Anesthesia selection for wrist joint denervations

Will local anesthesia suffice for a wrist joint denervation (severance of the pain-conducting nerves)?

Local anesthesia in this case means that the anesthetic agent is injected right into the surgical area above the pain-conducting nerve that needs to be severed. This type of anesthesia is simple and not too strenuous for a patient.
However, there are also some serious downsides to this form of anesthesia: Injecting the anesthetic agent into the surgical area will impair the visibility later on during surgery. As a result fine nerves and blood vessels may get overlooked and damaged.
In my opinion it is not possible to perform a wrist joint denervation unless the surgery takes place on a bloodless operating surface and on a pain-free patient.

So which type of anesthesia is appropriate for a wrist joint denervation?

There are a few options to prepare for a denervation:
• General anesthesia (Shut-down of consciousness)
• Brachial plexus block (anesthesia to the entire arm).

Wouldn´t it be better to perform the denervation under general anesthesia?

General anesthesia really allows for any surgery to the hand. A denervation however, does not require a complete shut-down of consciousness.

I personally prefer the plexus block (numbing just the arm) for denervations. This option offers the advantage of multiple hours of painlessness for a patient that underwent a wrist joint denervation. This is a considerable advantage of the plexus block considering the number of nerve tracks running in a wrist joint. In addition the patient is allowed food and drink shortly after the surgical denervation.

What does the term “Plexus block” mean?

Plexus block

Point of entry of the injection needle in the armpit for a plexus block.

This type of regional anesthesia requires the injection of an anesthetic agent close to the plexus within the shoulder area.

The brachial plexus is a network of larger nerve trunks, which run from the lower neck underneath the clavicle into the armpit.

The anesthesia is administered in close proximity of these large nerve tracts.

Plexus/axillary block

Execution of a plexus block in preparation of surgery

In case of brachial plexus block a local anesthetic agent is injected into the shoulder/armpit area to block all branches of the brachial plexus. In most cases the entire arm and hand are numb and cannot be actively moved within around thirty minutes of the injection.

The most commonly used injection site in connection with a brachial plexus block is the armpit. In medical jargon this site-specific procedure is also referred to as axillary block.

The physician injects an anesthetic agent into the armpit.

For procedures on hands, forearms and elbows the injection of the anesthetic agent into the armpit is customary.

What is the advantage of a plexus block for a hand or forearm?

Bloodless operating surface for surgery on a hand.

Cuff used to achieve a bloodless operating surface in a wrist joint.

A denervation requires an unconditional elimination of the pain as well as a bloodless operating surface. This is particularly true when dealing with more than just one pain nerve as in a full wrist joint denervation (interruption of several pain-conducting nerves)!

The risk of injuring fine blood vessels or nerves diminishes considerably by operating on a bloodless operating surface.

Only a bloodless operating surface offers a surgeon the appropriate visibility to operate on bones of the hand or the forearm, close to the radial artery or nerves in an accurate fashion.

In order to avoid bleeding during surgery, a cuff is applied to the upper arm.

(Image above: The cuff applied here works similar to a blood pressure cuff).

Just as the blood pressure cuff, the cuff used during surgery to create a bloodless operating surface is pumped up with air, creating an unpleasant pressure sensation on the upper arm. This pressure is maintained during the entire procedure! While experiencing brachial plexus block anesthesia, however, the patient does not consciously feel discomfort.

This anesthetic method is much less strenuous on patients than general anesthesia. Patients mostly appreciate that they are allowed food and drink shortly after the procedure. From a physician’s point of view the duration of the anesthesia keeps the patient painless for an extensive period of time without needing additional pain-killers.

If desired a light sedative can be administered along with the plexus block in order to allow the patient to sleep through the process – without ever being completely out!

The aforementioned advantages lead many surgeons to prefer plexus block when performing  wrist joint denervations.

Denervation:    1    2    3    4    5

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