Shoulder pain is one of the most prevalent musculoskeletal pain syndromes with a prevalence of 18%–26% . This presentation depict the various forms of neuromodulation in treating pain generators at shoulder joint

1. SHOULDER JOINT
NEUROMODULATION
Dr. Sherry Nabil Fanous
MD, PHD, FIPP, DESA

2. CONFLICT OF INTEREST
• Treasurer of World Institute of Pain – Middle
East Section
• Head of pain Management department St. George
Hospital
• Consultant of Interventional Pain Medicine KDC
• Present & Former faculty member at AFSRA,
PSI, WAPMU, WIP
• Global advisor at Guidepoint

3. INTRODUCTION
• Shoulder pain is one of the most prevalent musculoskeletal
pain syndromes with a prevalence of 18%–26% (Linaker & Walker-
Bone, 2015)
• Rotator cuff tendinopathy, degenerative tears and
impingement, glenohumeral (GH) and acromioclavicular(AC)
osteoarthritis, persistent postoperative pain ,adhesive
capsulitis and labral tears are the most common causes of
chronic shoulder pain (Bayam et al., 2011.). (Andrews, 2005).
• The incidence of chronic shoulder pain increases with age,
with the prevalence peaking in those over 70 years of age
(van der Heijden, 1999)
Shoulder joint neuromodulation 3

4. ANATOMY OF SHOULDER JOINT
Shoulder Joint Innervation 4

5. ANATOMY OF SHOULDER JOINT
Shoulder Joint Innervation 5

6. ANATOMY OF SHOULDER JOINT
Shoulder Joint Innervation 6

7. ANATOMY OF SHOULDER JOINT
Shoulder Joint Innervation 7

8. SHOULDER JOINT INNERVATION
Shoulder joint neuromodulation 8
• Posterior superior: SSN (Gofeld et al., 2013; Wu et al., 2014)
• Posterior inferior: posterior branch of AN (Kim et al., 2012; Nakamura et al., 2013; Osako et al., 2016).
• Anterior superior: upper nerve to subscapularis (NS) (Yoshimura et al., 2018) and
lateral pectoral nerve (LPN) (Eckmann et al., 2019).
• Anterior inferior: branches from the main AN (Kim et al., 2012; Nakamura et al., 2013; Osako et al., 2016).
• In summary, the GHJ is supplied by the SSN in the superior and
posterior aspects. The anterior aspect of GHJ is also innervated by
anterior branch of axillary nerve, nerves to subscapularis and possibly,
the lateral pectoral nerve.

9. A systematic review and meta‐analysis of radiofrequency procedures on innervation to the shoulder joint for
relieving chronic pain
European Journal of Pain, Volume: 25, Issue: 5, Pages: 986-1011, First published: 20 January 2021, DOI: (10.1002/ejp.1735)

10. • Most of the studies targeted the SSN for various pathologies
that cause chronic shoulder pain with a few publications on
other possible targets including the AN,the LPN and lower
subscapular nerves. Some publications described the GHJ joint
and the subacromial bursa or space as targets for RF.
• if the aetiology of the pain is from the rotator cuff
pathology (especially the supraspinatus and infraspinatus
muscles), the SSN is the main target for denervation.
TARGETS OF NEUROMODULATION

11. Shoulder joint neuromodulation 11
• Pain originating from arthritis of the GH joint tends to be severe and presents in the
anterior and posterior shoulder with some occasional referral to the ipsilateral arm (Kennedy
et al., 2015).
• Arthritis of the AC joint usually causes pain confined to the anterior shoulder.
• Pain involving rotator cuff pathologies and subacromial impingement results in a sharp and
severe pain around anterolateral shoulder with a diffuse, dull, aching sensation often referred
distally in the arm (Bayam et al., 2011).
SHOULDER PAIN PATTERN

12. SHOULDER PAIN PATTERN
• Calcific tendinosis also results in a discreet pain localized
around the shoulder (Bayam et al., 2011).
• Persistent postsurgical shoulder pain is shown to be
present in 22% of the population following shoulder
replacement surgery (Bjørnholdt et al., 2015).
12

13. REFERRAL PAIN TO SHOULDER
Shoulder joint neuromodulation 13
CERVICAL SPINE
• intervertebral discs and
facets
DIAPHRAGMATIC
• irritation
LUNG
• apical lung malignancy
(Bayam et al., 2011)

14. MODALITIES
Pain Pattern 14
FLUOROSCOPY IS THE MOST
COMMONLY USED MODALITY
FOR GUIDING THESE
PROCEDURES WITH THE
SUPRASCAPULAR NOTCH TO
ACCESS THE SSN.
USG TECHNIQUES ARE PREFFERED DUE TO , PROXIMITY OF
VITAL BLOOD VESSELS (POSTERIOR HUMERAL CIRCUMFLEX
VESSELS NEAR THE AN, THORACO-ACROMIAL VESSELS NEAR
THE LPN), THE SSN,AN WERE VISUALIZED (KIM ET AL., 2012). THE
5 AND 6 CERVICAL NERVE ROOTS WERE TARGETED VIA THE
INTERSCALENE APPROACH (DUA ET AL., 2016). THE LOWER
SUBSCAPULAR NERVES WERE APPROACHED IN THE
INTERFASCIAL PLANE BETWEEN THE TERES MAJOR AND
SUBSCAPULARIS MUSCLES IN THE MID-CLAVICULAR REGION
(YOSHIMURA ET AL., 2018).

