[Treatment of therapy refractory epicondylitis lateralis humeri by denervation. On the pathogenesis]

The pathogenesis of tennis elbow is still debated, the question of proper surgical treatment as well. Because the area of pain in tennis elbow and the concomitant spots of pain together with sensibility disorders of the hand are supplied entirely by branches of the radial nerve, we suggested a surgical procedure for complete denervation as early as 1962. The main purpose of this paper is to examine the possibilities of improving the surgical technique, thereby shedding light on the pathogenesis of tennis elbow.

Between 1970 and 1994, altogether 166 patients with 172 cases of resistant tennis elbow were treated by denervation. This procedure calls for careful exposure and the severing of only one tiny branch of the radial nerve. Denervation is otherwise accomplished by "blind" dissection by desinsertion of certain muscles, which are reinserted after denervation, however, with exception of the supinator muscle. Until 1990, the original procedure was performed 39 times (Group A). Afterwards, denervation involved only isolated desinsertion of the supinator muscle in 46 cases (Group B) without the temporary incision of the ECRB-origin, as performed previously. In a further series of 87 cases, an evaluation of denervation in combination with a direct decompression of the deep branch of the radial nerve was performed by resection of the supinator arcade (Group C). Postoperative results were evaluated and scored according to Roles and Maudsley (1972).

The denervations of Group A were controlled after an average follow-up time of 9.7 years in 36 cases (92.3%), in 91.6% they demonstrated good and excellent results. In Group B, 42 patients (91.3%) were followed-up after an average time of 4.9 years; these cases showed about the same results as in Group A (90.5% good and excellent). The time off work was 2.7 and 5.7 weeks respectively. The results of denervation, however, were not improved by additional direct decompression of the posterior interosseous nerve (Group C); in a follow-up rate of 86% after 3.6 years only 65.3% showed good and excellent results together with an extremely long time off work of up to 11.7 weeks.

The results in Group A and B prove that the temporary desinsertion of the ECRB, previously regarded as necessary for reasons of dissection, can be discontinued, without worsening of outcome, as long as the anterior and lateral portions of the supinator origin are incised directly, thereby resulting in indirect decompression of the posterior interosseous nerve simultaneously. The results of this procedure emphasize the fact that tennis elbow is the result of a compression syndrome of the radial nerve and its branches, where the pain-triggering nerve irritations are found at one or several localizations that can be treated successfully--as shown in the literature and by our own findings--by direct decompression of this nerve segment.