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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 37-39

Nerve Stimulator-guided radial nerve block at elbow: New approach for the treatment of tennis elbow


1 Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon
2 Division of Orthopedic Surgery, Mount Lebanon Hospital, Beirut, Lebanon
3 Department of Anesthesia, Makassed General Hospital, Beirut, Lebanon

Date of Submission09-Jul-2019
Date of Acceptance23-Jul-2019
Date of Web Publication21-Oct-2019

Correspondence Address:
Dr. Zoher Naja
Department of Anesthesia, Makassed General Hospital, P.O. Box 11-6301, Riad El-Solh 11072210, Beirut
Lebanon
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_6_19

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  Abstract 


Lateral epicondylitis, or “tennis elbow,” is a symptomatic chronic degeneration of the wrist extensor tendons that involves their attachment to the lateral epicondyle of the humerus. Analgesic, percutaneous, and arthroscopic surgery techniques have been used with no significant difference in the outcome. We report four cases of patients suffering from lateral epicondylitis who received nerve stimulator-guided radial nerve block for pain management. The patients had substantial and extended reduction of pain.

Keywords: Lateral epicondylitis, pain management, radial nerve block


How to cite this article:
Saghieh S, Nasreddine M, Haidar R, Naja AS, Hanna T, Haber G, Naja Z. Nerve Stimulator-guided radial nerve block at elbow: New approach for the treatment of tennis elbow. J Orthop Dis Traumatol 2019;2:37-9

How to cite this URL:
Saghieh S, Nasreddine M, Haidar R, Naja AS, Hanna T, Haber G, Naja Z. Nerve Stimulator-guided radial nerve block at elbow: New approach for the treatment of tennis elbow. J Orthop Dis Traumatol [serial online] 2019 [cited 2019 Nov 11];2:37-9. Available from: http://www.jodt.org/text.asp?2019/2/2/37/269583




  Introduction Top


Lateral epicondylitis, or “tennis elbow,” is a symptomatic chronic degeneration of the wrist extensor tendons that involves their attachment to the lateral epicondyle of the humerus.[1] It affects 1%–3% of the population.[2] Repetitive wrist extension, radial deviation, forearm supination motions, and regular heavy loads handling are responsible for the injury.[3] Patients typically complain of extra-articular lateral elbow pain exacerbated by repetitive movements. Pain severity ranges from having a minimal effect on sports and activities to severely impairing basic daily tasks and sleep.[2] While most cases are self-limiting and simple pain medication is often sufficient with 90% recovery within 1 year, a single effective and consistent algorithm of management is still lacking.[1] However, 10% of cases refractory to conservative management had open, percutaneous, and arthroscopic surgery techniques but with no significant improvement in the outcome.[1],[4] We present four cases of a new conservative management modality in patients with refractory tennis elbow who had successful long-term outcome.


  Case Report Top


Written informed consent was obtained from four patients, one woman and three men, who were referred for the management of tennis elbow [Table 1].
Table 1: Patients' characteristics and outcome

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Case 1 was a right-handed 53-year-old healthy man, whose weight was 60 kg, working as a plumber, with no history of trauma, presented with lateral epicondylitis of the right elbow progressing for 2 months. During his work, he noticed that he has a progressive difficulty in arm supination, especially that this movement is used in his work because it requires rotational movement of the elbow and wrist. This symptom increased until he became unable to do any rotational movement while holding any object with his affected hand. Moreover, he started noticing a new occupational symptom, which is a weak grip strength that also progressed till he became unable to use his grip with his affected hand. This is when his son started to help him and go with him to do most of the tasks that require rotational and grip acts.

The patient described a stiff, stabbing pain, located and limited to the lateral aspect of elbow. Pain measured through the visual analog scale was continuous during the day, was not worsening during the night, and was not associated with any numbness, tingling, or weakness. It ranged between 6/10 at rest and 9/10 at mobilization. Refractory to medication and splint immobilizer, the patient consulted with an orthopedic surgeon. Nevertheless, the pain was refractory to nonsteriodal anti-inflammatory drugs (NSAIDs), steroid injection, forearm-centered brace, and physiotherapy that he could not continue after the third session due to severe pain that hindered most of the required movements.

On physical examination, a decrease in range of motion of the shoulder and elbow upon passive abduction, flexion, and extension was noted. Mills and Cozen's tests were inconclusive. Hand grip was painful and weak, but active and resisted range of motion of the metacarpals was normal. Sensation was normal. Direct palpation showed severe tenderness of the lateral epicondyle, and mild referred pain upon the extensor carpi radialis brevis (ERCB) tendon and muscle. Reflexes were intact. The Elbow-Self Assessment Score was used to assess the function and clinical state of the elbow.

Diagnosis of right lateral epicondylitis was made clinically. However, radiography of the right elbow, magnetic resonance image (MRI) of the neck, and electromyogram allowed us to rule out arthritis, cervical disc herniation, and radial nerve entrapment. Finally, an MRI of the right elbow showed an insignificant ERCB thickening suggestive of lateral epicondylitis.[5]

A nerve stimulator-guided radial nerve block was performed at the elbow. Subsequent to prepping and draping the right upper extremity in sterile fashion, the cubital fossa and the lateral epicondyle were localized using the bony landmarks of the elbow to locate the radial nerve. The skin was then marked at the adequate site and infiltrated with 0.1 ml of 1% lidocaine. A 22-G, 2.5-cm nerve stimulator needle was subsequently advanced 0.5–1 cm (depending on the patient's weight) through the skin while passing 1.5–2.5 mA current at 1 Hz. Then, the stimulating current was reduced to 0.5–0.6 mA while maintaining muscle contraction. Finally, 3–5 ml of the anesthetic mixture was injected. The mixture is composed with 1:2,000,000 epinephrine, 3 ml 0.5% bupivacaine, and 1 ml clonidine 150 μg/ml.

