[ ISSN : 2576-5442 ]
Accessory nerve block; Chronic pain; Sleep-guided intervention; Pain management; Anatomy; Compression syndromes; Diagnosis; Treatment.
This article presents an innovative technique for the management of chronic shoulder pain, a prevalent condition that can result from traumatic injuries, repetitive activities, and chronic conditions such as tendinitis and bursitis. The accessory nerve, which plays a crucial role in the motor innervation of the neck and shoulders, is often involved in compression syndromes that result in chronic pain. The article describes a minimally invasive, ultrasound-guided technique for accessory nerve block. This technique allows real-time visualization of anatomical structures, increasing the accuracy and safety of the procedure. The combination of 5% glucose, 1% procaine, and N-acetylcysteine is used to provide pain relief, neuronal stabilization, and antioxidant support. Studies indicate that this multimodal approach can reduce the need for systemic pharmacological analgesia and promote functional recovery. In addition to the description of the technique, the article reports three cases of treated patients, demonstrating the therapeutic efficacy of the proposed intervention. However, the article emphasizes the need for further studies to assess the durability of therapeutic effects and to establish optimized protocols for different patient profiles.
Shoulder pain is a condition that affects a substantial portion of the population, with prevalence ranging from 6.9% to 26% [1]. Causes include traumatic injuries, repetitive activities, and chronic conditions such as tendonitis and bursitis, often leading to a decrease in quality of life [2,3]. The diagnosis of shoulder pain can be complex due to the wide range of etiologies, including rotator cuff injuries, subacromial impingement, and glenohumeral arthritis [4,5]. Chronic shoulder pain often arises from injuries that are not properly treated or from repeated injuries over 4,5]. Chronic shoulder pain often arises from injuries that are not properly treated or from repeated injuries over time, resulting in conditions such as Painful Shoulder Syndrome and adhesive capsulitis [6]. The treatment of this condition involves a multimodal approach, including physical therapy, pharmacological therapies, and surgical interventions [4,5]. Multidisciplinary approaches have been shown to be more effective, integrating supervised exercise, relaxation techniques, and regular physical therapy [3, 7].
Ultrasound-guided interventional procedures have become increasingly common in the treatment of chronic pain, including shoulder pain [4,8]. This approach allows real-time visualization of joint, tendinea, muscle, and nerve structures, providing greater precision and safety in the administration of therapies [2,9-11]. Studies demonstrate that ultrasound-guided nerve blocks offer significant relief and improve functionality for patients with chronic pain [3,4]. In the context of this approach, the accessory nerve plays a key role in the mechanism of chronic pain in the shoulder and shoulder girdle [12,13]. Its motor and sensory innervation of key structures makes it a relevant target for innovative therapeutic interventions such as nerve blocks [14,15]. Exploring new techniques for refractory pain management can significantly contribute to improving patients’ quality of life and reducing the overall impact of chronic pain [5,6].
This article aims to describe a minimally invasive, sonoguided, assertive technique for the management of chronic shoulder pain with accessory nerve block and to demonstrate its effectiveness with a series of clinical cases.
The accessory nerve is a mixed nerve whose main function is motor, innervating muscles crucial for neck and shoulder movement [12]. This review addresses the origin, anatomical correlations, sensory and motor functions, compression syndromes, and symptoms associated with complications of this nerve [4,13,14].
The accessory nerve plays a key role in innervating the muscles responsible for head and neck movement, as well as controlling shoulder elevation [8,16,17]. Understanding the anatomy and function of the accessory nerve, as well as its complications, is essential for clinical practice, especially in the areas of neurology, pain medicine, and physical therapy [2,13,15]. The accessory nerve has a unique origin that involves two roots: a cranial root, which emerges from the ambiguous nucleus of the brainstem, and a spinal root, originating from the anterior motor cells of the cervical medulla (C1-C5) [3]. Both roots join to form the accessory nerve, which follows a complex path through the neck, is closely related to crucial vascular and nerve structures [14,16], passes through the jugular foramen, and divides into branches that into branches that innervate specific muscles [6,12], we need to highlight the sternocleidomastoid and trapezius, allowing the movement of the head and the elevation of the shoulders, being critical for posture and daily movements [2,4,16]. Its motor functions facilitate head rotation and shoulder elevation [7], and its cranial root may be involved in sensory functions through connections with other cranial nerves [12,16,17].
