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Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: Long-term results in 50 cases

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  • Texas Nerve and Paralysis Institute

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Long thoracic nerve injury leading to scapular winging is common, often caused by closed trauma through compression, stretching, traction, direct extrinsic force, penetrating injury, or neuritides such as Parsonage-Turner syndrome. We undertook the largest series of long thoracic nerve decompression and neurolysis yet reported to demonstrate the usefulness of long thoracic nerve decompression. Winging was bilateral in 3 of the 47 patients (26 male, 21 female), yielding a total of 50 procedures. The mean age of the patients was 33.4 years, ranging from 24-57. Causation included heavy weight-lifting (31 patients), repetitive throwing (5 patients), deep massage (2 patients), repetitive overhead movement (1 patient), direct trauma (1 patient), motor bike accident (1 patient), and idiopathic causes (9 patients). Decompression and microneurolysis of the long thoracic nerve were performed in the supraclavicular space. Follow-up (average of 25.7 months) consisted of physical examination and phone conversations. The degree of winging was measured by the operating surgeon (RKN). Patients also answered questions covering 11 quality-of-life facets spanning four domains of the World Health Organization Quality of Life questionnaire. Thoracic nerve decompression and neurolysis improved scapular winging in 49 (98%) of the 50 cases, producing "good" or "excellent" results in 46 cases (92%). At least some improvement occurred in 98% of cases that were less than 10 years old. Pain reduction through surgery was good or excellent in 43 (86%) cases. Shoulder instability affected 21 patients preoperatively and persisted in 5 of these patients after surgery, even in the 5 patients with persistent instability who experienced some relief from the winging itself. Surgical decompression and neurolysis of the long thoracic nerve significantly improve scapular winging in appropriate patients, for whom these techniques should be considered a primary modality of functional restoration.
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BioMed Central
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BMC Musculoskeletal Disorders
Open Access
Research article
Microneurolysis and decompression of long thoracic nerve injury
are effective in reversing scapular winging: Long-term results in 50
cases
Rahul K Nath*
1
, Andrew B Lyons
2
and Gabriel Bietz
2
Address:
1
Director, Texas Nerve and Paralysis Institute, Houston, Texas 77030, USA and
2
Research Associate, Texas Nerve and Paralysis Institute,
Houston, Texas 77030, USA
Email: Rahul K Nath* - drnath@drnathmedical.com; Andrew B Lyons - andrew@drnathmedical.com;
Gabriel Bietz - gabriel@drnathmedical.com
* Corresponding author
Abstract
Background: Long thoracic nerve injury leading to scapular winging is common, often caused by
closed trauma through compression, stretching, traction, direct extrinsic force, penetrating injury,
or neuritides such as Parsonage-Turner syndrome. We undertook the largest series of long
thoracic nerve decompression and neurolysis yet reported to demonstrate the usefulness of long
thoracic nerve decompression.
Methods: Winging was bilateral in 3 of the 47 patients (26 male, 21 female), yielding a total of 50
procedures. The mean age of the patients was 33.4 years, ranging from 24–57. Causation included
heavy weight-lifting (31 patients), repetitive throwing (5 patients), deep massage (2 patients),
repetitive overhead movement (1 patient), direct trauma (1 patient), motor bike accident (1
patient), and idiopathic causes (9 patients). Decompression and microneurolysis of the long
thoracic nerve were performed in the supraclavicular space. Follow-up (average of 25.7 months)
consisted of physical examination and phone conversations. The degree of winging was measured
by the operating surgeon (RKN). Patients also answered questions covering 11 quality-of-life facets
spanning four domains of the World Health Organization Quality of Life questionnaire.
Results: Thoracic nerve decompression and neurolysis improved scapular winging in 49 (98%) of
the 50 cases, producing "good" or "excellent" results in 46 cases (92%). At least some improvement
occurred in 98% of cases that were less than 10 years old. Pain reduction through surgery was good
or excellent in 43 (86%) cases. Shoulder instability affected 21 patients preoperatively and persisted
in 5 of these patients after surgery, even in the 5 patients with persistent instability who
experienced some relief from the winging itself.
