suprascapular nerve block and radiofrequency ablation

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promethius

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Has anyone have any experience performing suprascapular nerve blocks and, if the blocks were successful, radiofrequency ablations of the suprascapular nerve for treatment of chronic shoulder pain? If so, what are the landmarks and techniques you use to perform both the block and the radiofrequency ablation of the suprascapular nerve? As the suprascapular nerve contains both sensory and motor fibers, I am also curious to know why radiofrequency ablation of the suprascapular nerve does not cause any paresis. Thank you.

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Has anyone have any experience performing suprascapular nerve blocks and, if the blocks were successful, radiofrequency ablations of the suprascapular nerve for treatment of chronic shoulder pain? If so, what are the landmarks and techniques you use to perform both the block and the radiofrequency ablation of the suprascapular nerve? As the suprascapular nerve contains both sensory and motor fibers, I am also curious to know why radiofrequency ablation of the suprascapular nerve does not cause any paresis. Thank you.

I've done this a number of times. It definitely DOES cause paresis of the supra and infraspinatus muscles. They will go bye bye. Find the supra scapular notch and, drive RF needle down to it, stimulate with motor, make sure you get supra and infraspinatus contractions, inject 4% Lidocaine, then RF.

I only do it on folks who are failed or too ill for surgical candidates
 
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Any luck with peripheral stimulation of the suprascap?
 
Any luck with peripheral stimulation of the suprascap?

If you mean pulsed RF treatment, I've done it and it can work ok. I've not done SCS stim of the suprascap, as it is not covered by insurance in my area. I don't see how it could stay put either...
 
I've done this a number of times. It definitely DOES cause paresis of the supra and infraspinatus muscles. They will go bye bye. Find the supra scapular notch and, drive RF needle down to it, stimulate with motor, make sure you get supra and infraspinatus contractions, inject 4% Lidocaine, then RF.

I only do it on folks who are failed or too ill for surgical candidates

I suspected radiofrequency ablation of the suprascapular nerve may cause some paresis, but could not find any evidence of that from searching online. What should I tell patients who get pain relief from a suprascapular nerve block if they ask how much paresis they should expect from the radiofrequency ablation? Are they still able to have full range-of-motion of their shoulder? I guess I just want to know how much paresis is to be expected, so they can decide whether or not it is worth it to undergo the radiofrequency ablation. Thanks!
 
I suspected radiofrequency ablation of the suprascapular nerve may cause some paresis, but could not find any evidence of that from searching online. What should I tell patients who get pain relief from a suprascapular nerve block if they ask how much paresis they should expect from the radiofrequency ablation? Are they still able to have full range-of-motion of their shoulder? I guess I just want to know how much paresis is to be expected, so they can decide whether or not it is worth it to undergo the radiofrequency ablation. Thanks!

Read the articles posted.
 
I suspected radiofrequency ablation of the suprascapular nerve may cause some paresis, but could not find any evidence of that from searching online. What should I tell patients who get pain relief from a suprascapular nerve block if they ask how much paresis they should expect from the radiofrequency ablation? Are they still able to have full range-of-motion of their shoulder? I guess I just want to know how much paresis is to be expected, so they can decide whether or not it is worth it to undergo the radiofrequency ablation. Thanks!

Are you asking about pulsed RF treatment or continuous RF ablation? Pulsed will cause zero paresis.

The supraspinatus and infraspinatus muscles are motor innervated by the suprascapular nerve. You will get profound paresis if you really kill the nerve with continuous RF ablation. The muscles will atrophy and you will see and feel it if the patient is thin enough. This is discussed in the articles, if I remember correctly. They also discuss that there was, somehow, minimal loss of function despite the paresis. Most likely due to reduced pain inhibition upon ROM.

I generally do continuous RF ablation at 90degC and inject 1 cc of Phenol as well to definitively cook the nerve, since we are forced to come at it with a perpendicular approach and thus the RF lesion size is not very large, unless you are using a venom or cooled RF cannulae, for example.
 
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I wrote a case report of such for pulsed RF using an ultrasound approach. I think it can work pretty good for shoulder pain.