The accessory nerve can undergo conditions that result in compression syndromes [12,18-20]. The most common causes include traumatic injuries, cervical region surgeries, and tumors or masses that compress the nerve [3,13,17]. Symptoms of accessory nerve involvement include difficulty moving the neck, trapezius weakness (difficulty elevating the shoulder), muscle atrophy, and neck pain or pain radiating to the shoulder. [4]. Myofascial pain of the shoulder is a common musculoskeletal condition that affects the quality of life of many individuals, being characterized by the presence of painful trigger points.
The incidence of shoulder pain is quite significant, with studies showing that in the United States, the prevalence of shoulder pain is approximately 24% in the adult population [21]. In addition, shoulder myofascial syndrome is one of the most frequent causes of musculoskeletal pain, affecting people of all ages, especially those who are sedentary. For the treatment of shoulder joint and tendon pain, the nerves usually blocked are the suprascapular nerve and the axillary nerve.
However, the muscular and myofascial origin of pain is often overlooked as a cause of shoulder pain, and it is critical to consider it in diagnoses and treatments. Myofascial pain can manifest as referred pain, i.e., pain perceived at a site far from the trigger point, complicating the diagnosis [22,23,24]. Recent studies highlight that the ultrasound-guided nerve block technique for the accessory nerve can improve the accuracy
Nerve block is widely used in the management of chronic pain, particularly in patient’s refractory to conservative treatments [7,11]. Traditional block techniques involve the use of anatomical palpation and superficial landmarks to locate nerves, followed by the administration of local anesthetics [1,15]. However, these approaches have significant limitations, including poor accuracy, increased risk of injury to adjacent structures, and limited efficacy in cases of anatomical variations [10,12].
Studies show that the accuracy of the traditional lock can be compromised by the difficulty in identifying the exact location of the nerve, especially in areas with a high density of vascular and nerve structures [14,16]. In addition, the lack of real-time visualization increases the risk of complications, such as IV injection or nerve tissue damage [4,6]. With the introduction of ultrasound-guided techniques, these limitations have been progressively overcome [5,8]. Ultrasound allows real-time visualization of the accessory nerve, facilitating a more accurate and safer approach [4,10].
Figure 1 : Image showing main pain points reported by patients with myofascial pain syndrome in the shoulder.
Studies such as the one by Finlayson et al. (2019) have demonstrated that the use of ultrasound for accessory nerve block significantly improves clinical outcomes by reducing pain and increasing shoulder functionality [3,4]. In addition, the ultrasound-guided interventional technique proved to be effective in releasing adhesions and restoring tissue mobility around the accessory nerve. Accessory nerve block is a widely used technique in the treatment of muscle and myofascial pain of the trapezius muscle.
Studies such as the one by Herbst and Sorkin (2022) demonstrate its effectiveness in controlling intractable pain in this region. However, we propose an original approach to this technique, employing it in the treatment of pain associated with the shoulder joint, especially in cases refractory to other conventional therapies.
To perform this procedure, an ultrasound device with a linear probe is required to visualize the sonoanatomy and accurately guide the needle during the block, as well as the professional who proposes to perform the procedure needs adequate training to use the equipment and to perform ultrasound-guided blocks. The patient should be comfortably seated, with one´s back to the examiner. The examiner should view both the posterior region of the shoulder to be treated and the ultrasound screen.
Figure 2 : Positioning of the transducer on the descending (superior) portion of the trapezius muscle, in the middle third, on a longitudinal axis in relation to the patient for adequate visualization of the local anatomy for block.
For the characterization of the accessory nerve (Nervus accessorius), the transducer should be positioned over the descending (superior) portion of the trapezius muscle, in the middle third, on a longitudinal axis in relation to the patient.
Infiltration will be performed from posterior to anterior of the patient, with the needle kept under direct visualization on sonoimaging. The needle should follow a craniocaudal and posteroanterior path, heading to the interaponeurotic space between the trapezius and levator scapulae (Musculus levator scapulae) muscles, where the medication should be applied. The technique uses direct sonovisualization to infiltrate 10 ml of solution into the aponeurotic fascia, making sure that the procedure was properly performed.
Figure 3 : Aponeurotic fascia between the trapezius muscle and the levator scapulae muscle. Virtual space through which the accessory nerve passes.
This article aims to present, in association with the description of the technique, a series of three clinical cases submitted to the blockade described for the treatment of refractory chronic shoulder pain at the Regenera Dor Institute, in Juazeiro do Norte – Ceará, Brazil, between October 2024 and January 2025. All patients were duly informed about the proposed procedure before it was performed and signed an informed consent form. After evaluation, the patients were submitted to the treatment as the blockade, as described in the technique of this article.
