30 Partial Wrist Denervation For Chronic Wrist Pain
Diagnosis and treatment of chronic wrist pain is challenging. Treatment has traditionally been focused on elimination of the source of the chronic pain with wrist reconstruction. Partial wrist denervation is an alternative surgical procedure. Neurectomy of the posterior and anterior interosseous nerve can decrease chronic wrist pain without compromising wrist anatomy and function.
Wrist pain remains a challenge in both diagnosis and treatment. The complex carpal kinematics, coupled with the anatomic intricacies, and variable injury patterns often present difficulty in evaluating and treating patients in a manner that minimizes disability and decreases or eliminates pain.
Chronic wrist pain can result from multiple pathologies including scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), scaphoid trapezial trapezoid arthritis, Kienbock’s disease, posttraumatic arthritis after distal radius fracture, and inflammatory arthropathies such as rheumatoid arthritis. 1 Traditional surgical management for these conditions is focused on elimination of the source of pain whether by means of resection, arthroplasty, or arthrodesis. These treatment methods have met with variable success 2 , 3 , 4 because these surgical procedures alter the anatomy and biomechanics of the wrist, which can compromise ultimate recovery.
Wrist denervation, which does not alter the gross anatomy or kinematics of the carpus, was first described by Wilhelm in 1965. 5 Denervation has been utilized with increasing frequency as an alternative to salvage procedures and has been associated with good-to-excellent outcomes in patients with chronic wrist pain from various etiologies. A complete wrist denervation includes branches of the radial and ulnar nerves and the anterior and posterior interosseous nerves, while a partial denervation addresses the anterior and posterior interosseus nerves (► Fig. 30.1).
30.2 Key Principles
Wrist denervation is an alternative for patients unwilling or unable to undergo reconstructive procedures with the potential for higher morbidity and uncertain relief of wrist pain. Furthermore, wrist denervation maintains carpal anatomy and wrist biomechanics while denervating carpal sensory branches and maintaining motor function.
Incomplete pain relief remains possible after partial wrist denervation procedures and should be discussed with patients. There can sometimes be minimal pain relief or increased pain after a wrist denervation procedure. However, if the wrist denervation procedure is unsuccessful, a more traditional wrist salvage procedure can still be completed in an effort to relieve wrist pain. Preoperative diagnostic anesthetic injections can give a rough approximation of how much pain relief the patient is likely to experience after surgical denervation.
Wrist denervation has progressed from the extensive or complete wrist denervation offered in the 1960s to a more conser-vative and minimalistic approach. The results appear to be consistent with approximately 65 to 75% of patients experiencing good or excellent pain relief. 6 , 7 , 8 , 9 , 10 , 11 Though only 45 to 50% of patients experience complete pain relief, most patients experience a level of pain relief that allows improved wrist function and improved ability to participate in activities of daily living. As many as 73% of patients are able to return to work. 11 Only 8 to 10% of patients have increased pain after surgery and are then recommended to undergo a more extensive reconstructive surgical procedure. 9 The outcomes data is based on studies that were for the most part completed in single institutions by one or two surgeons. There are no published prospective or randomized studies; therefore, results may be dependent on individual skill and experience of the surgeon.
Long-term complications are rare. Some patients describe parenthesis and sensory disturbances, but they are usually transient and generally do not persist past 6 months postoperatively. Wrist denervation resulting in a neuropathic joint has not been reported.
Wrist arthropathy and subsequent chronic pain can result from avascular necrosis as in Keinbock’s disease, inflammatory arthropathy, or it can be a consequence of trauma to the distal radius, carpus, or injury to the extrinsic or intrinsic wrist ligaments that can lead to SNAC or SLAC. When symptoms are severe, they can cause substantial loss of wrist and upper extremity function and diminish the ability of patients to perform activities of daily life and to be gainfully employed.
Wrist denervation procedures are usually offered to skeletally mature patients with severe, chronic pain unresponsive to conservative management with at least a somewhat functional wrist range of motion. 1 , 12
In cases of severe range of motion deficits and wrist deformity, arthroplasty and/or resection may be more appropriate for long-term pain relief and restoration of wrist function. Absolute contraindications for denervation include active infection and more acute conditions that could be managed nonoperatively. 1 Patient-specific concerns such as poor compliance, unrealistic expectation, or patient desire for a more definitive surgical procedure must also be addressed.