenol, glycerin, and methylene blue was injected into six unembalmed cadaver wrist specimens. The anterior interosseous (AIN), posterior interosseous (PIN), superficial branch of radial (SBRN), and lateral antebrachial cutaneous (LABCN) nerves were targeted through two injection sites.
1 Dissection of the anterior and posterior forearms were performed to confirm and objectively measure nerve staining and visualize dispersion.
Results
Dissection showed successful injectate dispersion along all four nerves. AIN dispersion was 1.9cm ± 0.9cm along the nerve with a total injectate dispersion area of 2.6cm
2 ± 0.6cm
2 between the pronator quadratus and interosseous membrane (IOM). PIN dispersion was 4.2cm ± 2.9cm with 7.4cm
2 ± 9.8cm
2 dispersion between the fourth extensor compartment and IOM. SBRN dispersion was 6.4cm ± 2.2cm with 16.1cm
2 ± 12.8cm
2 spread deep to the brachioradialis muscle. LABCN dispersion was 4.2cm ± 1.2cm with 15.2cm
2 ± 14.3cm
2 spread superficial to the brachioradialis muscle. This dispersion spared the radial artery and the main motor branches of the AIN and PIN. When the LABCN was injected in isolation, no spread to the SBRN was observed.
Conclusion
Minimally invasive ultrasound guided chemodenervation of the wrist with a phenol-glycerin mixture shows promise in targeting the majority of sensory distribution of the wrist without significant spread to surrounding neuromuscular and neurovascular structures.
References
- Wu CH, Strauch RJ. Wrist Denervation: Techniques and Outcomes. Orthop Clin North Am. 2019;50(3):345-356. doi:10.1016/j.ocl.2019.03.002
- D'Souza RS, Warner NS. Phenol Nerve Block. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 28, 2023.
- Weksler N, Klein M, Gurevitch B, et al. Phenol neurolysis for severe chronic nonmalignant pain: is the old also obsolete?. Pain Med. 2007;8(4):332-337. doi:10.1111/j.1526-4637.2006.00228.x
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