Figure 4 : Positioning of the ultrasound probe and syringe for adequate needle sonovisualization.
Figure 5 : Infiltration of the fascia between the trapezius and the levator scapulae should be performed, with the advancement of the needle being accompanied by direct sonovisualization and ensuring the effectiveness of the procedure.
Case one
A 68-year-old female patient was admitted complaining of chronic pain in the right shoulder. The condition began after a rotator cuff injury and persisted for one year after arthroscopic repair. The pain was severe, limiting physical activity and reaching 9/10 on the Visual Analogue Scale (VAS). Several therapeutic approaches had been tried, including physical therapy rehabilitation in the immediate and late postoperative periods, use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), opioid analgesics, and pregabalin, without significant improvement.
A previous suprascapular nerve block was performed blindly, without symptomatic relief. In the first evaluation, conducted on October 22, 2024, the patient presented pain and severe limitation of the range of motion of the right shoulder, with active abduction of 30o and assisted active abduction of 60o , above which she reported intense exacerbation of pain.
Figure 6 : The block can be confirmed by direct visualization of the medication in the fascial plane.
Figure 7 : Performing the ultrasound guided block according to the technique described in this article with the patient's pain improvement.
Figure 8 : ultrasound guided infiltration as described in this article. To relieve pain and reduce the patient's anxiety during the procedure, cryoanalgesia was used before application.
Ultrasound evaluation revealed an intact supraspinatus tendon, anchored to the greater tuberosity of the humerus, with no signs of adhesive capsulitis. In view of this situation, accessory nerve block was proposed, as described in this study. Immediately after the first session, the patient reported approximately 70% relief in pain and an increase in shoulder range of motion, as well as improved mobility of the scapulothoracic joint.
Weekly follow-up revealed maintenance of relief for about two weeks, when pain returned with less intensity (VAS 5-6/10), at which time a second block was performed, providing complete relief. The patient maintained weekly submitted to a third block in the fourth week. After this intervention, she remained asymptomatic for 120 days, with no new complaints.
A 63-year-old male patient, admitted after a motorcycle accident that occurred on July 20, 2024, evolves with persistent pain in the right shoulder, without a fracture or tendon injury that justifies the symptomatology. He was admitted to the clinic 3 months after the accident, with pain that prevented shoulder mobilization (VAS 8/10). The pain condition did not improve, although he was using NSAIDs, analgesics and opioids.
Figure 9 : Patient reports improvement of pain and improvement in range of motion after infiltration.
After diagnostic clarification, the treatment of chronic pain with the block described in the article was suggested. The patient progresses with improvement of pain and range of motion. Although he reported a 100% improvement in symptoms, the pain returned with less intensity 2 weeks after the procedure. At this time, he had shoulder abduction in eighty percent and reported moderate pain (VAS 5/10). The second block was performed with improvement of the pain and a new return was scheduled for 2 weeks. At the time of the second return visit, the patient returned without pain and no longer presented recurrence of the pain condition after 4 months of the procedures.
45-year-old patient was admitted complaining of pain in right shoulder associated with partial rupture of the supraspinatus tendon. This condition started about six months ago. The patient had already undergone an orthobiologic treatment, consisting of a bursal and intratendinous injection of BMA matrix, but experienced worsening pain and no symptom relief. After etiological clarification, the patient chose not to undergo surgical treatment of the lesion, which led us to start a treatment with shock waves.
Four sessions of focal shock waves (PiezoWave² - Richard WOLF)® were performed with 3,000 pulses at a depth of 15 mm (therapeutic target defined by ultrasound), at a frequency of 8 Hertz and energy density of 0.182 mJ/mm2. During the sessions, an improvement in the range of motion of the right shoulder was observed, but the patient continued to complain of shoulder pain. Two weeks after the fourth shockwave session, with the patient presenting normal range of motion on physical examination and a healed supraspinatus tendon on USG, the pain remained at an intensity of 8/10 on the VAS.
This pain condition prevented the patient from performing his work activities as a teacher, prevented him from driving and practicing physical activities. It was then suggested to perform accessory nerve block, which was performed according to the description of the present article. The patient progressed with a reduction in pain (5/10 in the VAS), and 2 more blocks were performed with an interval of 2 weeks between each application. At the end of 6 weeks, the patient presents only mild pain during physical activity (1/10 in the VAS) and has returned to his work activities, evolving with total improvement of the pain complaint 8 weeks after the first block session. The patient’s improvement was maintained until the publication of the present article, 4 months after the end of the therapeutic intervention with infiltrations.