Conclusion: Surgical decompression and neurolysis of the long thoracic nerve significantly
improve scapular winging in appropriate patients, for whom these techniques should be considered
a primary modality of functional restoration.
Published: 7 March 2007
BMC Musculoskeletal Disorders 2007, 8:25 doi:10.1186/1471-2474-8-25
Received: 17 October 2006
Accepted: 7 March 2007
This article is available from: http://www.biomedcentral.com/1471-2474/8/25
© 2007 Nath et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Background
Winging of the scapula due to long thoracic nerve palsy is
a common diagnosis [1-10] and a significant functional
problem, not simply an aesthetic issue. Secondary pain
and spasm result from muscle imbalances and tendonitis
around the shoulder joint caused by muscular activity that
compensates for impaired shoulder stability. Winging
also leads to adhesive capsulitis, subacromial impinge-
ment, and brachial plexus radiculitis [5]. Traditional man-
agement has relied on conservative therapy [2,3,11-14]
and pectoralis tendon transfer for refractory cases [4,5,13-
15]. A less common approach has been scapulothoracic
arthrodesis [16]. Most patients probably never undergo
surgery and hence live with chronic shoulder instability
and pain.
The unique anatomy of the long thoracic nerve predis-
poses it to injury, which often causes scapular winging.
Compared to the relatively robust adjacent nerves of the
brachial plexus, the long thoracic nerve is small in diame-
ter, appears fragile, and has much less (and much more
translucent) connective tissue. The lengthy course of the
nerve also increases chances of injury. Surgical dissection
in the axilla can directly injure the nerve in the infraclavic-
ular region in as many as 30% of procedures [17].
The anatomic feature usually associated with injury is the
long thoracic nerve's course through the fibers of the mid-
dle scalene muscle in the supraclavicular region [18-20].
In several of our patients, nerve injury appeared to have
occurred during exercise when the contractions of the
middle scalene muscle directly compressed the long tho-
racic nerve. Another injury category involves an extrinsic
crushing of the nerve in the vicinity of the middle scalene
muscle, a possible secondary source of injury. Most of our
patients relate a history of strenuous upper-extremity
activity or heavy weight-lifting. Deep massage treatments
directly compressed the supraclavicular fossa in two
patients, with associated pain and paresthesia during
treatment.
Scapular winging can be treated by directly addressing the
nerve injury. Nerve transfer surgery can be used to restore
long thoracic nerve function [21,22]. A simpler surgical
approach for continuous nerves with evidence of com-
pression in the scalene muscles is decompression and
microneurolysis. Disa and coworkers [19] reported suc-
cessful neurolysis of the long thoracic nerve in four
patients with winging caused by stretching or trauma
involving the middle scalene [18]. This study reports 50
cases in which decompression and neurolysis of the long
thoracic nerve where it traverses the middle scalene
improved scapular winging.
Methods
Forty-seven consecutive patients consisting of 26 males
and 21 females with a mean age of 33.4 years (24–57
years) underwent surgery after evaluation for a winging
scapula. All patients gave informed consent to participate
in this study. The investigation was carried out in accord-
ance with the Declaration of Helsinki. Winging was bilat-
eral and symptomatic in three patients; three others had
clear but asymptomatic winging of the contralateral side.
The total number of operations was 50. The most com-
mon symptoms were initial discomfort and spasm of the
affected shoulder girdle muscles with shoulder instability
and winging of the scapula. Thirty-one patients (62%)
could not abduct and flex the shoulder beyond 90
degrees. Of the 50 cases, 32 were right-sided, 18 left-sided
nerve injuries. Most patients were right-hand dominant.
