Shoulder 2019

Olav Rohof MD PhD FIPP

PRF SupraScapular Nerve
(first described O.Rohof) since 1998

• Issue on RF treatment 2002

• Pain Practice vol 2, nr 3,
257-260, 2002
“ Rotator cuff ”
 Shoulder complaints incidence

• pain, stiffness or both

10% of the population has period of shoulder
problems, often recurring and chronic
prevalence 150 per 1000 persons
in GP: 15-25/ 1000/year
50% quite improved after 6 weeks, painfree
after 6 months

40% remain painful, but do not revisit GP

Handboek Pijnbestrijding - De Tijdstroom 2000

Impingement rotator cuff : critical zone
Most common causes for shoulder pain

1 rotator cuff impingement, potentially with (partial) cuff rupture

2 biceps tendon rupture, caput longum

3 AC arthrosis, with(out) cuff impingement

4 frozen shoulder, often secondary to cuff impingement

5 posture problems with myalgias

6 instability of the shoulder

 Most common causes for shoulder pain

• 1. rotatorcuff impingement, eventually

• with a (partial) cuff rupture
• 2. biceps tendon rupture, caput longum
• 3. AC arthrosis, with(out) cuff impingement
• 4. frozen shoulder, often secundary to cuff
impingement.
• 5. posture problems with myalgias
• 6. instability of the shoulder joint
 Treatment shoulder pain

• NSAID’s
• Physiotherapy
• Intra-articular or intra-bursal corticosteroid
injections
Suprahumeral Injection Techniques
Trans AC: 3 Compartment Block
Glenohumeral/ Subacromial /AC
(Paul Schuermans Gent Melle Belgium)

clavicle
acromion
capsule
Trans AC
3 Compartment Shoulder Block
Glenohumeral SubAcromial
Arthrography, injection .
 Surgical Treatment shoulder pain

• correction cuff rupture

• curettage calcium depots
• partial AC resection
• removal of osteophytes
• biceps tendon repair
• correction coracoacromial ligament
• Correction of labrum glenoidale
• Arthroplasty
Treatment shoulder pain
Cryolesion Suprascapular nerve
Treatment Chronic Shoulder Pain

• -PRF SSB since 1997

• -mostly prevention of
operative indication
• -mostly other intake
diagnosis painclinic
Pulsed Radiofrequency Treatment of
Peripheral Nerves O.J.J.M. Rohof MD PhD FIPP

• Issue on RF treatment 2002

• Pain Practice vol 2, nr 3,
257-260, 2002

• PILOT STUDY suprascapular

nerve
Pulsed RF treatment
Peripheral Nerve
Entrapments
Andrea Trescot et al.
2016

Diagnosis and Treatment

Injections and PRF peripheral targets, Cryo??
 General Principles
Peripheral Nerve Entrapments
• Pressure induced injury to a peripheral nerve in a segment of its
course due to anatomic structures or pathologic processes
• Ulnar nerve elbow Paget 1864, CTS 1933, Tarsal tunnel 1962,
Radial nerve elbow 1972
• Variety of painful conditions from top to toe
Headache, backache, sciatica, endometriosis, foot pain, CRPS
(“double crush syndromes”)

• Nerve injury from stretching, blunt trauma, compression with

hypoxia, fibrosis with entrapment, suture ligature
• Pain often burning, shooting lancinating
• Intermittent to chronic, acute or late onset
• Relief with LA block is “ conditio sine qua non “
 Causes of Nerve Injury
Trescot et al.
• Intraoperative retraction, suture
• Compression and /or stretch material, scar; Joint hypermobility;
Expanding tumor, cyst; Dental work,
infection, edema, congenital
anomalies, blunt trauma +_ fracture
• DM, Chemotherapy, thyroid disease

• Systemic susceptibility • Dental care, Infection, Leaking

intervertebral disc

• Chemical • Total Joint replacement

• Thermal
 Conditions that may be caused by nerve entrapment of a
peripheral nerve

• Headaches, including “ migraines” • “Endometriosis”

• Atypical facial pain • Postherpetic neuralgia
• Chest wall pain • CRPS ( RSD)
• Carpal tunnel syndrome (CTS) • Low back syndromes
• Abdominal wall pain • “Sciatica”
• Pelvic pain • Foot pain

Courtesy Andrea Trescot et al

 Diagnostic Evaluation
• Thyroid function studies, fasting blood glucose, vit B12
• DD peripheral neuropathy/ and folate, nerve conduction studies, potentially imaging
MRI or US: mostly high frequency >12MHz linear probe
peripheral nerve entrapment