Chronic shoulder pain represents a significant challenge in clinical practice, with multiple etiologies, including musculoskeletal, neuropathic, and myofascial impairments [21,28-31]. The accessory nerve (XI cranial nerve) plays a fundamental role in the motor innervation of the trapezius and sternocleidomastoid muscles, being essential for the stabilization and mobility of the scapula [32-34].
Anatomically, the accessory nerve has complex pathways and is vulnerable to compression and trauma, which can lead to chronic shoulder pain [12]. Poor innervation of the trapezius can result in muscle imbalance and compensatory overload of adjacent muscles such as the levator scapula and rhomboids, exacerbating pain [2].
This phenomenon can be observed in patients with post-surgical neuralgia after cervical procedures or lymph node dissections, where injury to the accessory nerve is frequent [14,35-38]. Changes in the accessory nerve can occur at several points along its path, being more common in the posterior trigone region of the neck, where it becomes superficial and more susceptible to extrinsic compressions or post-traumatic fibrosis. Patients with this type of impairment often have chronic pain and significant scapular dysfunction, making it difficult to elevate the shoulder and predisposing to compensatory muscle syndromes.
Early diagnosis and targeted therapeutic interventions, such as myofascial release, ultrasound-guided infiltrations, and motor rehabilitation techniques, are key to restoring function and minimizing pain in these patients [39]. Ultrasound-guided infiltration has emerged as a promising technique for relieving pain associated with accessory nerve compression. Cass (2016) reviewed the use of this approach, highlighting its ability to reduce adhesion between the nerve and surrounding tissues, relieving compressive neuropathy. In addition, studies have shown that selective accessory nerve block significantly improves shoulder function and reduces pain in patients with patterns compatible with accessory neuropathy [40-42].
To perform the accessory nerve block by transtrapezoidal, we use a solution prepared from the combination of 5% glucose, 1% procaine and N-acetylcysteine (NAC) for its analgesic, regenerative and antioxidant effects. This combination integrates the principles of neural therapy and neuroprolotherapy, promoting pain relief and functional improvements [43]. Neural therapy is a therapeutic methodology that is based on the regulation of the autonomic nervous system through the administration of local anesthetics in low concentrations.
One percent procaine is widely employed due to its ability to stabilize cell membranes, reduce neuronal hyperexcitability, and modulate inflammatory responses [44]. Studies indicate that procaine has anti-inflammatory and antioxidant properties, inhibiting free radicals and attenuating degenerative processes in peripheral nerves [45]. In addition, its rapid and reversible blocking action on nerve impulse conduction provides a safe and effective analgesic effect. Neuroprolotherapy, also known as perineural prolotherapy, is a therapeutic modality that uses glucose solutions in low concentrations to modulate neuropathic pain and promote neural regeneration. Research shows that 5% glucose acts in pain modulation by blocking TRPV1 (Transient Receptor Potential Vanilloid 1) channels, decreasing peripheral sensitization and promoting prolonged analgesia [46].
In addition, glucose favors a biochemical environment conducive to healing and the restoration of neural homeostasis. N-acetylcysteine (NAC) is a direct precursor to glutathione, one of the most important antioxidants in the body. In the context of neural block, NAC has been explored for its neuroprotective and anti-inflammatory potential. NAC administration has shown positive effects in reducing oxidative stress and inhibiting neuro-inflammation, factors often associated with chronic neuropathic pain [43,47]. In addition, its ability to modulate inflammatory pathways and reduce neural hypersensitivity reinforces its usefulness in blocking sensory nerves.
Ultrasound-guided interventional procedures have become increasingly common in the treatment of chronic pain, including shoulder pain [3-5,7,8]. These procedures are minimally invasive and allow real-time visualization of joint, tendon, muscle, nerve, and ligament structures. This method has been shown to be effective for both acute and chronic injuries, especially in small joints such as the shoulder. Ultrasound-guided nerve blocks and infiltrations offer greater precision in the introduction of needles and medical devices into target tissues, minimizing the risk of injury to adjacent structures and improving therapeutic outcomes [8,10,12].
Studies have proven the effectiveness of ultrasound-guided peripheral nerve blocks in pain management, bringing greater safety and efficiency in clinical practice [35,40,42,48]. Other interventional approaches include ultrasound-guided interfascial blocks, which allow for more effective and minimally invasive analgesia for myofascial pain of the trapezius and adjacent structures [4,5].
