Motor-Sparing Neural Ablation with Modified Techniques for Knee Pain: Case Series on Knee Osteoarthritis and Updated Review of the Underlying Anatomy and Available Techniques

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.

Current Approaches to Four Challenging Pain Syndromes

During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.

Preliminary Study on Grading Diagnosis of Early Knee Osteoarthritis by Shear Wave Elastography

Knee osteoarthritis (KOA) is the most common chronic bone joint disease. The WHO points out that KOA has become the fourth most disabling disease in the world, and the main clinical treatment is prevention. At present, the clinical diagnosis of knee osteoarthritis with deformation is mainly made by X-ray and two-dimensional ultrasound, and the preventive treatment effect is not good. Shear wave elastography (SWE) has been widely used in clinical practice for its advantages of noninvasive, simple, rapid, and high accuracy in soft tissue hardness. This study investigates the feasibility of using SWE in the grading diagnosis of KOA and the detection of early skeletal muscle injury. 60 patients were enrolled with unilateral KOA who met the inclusion criteria. Routine scanning and SWE exploration were carried out and compared between the affected and healthy knee joints. The measurements included morphology, damage degree of cartilage, joint effusion, joint synovial thickness, the degree of meniscus convexity, and shear wave speed (SWS) in the tendon attachment area of the quadriceps femoris superior patella, and tendon thickness and SWS between and within groups. The affected was scored according to the ultrasonic characteristics. The correlation between them was analyzed to evaluate the feasibility of SWE in grading the diagnosis of KOA. 57 cases had knee cavity effusion (57/60, 95.0%), 58 cases had knee cartilage injury (58/60, 96.6%), and 35 cases had a lateral process of the medial meniscus (35/60, 53.3%); 30 cases had synovial hyperplasia (30/60, 50%), 21 cases had osteophyte formation (21/60, 35%), and no one had a popliteal cyst. There was no significant difference in tendon thickness between and within groups (p > 0.05), but a significant difference in SWS (p < 0.01); the SWS of the quadriceps femoris tendon is negatively correlated with ultrasound score (r = 0.955, p < 0.01). There is a strong negative correlation between SWS and the degree of KOA. It can be used in the grading diagnosis of KOA to help find more early strain points.