Thirty-one (62%) had a history of weight-lifting. Winging
followed rigorous, extended throwing exercises in five
patients (10%). In two patients (4%), winging immedi-
ately followed deep massage in the area of the supraclavic-
ular fossa, and one patient (2%) was a postal worker who
had performed repetitive overhead movements for several
years. One patient (2%) had been hit by a ladder at work
and gave a detailed history of direct trauma to the supra-
clavicular area. A motorbike accident caused winging in
one patient (2%) when his arm and shoulder were jerked
forward sharply while he gripped the handlebars during a
fall. Winging was idiopathic in nine patients (18%) and
considered to be related to Parsonage-Turner syndrome. It
is our belief, however, that many times Parsonage-Turner
Syndrome is misdiagnosed because of associated atypical
symptoms that can often be related to previous strenuous
physical activity.
Patient Evaluation
The senior author, an experienced brachial plexus sur-
geon, performed all surgery. Each surgical procedure fol-
lowed the same protocol (defined below). The same
author (ABL) performed follow-up evaluation (average,
25.7 months).
Physical examination uniformly revealed medial devia-
tion of the inferior angle of the scapula and prominent
winging of the medial border of the scapula with back-
ward pressure on the shoulder during forward protrac-
tion. The scapula was also elevated superiorly. Patients
experienced significant discomfort and feelings of shoul-
der instability with overhead arm and shoulder move-
ments: 31 (62%) of 50 patients could not flex or abduct
the shoulder beyond 90 degrees.
No grading systems for the serratus anterior muscle have
been established, so we quantified the degree of winging
by estimating the angle between the plane of the scapula
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and the posterior chest wall. British Motor Grading
(BMG), a grading system outlined by the Medical
Research Council for semi-quantitative assessment of
muscle strength, applied to upper-trunk examination
[23]. Muscle function is graded from M0 to M5 with M0
being complete absence of contraction and M5 being nor-
mal function.
Physical examination revealed weakness of the deltoid,
spinati, and biceps muscles (BMG, M3-M4) in 38 cases, a
finding consistent with concurrent injury to the upper
trunk of the brachial plexus.
Electromyography of the brachial plexus and long tho-
racic nerve distribution was performed prior to physical
examination, in all cases. Serratus anterior abnormalities
were present in 44 (88%) patients; subtle, transient
abnormalities of the serratus examination were detected
in 3 (6%). Abnormal EMG results all described neuro-
praxic injury with no loss of axonal continuity. Presurgery
MRI was performed in 12 patients and yielded normal
results except in 9 cases showing atrophy of the serratus
anterior muscle. Intraoperative nerve action potentials
were not tested in all cases, which may have potentially
shown regeneration after a 3 month interval despite a lack
of clinical recovery.
All 47 patients had undergone regular physical therapy
prior to surgery. Eight patients who had experienced
symptoms for longer than 7 years described possible
minor improvement with conservative management, but
all felt that winging constrained the scope and intensity of
their physical activity.
To qualify for surgery, the injury generally had to have
occurred at least 3 months before surgery (there were four
exceptions). The average time interval between the time of
injury and surgical treatment was 8 months. Progressive
improvement with physical therapy was another disqual-
ifying factor; slowly progressive symptoms or failed con-
servative management were qualifying factors. Another
consideration was a history that strongly suggested injury
to the long thoracic nerve in the region of the middle sca-
lene muscle. Scapular winging and proximal extremity
weakness after the lifting of heavy weights and aggressive
throwing motions do support the theory of middle and
anterior scalene compression of contained nerves.
Another important cause was thought to be direct extrin-
sic pressure to the relatively superficial long thoracic nerve
and the upper plexus in the supraclavicular area. Stretch-
ing and axial traction of these nerve elements by various
mechanisms was considered significant. Abnormal EMG
results were considered to confirm the presence of severe
injury, but the lack of such abnormalities was not consid-
ered a contraindication to surgery when clinical evidence
strongly supported severe injury.
Surgical candidates participated in a thorough discussion
of the risks and potential benefits. Discussed options were
continuing conservative management, pectoralis tendon
transfer, or scapulothoracic fusion. Patients understood
that we considered an excellent outcome less likely if
winging was more than 10 years old, given our knowledge
of denervated skeletal muscle, including the serratus ante-
rior.