The use of ultrasonography improves the accuracy and as intramuscular injection instead of interaponeurotic, which will not have the same therapeutic effect. Additionally, the use of mesotherapy has been studied as a complementary therapeutic option in cervicobrachial pain, which may benefit patients with accessory nerve involvement [6]. Pires et al. (2024) described a mesotherapy protocol for cervicoscapulobrachial pain, highlighting its effectiveness in reducing pain and improving functionality in patients with superior cruciate syndrome and excessive tension in the upper scapular muscles [49,50].
Therefore, understanding the contribution of the accessory nerve to chronic shoulder pain allows advances in differential diagnosis and the development of more effective therapeutic strategies, especially with the increasing use of ultrasound-guided minimally invasive techniques.
The accessory nerve plays a vital role in the motor function of the neck and shoulders. A detailed understanding of its anatomy, correlations, and complications is imperative for the effective diagnosis and treatment of dysfunctions related to this nerve. The combination of 5% glucose, 1% procaine, and N-acetylcysteine represents an innovative approach in the management of chronic pain and neurogenic dysfunctions. Glucose acts in the modulation of neuropathic pain, procaine stabilizes neuronal membranes and reduces inflammation, while NAC provides antioxidant and neuroprotective support.
This multimodal approach, based on neural therapy and neuroprolotherapy, may represent an effective alternative for patients with persistent pain, reducing the need for systemic pharmacological analgesia and promoting functional recovery. The combination of these agents provides synergistic effects, contributing to neuronal stabilization, reduction of oxidative stress, and tissue regeneration, in line with the principles of neural therapy and neuroprolotherapy. In addition, the precision provided by ultrasound improves the effectiveness of the procedure and minimizes risks, making this strategy a viable and safe option for patients with refractory pain. Accessory nerve block, when combined with other techniques such as suprascapular and axillary nerve block, can provide significant postoperative pain relief in shoulder surgeries. In addition, the multidisciplinary approach, which includes physical therapy and shockwave therapy, has shown promising results in the management of myofascial pain. This case series suggests that accessory nerve block may be an effective alternative for patients who do not respond to conventional treatments, offering rapid and prolonged relief.
Therefore, the application of this technique in the treatment of pain associated with the shoulder joint represents a significant innovation, expanding the therapeutic possibilities and improving the quality of life of patients. Given the challenges posed by chronic shoulder pain, the incorporation of minimally invasive techniques, such as ultrasound-guided nerve blocks, should be considered as part of a multidisciplinary protocol. However, further studies are needed to evaluate the durability of the therapeutic effects, compare this technique with conventional approaches, and establish optimized protocols for different patient profiles. Controlled clinical trials are also essential to validate the efficacy and safety of this intervention, enabling its wide adoption in clinical practice and optimizing this therapeutic approach, consolidating it as an essential resource in modern clinical practice.
1. Vincenzo R, Levent Ö. (2019). Windshield Wiper in the Shoulder: Ultrasound Imaging for the Proximal Rotator Cuff Interval. American Journal of Physical Medicine & Rehabilitation. 98: e27.
2. Chang KV, Wu WT, Mezian K, Naňka O, Özçakar L. (2019). Sonoanatomy of the muscles attached to the medial border of the scapula (levator scapula, rhomboid minor, and serratus anterior) revisited. American Journal of Physical Medicine & Rehabilitation. 98: e79-e80.
3. Wu WT, Chang KV, Ricci V, Özçakar L. (2024). Ultrasound and guidance in the treatment of myofascial pain syndrome: a narrative review. Journal of Yeungnam Medical Science. 41: 179-187.
4. Ricci V, Mezian K, Chang KV, Tarantino D, Güvener O, et al. (2023). Ultrasound imaging and guidance for cervical myofascial pain: a narrative review. International Journal of Environmental Research and Public Health. 20: 3838.
5. Marrone F, Pullano C, De Cassai A, Fusco P. (2024). Ultrasoundguided fascial plane blocks in chronic pain: a narrative review. Journal of Anesthesia, Analgesia and Critical Care. 4: 71.
6. Ranieri M, Marvulli R, D’Alesio E, Riccardi M, Raele MV, et al. (2024). Effects of intradermal therapy (mesotherapy) on bilateral neck pain. Journal of Personalized Medicine. 14: 122.
7. Suarez-Ramos C, Gonzalez-Suarez C, Gomez IN, Gonzalez MK, Co PH, et al. (2023). Efficacy of Ultrasound-guided Interfascial Hydrodissection with the Use of Saline Anesthetic Solution for Upper Trapezius Myofascial Pain Syndrome: A Blinded Randomized Controlled Trial. Frontiers in Rehabilitation Sciences. 4: 1281813.