15. ROLE OF PROGNOSTIC
BLOCKS PRIOR TO RF
PROCEDURE
Shoulder joint neuromodulation 15
All the papers on aRF except one (Brown et al., 1988) reported the use of
a prognostic block with a local anaesthetic while none of the
RCTs on PRF described its usage
Given the overlapping innervation of the shoulder (Tran et al., 2019a; Tran
et al., 2019b) by the targeted nerves, it seems that prognostic nerve
blocks have better predictive value than prognostic joint (i.e.
blocks carry significant false-negative and false-positive rates).

16. TYPES OF
NEUROMODULATION
16
ABLATIVE RF
• It requires temperatures of
70–80°C for a duration of
60–90 s. and results in
neuronal destruction (Bone
et al., 2013) used for
subjects who had lost
function of the muscles
innervated by the SSN as
with with malignancy-related
shoulder pain (Simopoulos et al., 2012,
Chang et al., 2015).
PRF
• At temperature of 42°C, The
duration of electrical field and
the number of cycles varied
significantly in the papers with
the time ranging from 240 sec.
to 8 min. (Tanaka et al., 2010, Huang
et al., 2012) studies suggest longer
exposures may provide increased
benefit it can modulate
nociceptive transmission, gene
expression alteration is another
postulated mechanism (Vanneste
et al., 2017).

17. TYPES OF
NEUROMODULATION
17
CERVICAL SCS
• Optimal placement of SCS electrodes over segments
along the dorsal column alter pain perception as it
relates to stimulation above C5 for shoulder pain,
• decrease in shoulder pain at 6 months with 10 kHz
SCS (Russo 2016 )
• the increased mobility of the cervical spine makes it
more vulnerable to changes in paresthesia coverage.

18. TYPES OF
NEUROMODULATION
18
PNS Anthony Mazzola and David Spinner

19. TYPES OF
NEUROMODULATION
19
PNS

20. TYPES OF
NEUROMODULATION
20
PNS

21. MEET OUR TEAM
Shoulder joint neuromodulation 21

22. MEET OUR TEAM
Shoulder joint neuromodulation 22

23. MEET OUR TEAM
Shoulder joint neuromodulation 23

24. RF PROCEDURES TECHNIQUE
Shoulder joint neuromodulation 24
The transducer is placed in a coronal plane over the supraspinatus
muscle. A linear probe can be used for smaller shoulders, whereas a
curved transducer should be utilized for larger shoulders. The posterior
part of the suprascapular fossa and suprascapular spine should be
visualized. Care should be taken to avoid targeting anteriorly as the
needle can inadvertently enter the thoracic cavity. Once the
suprascapular notch is identified, the suprascapular artery can be seen
above the transverse suprascapular ligament, and the suprascapular
nerve below). The needle is entered from a medial to lateral approach
as the acromion lies laterally and does not allow for needle entry. An
in-plane approach allows for needle visualization and targeting adjacent
to the nerve. Ultrasound imaging identifying the suprascapular nerve
and the suprascapular artery at the location of the suprascapular
notch.

25. MEET OUR TEAM
Shoulder joint neuromodulation 25

26. RF PROCEDURES TECHNIQUE
Shoulder joint neuromodulation 26
https://youtu.be/hswB3SNu x1o

27. RF PROCEDURES TECHNIQUE
Shoulder joint neuromodulation 27
AN originates from C5 and C6, forms part of the posterior cord of the brachial
plexus, and descends inferiorly to the quadrangular space. The nerve then
branches further as it traverses around the humerus at the inferior margin of
the teres minor .The nerve can be targeted for interventions anywhere along its
course from the brachial plexus to the posterior humerus. The most common
location for targeting the nerve regarding peripheral nerve stimulation is at the
posterior humerus. The transducer is placed in a sagittal plane over the humeral
head and neck. A linear probe can be used for smaller shoulders, whereas a
curved transducer should be utilized for larger shoulders. The infraspinatus is
seen in cross-section at the cranial portion, and the teres minor seen caudally.
The AN and circumflex artery are visualized at the inferior border of the teres
minor .Doppler imaging can be used to help identify vasculature .The needle can
enter from a caudal to cranial approach or a lateral to medial or a medial to
lateral approach. Both in-plane and out-of-plane approaches have been described

28. MEET OUR TEAM
Shoulder joint neuromodulation 28

29. MEET OUR TEAM
Shoulder joint neuromodulation 29

30. THANK YOU