Follow-up consisted of serial physical examination (same
examiner) and long-term postoperative evaluation
through phone conversations (WHO WHOQOL-100 field
trial questionnaire) in which a 1–5 scaled was used to
assess changes in 11 facets of four quality-of-life domains.
The Wilcoxon signed ranks test was used for statistical
analysis.
Surgical Technique
Patients were placed in the lawn-chair position, with a
shoulder roll. The head and neck were abducted away
from the side of surgery. The entire supraclavicular area
was prepared and draped with a thyroid sheet. The skin
incision was created two fingerbreadths posterior and par-
allel to the clavicle. The incision was sinusoidal and
extended 6–8 cm lateral to the palpated lateral clavicular
border of the sternocleidomastoid muscle. Dissection
proceeded through the platysma muscle while carefully
protecting the underlying supraclavicular nerves. Resec-
tion of the omohyoid muscle allowed access to the scalene
fat pad and removal of a potential compressive structure
of the brachial plexus. Inferior to superior elevation of the
scalene fat pad revealed the upper brachial plexus. Identi-
fication of the suprascapular branch of the upper trunk
required great care: this branch often traverses the middle
layers of the scalene fat pad, producing a potential site of
iatrogenic injury.
The next stage involved exploration of the upper trunk
and its trifurcation into the anterior and posterior divi-
sions and the suprascapular nerve. Epineurial scarring was
typical at this point, and microsurgical instruments and
technique were used for external neurolysis. Simultane-
ous anterior scalene resection was generally partial, releas-
ing only the most superficial fibers compressing the upper
trunk. Thus, resection typically involved 15%–20% of the
thickness of the anterior scalene muscle.
The long thoracic nerve was then exposed laterally and
posteriorly to the upper trunk. The long thoracic nerve
and its tributaries are delicate here, no more than 2–3 mm
in diameter. Passage of the nerve through the thick middle
scalene muscle and the nerve's slightness compared to the
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serratus anterior muscle may predispose the neuromuscu-
lar unit to dysfunction [18].
Internal and external neurolysis of the isolated nerve was
performed with microsurgical instruments and the oper-
ating microscope in light of the nerve's delicate nature and
to reduce surgical scar formation. The long thoracic nerve
has several fascicles, visible under magnification and pre-
viously dissected and described anatomically by Zancolli
and Cozzi [24]. Internal neurolysis was performed in all
cases as a standard approach to repair. The middle scalene
was resected enough to decompress the long thoracic
nerve and its branches as they traverse and exit the muscle.
A demarcated area of compression within the nerve was
apparent in 47 (94%) of the 50 procedures, more so
toward the point of exit from the muscle. The site of com-
pression showed narrowing and surface neovasculariza-
tion of the epineurium. One case required complete
resection of the middle scalene; the other 49 cases
required partial release, which was enough to expose the
long thoracic nerve and remove the circumferential mus-
cle fibers.
Prior to closure, the superior-most and inferior margins of
the surgical wound were examined via direct vision and
sharp dissection to identify and release compressive fas-
cial bands that might compress the upper trunk and long
thoracic nerve.
Closure involved reconstruction of the platysma and two
skin layers with no drains. Immediate postoperative man-
agement consisted of active range of motion at the shoul-
der and neck. The goal for the third postoperative day was
full range of motion at or beyond preoperative levels.
Results
As noted earlier, our series of 50 long thoracic nerve
decompression and neurolysis procedures is the largest
such series in the literature. Forty-four (88%) of these pro-
cedures significantly improved scapular winging within 1
day to 3 months. Winging improved in 98% of patients in
whom it had been present for less than 10 years. Subjec-
tively speaking, decompression and neurolysis appeared
to improve contractions of the serratus anterior. Recovery,
as assessed through British Motor Grade muscle strength
analysis and estimating the decrease in the angle between
the plane of the scapula and the posterior chest wall,
occurred within 24 hours in 50% of cases.
Half of the patients experienced pain, which was
improved in 73% of cases. All 31 patients who had shoul-
der instability that interfered with abduction and shoul-
der flexing beyond 90 degrees experienced relief following
surgery.