8. Cass SP. (2016). Ultrasound-guided nerve hydrodissection: what is it? A review of the literature. Current Sports Medicine Reports. 15: 20-22.
9. Tang TY, Wu CH. (2019). Identification of the dorsal scapular artery optimizes the safety and accuracy of ultrasound-guided 5-in-1 injection. American Journal of Physical Medicine & Rehabilitation. 98: e80-e81.
10. Ratto C, Szokol J, Lee P. (2024). Safety considerations in peripheral nerve blocks. Anesthesia Patient Safety Foundation.
11. Naughtin S, Erskine R. (2021). Management of Postamputation Limb Pain. Anaesthesia Tutorial of the Week. 438.
12. Heo Y, Cho N, Cho H, Won H, Yang M, et al. (2020). New insights into pathways of the accessory nerve and transverse cervical artery for distal selective accessory nerve block. The Korean Journal of Pain. 33: 48-53.
13. Ataíde RA, Paiva ALL, Soares ACC, Batista E de C, Filho G, et al. (2022). Implications of accessory nerve injury in thyroidectomy: case report. Memorial Journal of Medicine. 4: 20.
14. Kierner AC, Zelenka I, Heller S, Burian M. (2000). Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Archives of Surgery. 135: 1428-1431.
15. Ricci V, Mezian K, Chang KV, Tarantino D, Güvener O, et al. (2023). Ultrasound imaging and guidance for cervical myofascial pain: a narrative review. International Journal of Environmental Research and Public Health. 20: 3838.
16. Magalhães e Reis et al. (2019). Accessory nerve - Neuroanatomical revision. Braz J Neuroanat. 3: 1-8.
17. Alonso JL, Reis RG. (2000). Spinal accessory nerve neuropathies secondary to cervical surgeries: a clinical and electrophysiological study of seven cases. Neuro-psychiatry Archives. 58: 704–712.
18. Verma V, Dhillon MS. (2020). Entrapment Syndromes of the Accessory Nerve. Journal of Orthopaedics & Traumatology.
19. Hwang SK, et al. (2020). Clinical Presentation and Management of Accessory Nerve Entrapment. Clinical Shoulder and Elbow.
20. Ali AN, Mehta B. (2019). Current Strategies for Accessory Nerve Entrapment Syndromes. Neurosurgical Review.
21. Bento TPF, Genebra CV. dos S, Cornélio GP, Biancon RDB, Simeão SFAP, et al. (2019). Prevalence and factors associated with shoulder pain in the general population: a cross-sectional study. Physiotherapy and research. 26: 401–406.
22. Fernandes MR, Barbosa MA, Sousa ALL, Ramos GC. (2012). Suprascapular nerve block: an important procedure in clinical practice. Brazilian Journal of Anesthesiology. 62: 100–104.
23. Pitombo PF, Barros RM, Matos MA, Módolo NSP. (2013). Selective suprascapular and axillary nerve block promotes satisfactory analgesia and a lower degree of motor block: compared with interscalene block. Brazilian Journal of Anesthesiology. 63: 52-58.
24. Mizuno K, Muratsu H, Kurosaka M, Yamada M, Harada Y, et al. (2014). Compressive neuropathy of the suprascapular nerve. Portuguese Journal of Orthopedics and Traumatology. 22: 249-264.
25. Levy D, McEwen A. (2019). Ultrasound-Guided Popliteal Block. Anaesthesia Tutorial of the Week, 401.
26. Finlayson RJ, Dukelow A, Poxon J. (2011). Ultrasound-guided spinal accessory nerve block in the diagnosis and management of trapezius muscle-related myofascial pain. Anaesthesia. 66: 285-289.
27. Herbst MK, Sorkin R. (2022). Ultrasound-guided spinal accessory nerve block for intractable trapezius pain. Am J Emerg Med. 52: 268.
28. Acharyya S, Chatterjee ND, Dutta S. (2021). Prevalence and impacts of chronic shoulder pain. Brazilian Journal of Orthopedics. 56: 230- 238.
29. Garzedin DD. da S, Matos MAA, Daltro CH, Barros RM, Guimarães A. (2008). Pain intensity in patients with painful shoulder syndrome. Acta Ortopédica Brasileira, 16: 165–167.
30. Smith JH, et al. (2022). The impact of accessory nerve injuries on quality of life. Journal of Shoulder and Elbow Surgery.
31. Lai CH, et al. (2019). Accessory Nerve Injuries: Clinical Cases and Literature Review. China Journal of Orthopaedics and Traumatology.
