Wrist denervation

Wrist denervation is indicated in patients with chronic pain but preserved motion after exhausting nonoperative treatments. Patients are candidates for denervation if they have pain from primary degenerative or inflammatory arthritis, osteonecrosis (Kienböck or Preiser disease), or traumatic conditions, such as scaphoid nonunion advanced collapse (SNAC) or scapholunate advanced collapse (SLAC) wrist, ligamentous instability, or sequelae of distal radius fractures.

Transecting articular nerve branches reduces pain without causing major motor or sensory deficits. Although theoretically possible, neuropathic arthropathy (Charcot joint) has not been reported in the wrist.

Wrist denervation can be performed in isolation or can be combined with other procedures.

Patients must be counseled that denervation does not treat the underlying disease and arthritis will progress. This procedure is best suited for low-demand, younger patients who are expected to have slow disease progression. Additional surgery may be necessary if denervation does not provide adequate pain relief or if pain recurs over time.

This operation should not be viewed as a salvage procedure but as an alternative treatment of chronic wrist pain. It has no effect on the ability to proceed with subsequent operations, such as partial or complete wrist arthrodesis, proximal row carpectomy (PRC), or arthroplasty.

Between 1 to 2 mL of local anesthetic is sequentially injected around each of the articular nerve branches. Blockade is performed in the specific order listed here and improvement is assessed after each injection. If pain improves after blockade, the nerve is targeted with surgery.

• Posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN). The injection point is 1-cm ulnar and 3-cm proximal to Lister tubercle ( Fig. 54.1 ). The needle is inserted vertically until resistance from the interosseous membrane is felt. Then it is withdrawn 2 mm, and local anesthetic is injected around the PIN. The needle is then advanced through the interosseous membrane and another 1 to 2 mL of local anesthetic is injected around the AIN. If PIN/AIN blockade is effective, there is no need to perform another injection.

  

• Dorsal sensory branch of the ulnar nerve (DSBUN). The needle is inserted vertically at the border of the ulnar styloid and local anesthetic is injected just above the bone.

• Superficial sensory branch of the radial nerve (SSRN). Local anesthetic is injected about 3 cm proximal to the wrist crease around the radial vessels; be sure to aspirate before injecting. The needle is then directed dorsally and the subcutaneous tissues proximal to the radial styloid are infiltrated (See Chapter 1 Anesthesia of the Hand, Fig. 1.8 ).

Three-view radiographs of the wrist are required to evaluate the bony anatomy.

Magnetic resonance imaging (MRI) is considered if soft tissue injury (triangular fibrocartilage complex [TFCC] tear, ligamentous injury) or osteonecrosis (Kienböck disease) is suspected.