In 8 (9%) of 50 extremities, patients reported a 2 cm
2
swelling at the area of incision between 3 and 6 weeks
after surgery, which in all cases resolved spontaneously
within 1 week and may have represented an unusually
late-appearing seroma. The prevalence of swelling in these
cases occurred equally bilaterally.
All 47 patients completed the WHOQOL-100 question-
naire. The average quality-of-life rating was 3.4 ("excel-
lent") for all 11 facets. Except for three patients who
considered their appearance, pain level, or sleep to have
worsened slightly, all responses affirmed improvement.
These three patients included one, a 32 year old male,
with winging persisting over 10 years. The other two cor-
respond to one patient, a 28 year old male with a severe
case of bilateral winging.
All 11 QOL categories achieved significance (p <0.001 –
see Table 1). The average response to surgery was 3.6
(treatment within 2 years of the onset of winging) and
1.84 (treatment after 8 years from onset). No preoperative
survey was administered because of the nature of the
WHOQOL-100 questionnaire as a historical survey.
Table 1: Quality of life questionnaire statistics
Facet Z-score p value
Energy -3.845 < 0.001
Pain -3.741 < 0.001
Sleep -3.736 < 0.001
Appearance -3.837 < 0.001
Feelings -3.838 < 0.001
Range of Motion -3.745 < 0.001
Activities of daily living -3.839 < 0.001
Medications -3.843 < 0.001
Work -3.640 < 0.001
Relationships -3.744 < 0.001
Overall -3.736 < 0.001
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Poorer outcomes were associated with delays longer than
8 years between onset of winging to surgery (Figure 1). No
infections or other complications occurred. One patient
who had been injured while playing softball experienced
partial recurrence 6 months after initially showing
improvement, but this was due to premature resumption
of competitive softball pitching. The recurrence had not
resolved 6 months after beginning, and the patient is
being considered for a pectoralis tendon transfer.
Discussion
Scapular winging is an important cause of functional dis-
ability. The morbidity associated with long thoracic nerve
dysfunction is underappreciated and under treated. Ferry
[25] argues that conservative treatment is an option based
on inadequate data; we likewise favor a more aggressive
approach involving surgery. Ten of our patients had sig-
nificant functional deficits due to winging that had been
present for more than 6 years; all 10 responded to surgery,
often (70% of cases) within 1 week of surgery. The average
time to improvement was 5 days (range 1 day to 3
months).
Our findings support nerve surgery as a treatment option
in specific cases of supraclavicular injury to the long tho-
racic nerve and diminish the possibility that improvement
was spontaneous. Risk factors for supraclavicular nerve
injury include vigorous athletic maneuvers with the
affected extremity, lifting heavy weights, and direct exter-
nal pressure (as in deep massage). Injury to the upper
trunk of the brachial plexus is also associated with the
proposed stretch or compression mechanisms of injury.
Upper-trunk disease reduces the reliability of shoulder
examination because deltoid and spinati strength are
reduced by long- standing scapular instability. However,
all of our patients showed direct evidence of upper-trunk
injury (BMG biceps score of M3 or M4).
The relatively delicate structure of the long thoracic nerve
is contrasted with the densely composed upper trunk and
predicts the consequences of trauma to each element:
given similarly applied forces, the upper trunk shows less
dysfunction than the long thoracic nerve. This explains
why electrophysiologic examination of the upper trunk-
supplied muscles of the affected extremity often reveals no
clear abnormalities, the upper trunk injury being rela-
tively minor [19,26]. EMG of the serratus anterior, how-
Quality of life improvement in 50 scapular winging instancesFigure 1
Quality of life improvement in 50 scapular winging instances.