32. Miller RC, Heller C. (2015). The Accessory Nerve’s Role in Cervical Function. Cervical Spine Research Society Journal.
33. Gao K, Chen Y, Liu Y. (2016). Neuroanatomy of the Accessory Nerve: Implications for Surgery. Frontiers in Neuroscience.
34. Davis RL, Lentz RE. (2020). Anatomy of the Accessory Nerve: A Review of the Literature. Head & Neck.
35. Shah BR, Tzeng JC. (2017). The Role of the Accessory Nerve in Shoulder Rehabilitation. Physical Medicine and Rehabilitation Clinics of North America.
36. Khaire N, Patil R. (2021). Clinical Implications of Accessory Nerve Pathologies. Neurology International.
37. Fischer M, Horstmann G. (2014). Accessory Nerve Injury: Etiology and Clinical Consequences. Journal of Neurology, Neurosurgery & Psychiatry.
38. Cheng D, Yang X. (2015). Management of Accessory Nerve Injury: An Evidence-Based Review. Neurotrauma Reports.
39. Kumar S, Gupta R. (2019). A Review of Accessory Nerve Entrapment Syndromes. Journal of Neurology.
40. Karaman H, Doğu B, Taş F, Yıldırım N. (2020). Ultrasound-guided nerve blocks in the treatment of chronic shoulder pain. Pain Medicine. 21: 1921-1931.
41. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, et al. (2014). Prevalence and risk factors of shoulder pain in the general population. Spine. 29: 459-468.
42. Johanessen EC, Bakke SA, Rygh LJ. (2019). The accessory nerve as a therapeutic target in chronic shoulder pain. Journal of Pain Research. 12: 2331-2338.
43. Shahripour BR, Harrigan MR, Alexandrov AV. (2018). N-acetylcysteine (NAC) in neurological disorders: Mechanisms of action and therapeutic opportunities. Brain Behavior and Immunity. 78: 312-321.
44. Dosch M, Dosch E. (2018). Second Huneke Neural Therapy Manual. Elsevier Publishing House.
45. Sperber S, McGrath B, Montero A. (2021). Procaine and its role in neural therapy: A review. Journal of Pain Research. 14: 123-134.
46. Reeves KD, Lyftogt J. (2019). Prolotherapy: regenerative injection therapy. Physical Medicine and Rehabilitation Clinics. 30: 309-325.
47. Tortora S, Messina C, Gitto S, Chianca V, Serpi F, et al. (2021). Ultrasound-guided musculoskeletal interventional procedures around the shoulder. Journal of Ultrasonography. 21: e162–e168.
48. Vincenzo R, Kevin C, Levent Ö. (2022). Ultrasound Imaging and Guidance for Musculoskeletal Interventions: “Crosstalk” Between EURO-MUSCULUS/ USPRM and Pain Physicians. 16-18.
49. Pires L, Santos N, Lana JV, de Macedo AP, Costa FR, et al. (2024). Upper Crossed Syndrome and Scapulae Upper Trapping: A Mesotherapy Protocol in Cervicoscapulobrachial Pain. The 8:1 Block. Bioengineering. 11: 1142.
50. Wang Y, et al. (2020). Regenerative Therapies for Accessory Nerve Injury. Neurology Research International.
Occlusion is biologically defined as the coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail and repair
Talia Becker*
Achilles tendon is a common site of foot and ankle discomfort but its rupture is not frequent. It’s a superficial tendon and this lends it to excellent evaluation by sonography instead of magnetic resonance imaging. Recently ultrasonography has been widely used in musculoskeletal practice. We present a case of Achilles tendon ruptures diagnosed based on fundamental sonographic findings.
Arash Babaei-Ghazani¹,², Safoora Ebadi¹,², Bijan Forogh¹,³, and Bina Eftekharsadat⁴*
Osteoarthritis (OA), one of the most common skeletal disorders characterized by cartilage degradation and osteophyte formation in joints, is induced by accumulated mechanical stress; however, little is known about the underlying molecular mechanism. Several experimental OA models in mice by producing instability in the knee joints have been developed to apply approaches from mouse genetics. Although proteinases like matrix metalloproteases and aggrecanases have now been proven to be the principal initiators of OA progression, clinical trials of proteinase inhibitors have not been successful for the treatment, turning the interest of researchers to the upstream signals of proteinase induction. These signals include under graded and fragmented matrix proteins like type II collagen or fibronection that affects chondrocytes through distinct receptors. Another signal is pro inflammatory factors that are produced by chondrocytes and synovial cells; however, recent studies that used mouse OA models in knockout mice did not support that these factors have a role in the central contribution to OA development. Our mouse genetic approaches found that the induction of a transcriptional activator Runx2 in chondrocytes under mechanical stress contributes to the pathogenesis of OA through chondrocyte hypertrophy. In addition, chondrocyte apoptosis has recently been identified as being involved in OA progression. We hereby propose that these endochondral ossification signals may be important for the OA progression, suggesting that the related molecules can clinically be therapeutic targets of this disease.
