Hybrid percutaneous technique guided by ultrasound and fluoroscopy: anatomical bases for sensitive glenohumeral joint neuroablative denervation
Authors: Barros Mirna Duarte , de Campos José Luiz , Mendes Carlos José Lazzarini 
Published: April 2020

IntroductionSince John Hilton (1873), an anatomist physician and British surgeon, joint sensitive innervation had been studied. Understanding this anatomy allows neuroablative joint denervation (NJD) through percutaneous access to the treatment of joint pain in cases of osteoarthritis and shoulder capsulitis, for examples. The shoulder has a rich sensory innervation from mixed nerves, with motor components. Thus, for the NJD the approach should be guided to the sensitive branches of the nerves, avoiding motor sequelae. Suprascapular (SSN), axillary (AN) and lateral pectoral (PLN) nerves are responsible for 98% of sensory innervation of the glenohumeral joint, then represent the most important anatomical target in NDJ procedure.ObjectiveThe aim of this study is to show the anatomical and radiological landmarks for NDJ procedure.Method

Dissection of SSN, AN and PLN nerves sensitive branches.
Definition of anatomical landmarks of SSN, AN and PLN nerves sensitive branches, by fluoroscopy (FC) and ultrasound (US).
NJD was performed on the glenohumeral joint of 8 patients, by cooled radiofrequency (CRF), through percutaneous anatomical accesses using hybrid technique, guided by US and the positioning of the cannulas by bone anatomical references were confirmed by FC.
The 8 patients presented joint pain without muscle or tendinous components and without indication of surgical therapy. The visual analogue scale (VAS) and shoulder disability index test were applied before and after the procedure during 6 months. (Figure
1,
2)ResultsThe dissection of SSN, AN and PLN nerves sensitive branches showed the anatomical topography of the sensitive area of the glenohumeral joint innervation. Those anatomical information supported the NDJ procedure in all the 8 patients, were performed feasible and safely, using the hybrid technique (FC and US).Discussion and ConclusionSupported by the anatomical results, the steps of the NDJ procedure were established. The SSN, after passing through the spinoglenoid notch, sends laterally articular sensory branches. Thus, guided by US, the needle tip was placed at the lateral extreme point from the glenoid notch without joint or labrum injury. The AN sends sensory branches after passing through the greater tuberosity inferior margin of the humerus, accessed by US locating the tip of the needle cranially to the posterior humeral circumflex artery and touching the humerus laterally. The PLN sensitive branches go through the caudal and lateral region of the coracoid process, and this area is identified for US guided cannula position. After the cannulas were located, their position was checked by FC, using the bone as reference, and some adjustments could be performed, if necessary. Sensory innervation was properly accessed and NJD procedure was performed without motor innervation damages. Knowledge of anatomical landmarks recognized by dissection or by radiographic or dynamic images such as ultrasound, when combined, can present themselves as tools that contribute to increasing the effectiveness and safety of clinical procedures.Support or Funding Information
www.mobissom.com.brA, B, C, D ‐ Suprascapular nerve (SSN); E, F, G, H – Axillary nerve (AN); I, J, K ‐ Lateral pectoral nerve (PL). C, G, J – Ultrasound; D, H, K ‐ Fluoroscopy.1. SSN; 2. M. Infraspinatus1. SSN; 3. Fossa supraspinata; 4. Fossa infraspinataYellow arrow – SSNE. 1. AN (anterior view)F. 1. AN (posterior view); 2. Sensitive branch of ANG. Yellow arrow – NAI. 1. M. pectoralis major; 2. M. pectoralis minor; 3. PL; 4. Sensitive branch of PL.J. Yellow arrow – PLFigure 1Ultrasound.Figure 2