American Society for Peripheral Nerve

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Joint Denervation to Manage Painful Wrist and Trapezio-Metacarpal Arthritis in Patients with Spinal Cord Injury
Andreas Gohritz, MD
Swiss Paraplegia Center, Nottwil, Nottwil, Switzerland

Introduction: Patients with SCI have significantly higher rates of painful osteoarthritis, above all of the wrist and trapezio-metacarpal joint of their dominant hand - most likely due to increased load during wheelchair propulsion and transfer [1]. However, standard bony procedures in able-bodied patients, such as arthoplasty or arthrodesis, require lengthy immobilization and total joint prostheses mmay not be suitable for SCI patients due to high mechanical load.

Methods: The results of surgical denervation of wrist and trapezio-metacarpal joint was studied in a group of 11 patients operated between 2012 and 2017. A wrist denervation modified after the original description by Wilhelm [2] was performed in 6 cases, a thumb carpo-metacarpal joint denervation according to Loréa [3] 6 times (1 bilateral), one patient had a combination of both procedures. Prerequisite was a preoperative test block using local anaesthesia reducing the pain level at least by 50%. The result regarding function and pain intensity was evaluated by the patients prior to and 3 months after surgery using a visual analogue scale (0 = pain free, 10 = worst pain).

Results: Pain levels dropped markedly by at least 50% in all cases and results were rated as satisfactory by all patients. Function did not deteriorate in any case. No conversion to total joint arthrodesis occurred during follow-up time. There were no complications.

Discussion: Surgical joint denervations is an underused option to treat painful osteoarthrititis and we are unaware of a description in a patient with SCI. However, compared to more invasive methods, such as bony fusion, arthroplasty or prostheses provides important advantages: 1. Joint integrity is preserved, 2. Muscle function remains unaffected, 3. Postoperative immobilization is not necessary, 4. Operation is possible under local anesthesia, 5. The method is technically simple, inexpensive and with low risks. 6. All alternatives remain possible for future, e. g. arthrodesis or arthroplasty prosthesis. 7. The results can be reliably anticipated by preoperative test nerve blocks.

Conclusion: Surgical denervation seems a promising alternative to treat osteoarthritis in para- or tetraplegic individuals who are often not well suited for standard bony procedures, such as arthroplasty or arthrodesis .

[1] Akbar M et al. (2014). J Hand Surg Eur Vol 39: 132-138.

[2] Wilhelm A (2001). Techn Hand Upper Extr Surg 3: 14-18.

[3] Loréa P (2003). Techn Hand Upper Extrem Surg 7: 26–31

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