Managing Chronic Knee Pain Using Selective Denervation Guided By High-Resolution Nerve Ultrasound - Treatment Algorithm and Typical Clinical Cases
Veith Moser, MD1; Andreas Gohritz, MD2; Dirk J Schaefer, MD3
1Trauma Hospital, Vienna, Australia; 2Swiss Paraplegia Center, Nottwil, Nottwil, Switzerland; 3University Hospital Basel, Basel, Switzerland
Background: A considerable group of patients after knee trauma and surgery remains with chronic pain, e.g. up to 20% after total knee arthroplasty (TKA). Potential causes include neuroma or scar traction of sensory branches innervating the knee, mostly from the femoral and saphenous nerve which yet can be detected accurately by high-resolution ultrasound (HRUS). This paper presents results of HRUS-supported knee denervation.
Methods: During a 4-year period, more than 40 patients were operated at 2 hospitals of which 4 cases were chosen to demonstrate typical scenarios. All patients underwent preoperative HRUS-guided nerve blocks, pain levels were determined on a visual analogue scale (vas) from 0 to 10. HRUS was used to mark relevant joint nerves or neuroma on the skin prior to surgery.
Case 1: After blunt trauma, a police-woman (56 y) had chronic knee pain for over 3 years until a medial knee denervation (vas 8 to 2/10). She was able to fully resume her work as and leisure activity as soccer trainer.
Case 2: After a fall, a social worker (27 y) had knee chronic pain (8/10) and residual pain of 4/10 remained after saphenous neurectomy. Following further HRUS and additional neurectomy of the medial femoral cutaneous nerve her pain completely resolved.
Case 3: After TKA, a pensioner (66 y) suffered from chronic pain for over 7 years until HRUS-guided medial and lateral knee denervation decreased her pain from 7-8 to 1-2/10.
Case 4: After 3 previous knee operations, medial and lateral knee denervation guided by HRUS markedly reduced pain knee levels from 8 to 2/10 in a worker (41 y).
Conclusion: Our experience suggests that selective denervation based on HRUS-guided preoperative nerve blocks and marking of relevant nerves on the skin provides an effective algorithm to decrease chronic knee pain of various origin by at least 50% with success rates of about 80%.
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