• History and Physical examination

should support the diagnosis and EMG
often no need of further studies • Denervation of distal muscles (positive sharp waves)
• Fibrillations
• Giant motor unit potentials (MUPs)
• EMG and NCV (Nerve Conduction Velocities) NCV
• Assessment of both motor and sensory function, slowed conduction
velocity (demyelinisation)

• Most common entrapment locations

Ulnar nerve elbow, median nerve wrist, radial nerve at
spiral groove, peroneal nerve at fibular neck.
 Treatment Options PRF suprascapular block and other peripheral
nerves
Pain Practice 2002 Vol 2 nr 3 O. Rohof

• Block with LA and • Landmarks

corticosteriods (max 80
mg)
• Fluoroscopy
• PRF
with LA , no • Ultrasound
corticosteriods
• CT
• Cryo
RF lesion of a peripheral nerve could cause deafferentiation pain, PRF is indicated
Principally only use RF if PRF is not effective and be aware of this complication
Double Crush Syndromes
Trescot et al.
• CTS and cervical radiculopathy
• Median • CTS and TOS
• CTS and median nerve elbow (pronator syndrome)

• Ulnar • CuTS and cervical radiculopathy

• CuTS and TOS
• CuTS and ulnar nerve at wrist (Guyon’s canal syndrome)

• Radial
• RTS and cervical radiculopathy

• Deep peroneal • ATTS (Anterior tarsal tunnel sndrome) and low back pain

• Posterior tibial • TTS (Tarsal Tunnel Syndrome) and low back pain
 Shoulder
• PRF suprascapular nerve (SSB)
TOP XE 6, ES: 2 Hz mot 0.3V
PRF STP or 5.5 45V , 3 min

• -Diagnostic (dye)
• -Therapeutic,
20 ml syringe with
18 ml ropivacain 0.2%
20 mg depomedrol
25 mg adant
SCK 10.10 PRF STP 55V 8 min + injection
GlenoHumeral: 10ml + adant (HA)
SubAcromial: 8ml + adant (HA)
AcromioClavicular: 2 ml
 NEW:combination PRF SSB (SupraScapular Block) with 1
entry- 3 compartment block and PRF joint
(O.Rohof, P.Schuermans)

Entry via AC with SCK 10.10

electrode
During procedure apply
PRF STP 55V 8 minutes
• 1.First target GH joint
• 2.Subacromial
compartment
• 3.AC joint
GH=GlenoHumeral
SA= SubAcromial
AC= AcromioClavicular
Glenohumeral joint
First compartment
 Entry: First compartment: Intra- articular
Gleno-Humeral (GH) joint (P. Schuermans)

• Entry via AC joint (or just in front of it) Target region i.A.:
GH

• Arthrography: capsule, bicepstendon, cuff integrity,

cartilage state?

Options:

• -i.A. injection LA block(10 ml) and mobility testing

• -Distention technique: in capsular retraction pathology
• -i.A. visco-suppletion:
Hyaluronic acid (adant, ostenil)
Second Compartment:
Subacromial
 Second Compartment
SubAcromial (SA)
• Target: SA space
Bursography: normal,
hypertrophic, communication GH or
AC joint ?

Options:
• -SA: LA block (8 ml) and mobility
testing
• -SA infiltration techniques (LA,
steroids)
• -SA viscosuppletion: hyaluronic acid,
in partial inner tear, inflammation
and microcalcifications of tendon
insertion
Third Compartment:
AC joint
 Third Compartment AC joint

• Target: AC joint

• Arthrography: provocation distention: laxity,

capsule rupture, degenerative pathology or
communication with SA space ??

Options:
• ACJ: anesthetic block
• ACJ: infiltration
• ACJ: visco-suppletion: hyaluronic acid
 Retrospective Study (Schuermans/Rohof)

• N=100
• >3 months shoulder pain, VAS>5
Clinical diagnosis
-ACJ: 7
-Cuff: 21
-GH joint: 10
-combination: 62
• Therapy according new algorithm
• Results after 6 months:
• 71% good, 29% moderate
• Conclusion: RCT is justified
 PRF Bipolar lesion
Shoulder
2 SMK 10 or 15 cm with active tip 10 to 20
mm active tip needles
SA placement
Arthrography

PRF (dual) bipolar lesion

5/5/60V 8 min

Ropivacaine 0.2% 10 ml
No corticosteroids
hyaluronic acid 25 mg optional