Treatment Strategies for Injuries of the "Unforgiving" Radial Sensory Nerve
Elisabeth Maria Brakkee, MD, MSc, UMC Utrecht, Utrecht, Netherlands, Annemieke Stokvis, MD, MSc, PhD, Erasmus MC, Rotterdam, Netherlands, Erick DeVinney, BS, Clinical and Translational Sciences, AxoGen Inc, Alachua, FL and J. Henk Coert, MD, PhD, University Medical Center Utrecht, Utrecht, Netherlands
Introduction
Neuropathic pain of the superficial branch of the radial nerve (SBRN) caused by adhesions or neuroma formation remains challenging to achieve satisfactory results in pain relief. This study was conducted to compare different surgical treatment methods for SBRN neuralgia. In addition, we explored the prognostic value of a pre-operative diagnostic nerve block.
Materials & Methods
We performed a retrospective cohort study and included patients with SBRN neuralgia caused by lesions or adhesions; compression neuropathies were excluded. Surgical records were searched for procedures on the SBRN between 2001 and 2009 in Rotterdam, and between 2015 and 2019 in Utrecht, performed or supervised by a single surgeon. Patient satisfaction was scored as satisfied or unsatisfied. The second outcome was pain intensity, scored with the numerical rating scale (NRS), measured pre- and postoperatively, and after a diagnostic lidocaine block.
Results
We included 71 patients: 25 male, 46 female, mean age 43 years (SD 14 years), 43 patients with a SBRN neuroma and 28 patients with SBRN adhesions. The mean duration of pain was 34 months (SD 47 months). An iatrogenic cause was found in 79%. The mean follow-up duration was 32 months (SD 24 months). In patients with a neuroma, more patients (53% vs 0%, p<0.001) were satisfied after proximal denervation and burying into the brachioradialis muscle (BRM) compared to other burying techniques. In patients with adhesions of the SBRN, 39% was satisfied after neurolysis. If neurolysis or denervation did not suffice, an additional 38% was satisfied after denervation of the LABCN or PIN. In patients with a poor nerve block effect (<3.5 decrease in NRS), the post-operative NRS pain scores were significantly higher (4.3 vs 7.3, p=0·005) and none were satisfied. In addition, we found that 39% of the effect of denervation and burying into BRM is accounted for by the result of the lidocaine block, see figure 1.
Conclusions
From the results of this retrospective study, we can provide treatment strategy of neuralgia of the SBRN caused by (suspected) injury. After a good result of a diagnostic nerve block, either a neurolysis or proximal denervation and burying into the BRM should be performed. If pain persists, denervation of the LABCN followed by the PIN should be considered.
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