I have heard Cryoablation works better than RF ablation - and better I mean more preservation of nerve structure - but I don't know that for sure.

http://www.sciencedirect.com/science/article/pii/S0952818013000871

Article is attached - but if you follow the link - you can get a video of me doing a local injection around the nerve. The video starts out with a brachial plexus view - moving caudad, you can see the top nerve split and the suprascapular nerve moves posterior away from the plexus.
 

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I used to do cryo on the nerve at the notch....I agree there was less motor dysfunction, and had a much larger lesion making it possible to do a lesion posterior to the notch, and preserve the supraspinatus muscle branch. It did not preserve the infraspinatus branches, but this muscle seems to be less important in the usual ROM of the shoulder. The downside to cryo is that it lasts only 3 months.....
 
For adhesive caps = IA injection, +SSNB and PT rx

echo (spinoglenoid notch) approach

(caveat: have to give away the 20611, as NB and joints mutually exclusive nowadays)




Anyone ever RF from this approach?
 
Go the pulsed RF route; why take out the Supra/infraspinatus if you can maintain them?


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I see pretty significant supra and infraspinatus weakness on exam, but the patients rarely complain of "weakness" as they have pain relief...do you not see weakness on exam after RFA?

Unless a functional deficit occurs, i do not do more than check ROM, delt strength. The folks I am treating hurt too bad to brush hair, wipe butt, or get dinner plate from cupboard. Or the ladies will say they can hook their bra in the back, not in the front then spin it.
 
Unless a functional deficit occurs, i do not do more than check ROM, delt strength. The folks I am treating hurt too bad to brush hair, wipe butt, or get dinner plate from cupboard. Or the ladies will say they can hook their bra in the back, not in the front then spin it.

Makes sense. :) I just test the strength out of curiosity.
 
Are you asking about pulsed RF treatment or continuous RF ablation? Pulsed will cause zero paresis.

The supraspinatus and infraspinatus muscles are motor innervated by the suprascapular nerve. You will get profound paresis if you really kill the nerve with continuous RF ablation. The muscles will atrophy and you will see and feel it if the patient is thin enough. This is discussed in the articles, if I remember correctly. They also discuss that there was, somehow, minimal loss of function despite the paresis. Most likely due to reduced pain inhibition upon ROM.

I generally do continuous RF ablation at 90degC and inject 1 cc of Phenol as well to definitively cook the nerve, since we are forced to come at it with a perpendicular approach and thus the RF lesion size is not very large, unless you are using a venom or cooled RF cannulae, for example.

Where I trained, we never used pulsed radiofrequency ablation; we only used continuous radiofrequency ablation. Why would pulsed radiofrequency ablation cause no paresis compared to that of continuous radiofrequency ablation?

Thank you for the posting the articles lobelsteve. I read the Simopoulos article and found it to be very informative. The article states that even though the supraspinatus and infraspinatus muscles are denervated by continuous radiofrequency ablation of the suprascapular nerve, other muscles exist that will compensate for the loss of function in abduction and external rotation of the supraspinatus and infraspinatus muscles respectively, so no significant loss of function was noticed after continuous radiofrequency ablation of the suprascapular nerve.
 
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Where I trained, we never used pulsed radiofrequency ablation; we only used continuous radiofrequency ablation. Why would pulsed radiofrequency ablation cause no paresis compared to that of continuous radiofrequency ablation?

Thank you for the posting the articles lobelsteve. I read the Simopoulos article and found it to be very informative. The article states that even though the supraspinatus and infraspinatus muscles are denervated by continuous radiofrequency ablation of the suprascapular nerve, other muscles exist that will compensate for the loss of function in abduction and external rotation of the supraspinatus and infraspinatus muscles respectively, so no significant loss of function was noticed after continuous radiofrequency ablation of the suprascapular nerve.

Pulsed radiofrequency treatment is non-destructive. No ablation occurs. It is a neuromodulation procedure. Max temp is at 42deg C, which is non-destructive.

Continuous radiofrequency ablation is destructive. It destroys nerves, typically at temps of 70-90deg C.

Yes, people tend to have improved function after radiofrequency ablation of the supra scapular nerves despite supra and infraspinatus palsy. But make no mistake, these muscles will atrophy after this procedure.
 
Great discussion. Do most sensory fibers originate after sphenoglenoid notch? That would be an interesting tradeoff for themal rf
 
anyone doing suprascapular nb more proximal than the suprascapular notch?
 
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