After the injection, the patient felt instant pain relief. Biceps, triceps, and coracobrachialis reflexes were intact. Sensation was reduced over the posterior forearm, elbow, and hand. The patient did not have pain at rest and pain at movement gradually disappeared.

The remaining three cases underwent the same assessment and physical examination. They differed in age, occupation, duration of pain, and response to the nerve block. All cases were followed up by phone calls for 1 year.

Case 2 was a right-handed 34-year-old healthy woman, whose weight was 56 kg, working as a nurse, who presented with lateral epicondylitis of the right elbow progressing for a month and a half. The nerve block was performed after which she did not have pain and returned to normal daily activity.

Case 3 was a right-handed 60-year-old male surgeon (weight 74 kg), presented with lateral epicondylitis of the right elbow progressing for 3 months. The nerve stimulator-guided radial nerve block was performed. 2 weeks later, the patient had elbow pain and required a nerve block after which he was painless.

Case 4 was a left-handed 45-year-old healthy man (weight 77 kg), working as an administrative director, presented with lateral epicondylitis of the left elbow progressing for 4 years. A nerve stimulator-guided radial nerve block was performed at the left elbow. However, after 1 week, the pain reappeared. Radial nerve block was repeated and the pain was reduced. After another week, the pain reappeared and required a nerve block after which the pain severity was decreased. However, the pain persisted and the radial nerve block was repeated two more times. After the five radial nerve block trials, corticosteroid (dexamethasone) was injected with the radial nerve block. The patient had pain relief and did not require medication.


  Discussion Top


Despite the different theories pertaining to tennis elbow, yet its etiology is unclear. While it is usually self-limiting between 12 and 18 months, some patients' symptoms can persist and be refractory to conservative treatment.[1]

Management of lateral epicondylitis starts with relative rest that promotes healing by preventing more damage and reducing pain. Braces protect the elbow during activity; they also alleviate pain and improve function by reducing strain in extensors muscles and tendons.[5] Although physiotherapy's effectiveness has been debated, it is to believe that eccentric strength training and stretching exercises allow pain reduction and healing by reducing tension on the injured tendon.[6] Finally, aside of their anti-inflammatory property, topical and oral NSAIDs seem to equally promote healing simply by reducing pain.[1] Secondary management often includes corticosteroids injections which seem to be more effective than oral NSAIDs even though inflammation has little role in chronic tendinopathies.[7]

The chronicity in tendinosis might arise from a vicious cycle where tissue injury leads to pain, which slows the healing and cause more pain. While many conservative management modalities have been proposed as alternative repair methods, we decided to perform nerve block since it was shown to be effective in pain management in different cases such as piriformis syndrome, thoracic myofascial pain syndrome, and postherpetic neuralgia.[8],[9],[10]

Xylocaine and bupivacaine block conduction in the radial nerve by inhibiting nociceptor and motor stimuli. Epinephrine and clonidine prevent the anesthetics' systemic absorption, allowing a longer effect.[10] The use of nerve stimulator-guided technique improves the accuracy of needle placement and the chance of an adequate nerve block. Previous studies showed that the combination of clonidine and opioids with local anesthetic solutions prolonged the duration of the peripheral nerve block.[10]

This case series demonstrated that age and duration of pain might play an important role in pain management. Younger patients with shorter duration of pain make the radial nerve block more effective without the need for repetitive nerve block.

In summary, nerve stimulator-guided radial nerve block showed a substantial and extended reduction of pain in patients with lateral epicondylitis. More evidence-based clinical trials are needed to evaluate this new modality of treatment that might become a cornerstone in the therapy of tendinopathies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-7.  Back to cited text no. 1
    
2.
Tosti R, Jennings J, Sewards JM. Lateral epicondylitis of the elbow. Am J Med 2013;126:357.e1-6.  Back to cited text no. 2
    
3.
Buchbinder R, Johnston RV, Barnsley L, Assendelft WJ, Bell SN, Smidt N. Surgery for lateral elbow pain. Cochrane Database Syst Rev 2011;3:CD003525.  Back to cited text no. 3
    
4.
Savnik A, Jensen B, Nørregaard J, Egund N, Danneskiold-Samsøe B, Bliddal H. Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow. Eur Radiol 2004;14:964-9.  Back to cited text no. 4
    
5.
Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician 2005;72:811-8.  Back to cited text no. 5
    
6.
Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: A systematic review. Ann Med 2003;35:51-62.  Back to cited text no. 6
    
7.
Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: A systematic overview. Br J Gen Pract 1996;46:209-16.  Back to cited text no. 7
    
8.
Naja Z, Al-Tannir M, El-Rajab M, Ziade F, Daher Y, Khatib H, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain 2009;25:199-205.  Back to cited text no. 8
    
9.
Naja ZM, Al-Tannir MA, Zeidan A, El-Rajab M, Ziade F, Baraka A. Nerve stimulator-guided repetitive paravertebral block for thoracic myofascial pain syndrome. Pain Pract 2007;7:348-51.  Back to cited text no. 9
    
10.
Naja ZM, Maaliki H, Al-Tannir MA, El-Rajab M, Ziade F, Zeidan A. Repetitive paravertebral nerve block using a catheter technique for pain relief in post-herpetic neuralgia. Br J Anaesth 2006;96:381-3.  Back to cited text no. 10
    



 
 
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