Hiroshi Kawaguchi
Estimating the Knee Functional Axis (KFA) is crucial to both correctly implanting the prosthesis and accessing the joint kinematics. Researchers have mainly reported KFA by manual management of flexion extension movements, which are passively performed without any voluntary movements. Active touch and movement refers to what is ordinarily called as touching, which is defined as variations in skin stimulation caused by variations in a person’s motor activity.
The difference is very important for the individual. However, it has not been emphasized in the biomechanical literatures. This study aims to confirm the distinction between touching and being touched. We are particularly interested in measuring the Instantaneous Axes of the Knee (IAK) during locomotion. This geometrical “pattern” of the IAK is altered along with the touch pattern by the mechanical necessities of terrestrial movement.
Wangdo Kim¹, Young Choi², and Hong-Gi Lee³*
Although fractures of the epiphyseal cartilage injuries are common in childhood, epiphyseal fractures involving the proximal tibia entities are very rare and are usually caused by high-energy trauma, with an incidence ranging between 0.5 and 3.1% of patients; peak incidence between the ages 12-14 years in male patients. The aim of this report is describe a case of fracture of the epiphyseal cartilage of a 13 year old boy, a victim of sports trauma showing lateral tibial plateau fracture and epiphyseal cartilage fracture at the same side, not compatible with the classifications of fractures in children.
Omar Ferreira Miguel
In the last few years, clinical applications of regenerative medicine have been increasing their way in medical practice.
Valerio Di Nicola¹,² and Mauro Di Pietrantonio³*
The twentieth century epidemic of low back pain has continued unabated into the 21st century. Up to 20% of the Australian population will experience low back pain at some stage of their lives
J Saunders¹, M Cusi¹,³ and H Van der Wall¹,²*
Music is the most essential ingredient of any entertainment. In order to create successful entertaining event musicians plays an imperative role. Musicians are wizards who spread the fragrance of joy by absorbing woes, in the form of Playing Related Musculoskeletal Disorders (PRMDs), for themselves. Like other occupations, musicians also suffer from work related musculoskeletal disorders which are often disabling
Wricha Mishra
Dupuytren’s Contracture (DC) is a fibro-proliferative tumor according to ICD 10 - fascial fibromatosis of unknown etiology (M 720), accompanied by a stable bending contracture of fingers. In CD in the postoperative period extremely high rate of surgical complications is observed: intraoperative (injury of blood vessels, nerves, tendons), general postoperative (hematoma, necrosis, odema, stiffness, etc.), late postoperative (recurrence, spread, progression). In the last case according to the data of different authors, complications frequency is depend upon the degree (from partial up to the total) and the accuracy of excision of the affected aponeurosis ?almaris. One of the problems in choosing the type of operation and technology is the complexity of the cutoff determination boundaries of the affected CD. Up to now there is no suitable for use in the practical CD surgery algorithm of the affected aponeurosis ?almaris spread non invasive visualization in a particular patient. The most appropriate method for the solution of this problem is a method of MRI. The technology of identifying the boundaries of surgery of the affected aponeurosis palmaris in Dupuytren’s contracture by means of MRI has been elaborated. It has been shown that MRI is a highly informative method in the assessment of topographic anatomy of aponeurosis palmaris in normal and CD states. PD, T1, T2 - weighed images allow objectively to visualize the border areas of the affected aponeurosis in I - III stages of CD. PD fsat (fat tissues signal saturation) MRI mode is not recommended for use.
Baikeev RF¹, Mikusev GI², Osmonaliyev IZh², Zakirov RH² and Afletonov EN²*
Metallosis is an aseptic fibrosis, local necrosis, inflammation, or loosening of an implant device secondary to metallic corrosion and release of wear debris. The condition has been highlighted recent years due to the clinical complications caused by metal-on-metal (MoM) hip replacement. Although some major types of MoM hip prostheses have been recalled from the market, metallosis is far from over as not only there are still a million implanted MoM hip prosthetic cases worldwide, but also it has been found in non-MoM hip prostheses and other metal implants. This mini review aims to provide recent findings of implants related metallosisin skeletal tissue.
Zhidao Xia