Denervation of the Humeral Epicondyles

Fig. 13.1

Right forearm and elbow of man who had four previous surgical attempts to treat his “tennis elbow” pain. a Outline of the path of the posterior cutaneous nerve of the forearm with asterisk over the painful neuroma. The pathways distally into the area of dysesthesias are shown as is the origin and innervation of the branches to the epicondyle. b The branches to the dysesthetic skin are shown. c The branches to the lateral humeral epicondyle are shown. d The proximal end of the entire posterior femoral cutaneous nerve is implanted into the lateral head of the triceps muscle

Fig. 13.2

Patient from Fig. 13.1 at a 1-year follow up. a Having resumed his coaching activities, he is with his team as they win the championship for their league. b Back playing tennis

Fig. 13.3

In a cadaver, the anatomy of the posterior cutaneous branch of the radial nerve is outlined in a and demonstrated in b

The next phase of the investigation involved a collaborative study with the hand surgeons at the Southern Illinois College of Medicine, whose preferred surgical approach was to do a lateral epicondylectomy. In our retrospective study, we studied the patients that had only had a denervation as well as patients treated with epicondylectomy, compared to a group of patients that had both an epicondylectomy and a denervation. While one can argue that epicondylectomy effectively denervates the epicondyle, the proximal end of the nerve is left in close proximity to the bone resection and can regenerate into that scar. The results of that study [26] demonstrated that the denervation alone group, and denervation plus epicondylectomy group had significantly better pain relief, as measured with a visual analog scale (VAS; p < 0.001), and a significantly shorter recovery time to return to work (p < 0.001) than did the epicondylectomy alone group (Tables 13.1 and 13.2).

Table 13.1

Demographics from study comparing denervation results to epicondylectomy. [26]

Group	Age	Gender	Number in group
Epicondylectomy	46.8 years	9 male, 8 female	17
Epicondylectomy and denervation	43.1 years	1 male, 6 female	7
Denervation	44.7 years	4 male, 2 female	6

Table 13.2

Results from study comparing return to work in treatment groups. [26]

Group	Average time to return to work	Statistical significance
Epicondylectomy	125 days
Epicondylectomy and denervation	41 days	p < 0.001
Denervation	28 days	p < 0.001

A prospective study was then performed with surgeons from Irvine, CA, with patients who had epicondylar symptoms that had persisted for more than 6 months despite nonoperative measures [27]. These patients underwent a simple denervation of the lateral epicondyle, as demonstrated in Figs. 13.3 and 13.4. Inclusion criteria included a successful preoperative nerve block with 1 % xylocaine mixed 1:1 with 0.5 % Marcaine. This was performed with the placement of approximately 3–5 cc at the level of the fascia and more deeply about 3–4 cm proximal to the lateral humeral epicondyle. A visual analog scale preinjection level was compared with the pain 15 min after the injection, with a decrease in level of ≥ 5 being required to consider the block a success. Also, preinjection grip strength with the elbow extended and with the elbow flexed at 90° was compared with the same measurements 15 min after the block.

Fig. 13.4

Clinical intraoperative example of denervation of the left lateral humeral epicondyle. a Typical incision demonstrates the posterior cutaneous nerve to the forearm in the top blue vessel loop, as determined by gently pulling on it and observing the skin move, and two branches to the lateral epicondyle, demonstrated by pulling on the nerves and seeing the skin move directly over the perisoteum. b The two branches divided and lying on the skin. c These branches have been turned 180° and are implanted loosely into the lateral head of the triceps without a suture

Denervation Technique

As the technique is done currently, the patient is positioned supine under either local or general anesthesia, and no pneumatic tourniquet is used. The incision site is 2–3 cm proximal to the lateral humeral epicondyle and is longitudinal, being about 4–5 cm in length depending upon the size of the arm (Figs. 13.4 and 13.5). The fat is gently dissected until one or sometimes two branches are identified, usually, but not always, above the deep fascia. A gentle pull on these nerves will cause the skin at the lateral humeral epicondyle to move. Sometimes, the posterior cutaneous nerve of the forearm is identified first, in which case it can be followed distally or proximally until these branches are identified. The posterior cutaneous nerve of the forearm is then injected with local anesthetic, usually 0.5 % Marcaine without epinephrine. Then the branch(es) to the lateral epicondyle is/are cauterized distally, divided, a piece sent to pathology, and the proximal end turned and implanted deep to the fascia into the triceps muscle. The posterior cutaneous nerve itself can usually be preserved. Sometimes an intraneural dissection to obtain length on the divided nerves is necessary to bring them up for implantation into the triceps muscle (Fig. 13.4 and 13.5).

Fig. 13.5

Clinical intraoperative example of denervation of the right lateral humeral epicondyle. a Forearm demonstrates with asterisk the site of pain, and the “negative” indicates no clinical entrapment of the radial nerve at the elbow or forearm. b Typical incision demonstrates the posterior cutaneous nerve to the forearm branches to the lateral epicondyle, demonstrated by pulling on the nerves and seeing the skin move directly over the periosteum. c These branches have been divided and turned 180° and are implanted loosely into the lateral head of the triceps without a suture

Denervation of the Medial Humeral Epicondyle

During anterior transposition of the ulnar nerve, it has always been the author’s practice to excise the medial intermuscular septum, not simply to divide it. Wearing loupes during this surgery, a fascicle within the septum was often observed (Fig. 13.6). In order to understand this, 20 consecutive specimens were evaluated pathologically for the presence of neural tissue. Histology identified a nerve in 15 of the 20 specimens, and in the remaining 5, a nerve was identified with an S-100 stain. This demonstrated that there was a nerve present, and since there was never any clinical deficit associated with this “denervation,” it was assumed this was a nerve to the medial humeral epicondyle.

Fig. 13.6

Intraoperative view of resection of the medial intermuscular septum during ulnar nerve anterior transposition. The resected specimen usually contains the nerve to the medial humeral epicondyle, and this resection can be the cause of a painful neuroma

The most common source of complaints of pain in the medial epicondyle were in patients referred to me as recurrent ulnar nerve entrapment. Some of these patients had pain around the elbow, which was not from the usual neuroma of the medial antebrachial cutaneous nerve. The pain could be localized to the juncture of where the medial intermuscular septum joined the medial humeral epicondyle, and it was the author’s impression this represented a true neuroma of the nerve that was located within that septum (Fig. 13.7). At surgery, in addition to resecting a neuroma of the medial antebrachial cutaneous nerve, and doing the neurolysis of the ulnar nerve, the author’s practice evolved to resect more proximally the medial intermuscular septum, and send it to the pathologist, where often a true neuroma was identified. This experience has been reported anecdotally [22].

Fig. 13.7

Cadaver dissection of the nerve to the medial humeral epicondyle. a Overall, axilla to epicondyle view. b Close-up of the origin of the nerve from the radial nerve in the axilla. c Close-up of the distal end of the nerve, in the forceps, in relation to the epicondyle and the ulnar nerve (lying on the blue paper)

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