0
1
2
3
4
5
0 20 40 60 80 100 120 140
Duration of Winging Scapula (months)
Improvement
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ever, often reveals greater dysfunction than in the other
muscles. Unfortunately, electrodiagnostic studies of the
long thoracic nerve can be unreliable indicators of injury
severity[27]. The tendency toward normal results with ser-
ratus anterior testing in our population may then be
ascribed to inadvertent testing of the latissimus dorsi,
teres major, or other unaffected chest wall muscles, which
can be difficult to isolate [28]. The three main portions of
the serratus anterior are preferentially innervated by
branches from different roots of the long thoracic nerve
[29], and both the stimulation point and measurement
point in relationship to the nerve constriction site could
all affect the EMG results [28]. The fact that the long tho-
racic nerve was in continuity in all 50 cases might also
have hampered EMG-based attempts to uncover subtle
(but functionally significant) denervation abnormalities.
The observed rapid recovery of half of the patients might
indicate a less severe nerve injury (no focal demyelina-
tion) that remains functionally debilitating. It is unlikely
that the fast recovery is due to an ischemic mechanism,
since muscle atrophy and denervation would be expected
in cases persisting several years. Such injury may be classi-
fied as a Sunderland grade 0.5, wherein the myelin of the
injured nerves is apparently intact and a different mecha-
nism causes loss of function [30,31]. One possibility is the
concept of "silent synapses" – inhibited acetylcholine
release at the motor end plate due to blocked axonal flow
caused by mechanical forces. Transport is sufficient to sus-
tain nerve health, but not to stimulate muscle contraction.
By surgically removing the source of nerve constriction,
normal muscle function could quickly resume [30].
This study expands the database of nerve-based manage-
ment of scapular winging caused by supraclavicular long
thoracic nerve injury. Muscle- and tendon-based proce-
dures should remain important tools in cases of refrac-
tory, symptomatic scapular winging, but the effectiveness
and low morbidity of long thoracic nerve decompression
appear to justify its becoming the initial treatment of
choice in appropriate cases, for which we suggest the fol-
lowing paradigm:
1. Clinical evaluation with particular attention to the
cause of injury or any associated events. Patients with
symptomatic scapular winging related to injury localized
at the long thoracic nerve near the middle scalene are can-
didates for nerve surgery.
2. Direct physical examination, with particular attention
to scapular movements and strength. Strength of the ser-
ratus anterior muscle can be measured in terms of maxi-
mal protrusion at the inferior scapular angle (normal is 0
cm; >5 cm signifies extreme loss of function).
3. Electrical studies to detect loss of nerve continuity,
which could indicate the need for nerve grafting or trans-
fer. The lack of abnormal findings with electrical testing
should not obviate surgery when clinical findings suggest
surgical intervention.
4. Observation of the following guidelines for determin-
ing surgical candidacy and time since onset of injury:
• <7 years, candidate for nerve surgery in the absence of
other contraindications such as established loss of nerve
continuity for > 18 months
• 7–10 years, relative candidate (good outcomes are less
predictable)
• >10 years, tendon transfer becomes the primary treat-
ment option (nerve surgery is a secondary option)
Pain and inflammation do not automatically improve
even with successful flattening of the scapula, and they
improve unpredictably in our experience. We find that
patients are not always happy with the results of surgery
when the primary presenting symptom is established
pain, even when the winging is reversed. These cases, how-
ever, represent a minority of all patient experiences.
Postoperative management is generally restricted to gentle
range-of-motion (ROM) therapy and electrical stimula-
tion. The protocol for patients with longstanding winging
is daily stretching for up to 1 year following surgery, after
which strengthening work can begin. Patients with wing-
ing for less than 2 years begin strengthening after 3
months of ROM therapy, which helps prevent and treat
adhesive capsulitis at various shoulder girdle joints.
Conclusion
Winging of the scapula is an important but underappreci-
ated public health problem. Many sufferers live with pain
and ongoing functional deficits. Peripheral nerve surgery
is becoming increasingly important in managing scapular
winging related to the long thoracic nerve, often treating
the cause of the problem rather than the result of the
injury. In many cases, the effectiveness and low morbidity
of nerve surgery make it the treatment of choice. Ongoing
research into surgical and conservative management will
further improve the management of scapular winging.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
RKN Performed surgery, conceived of the study, analyzed
data, and wrote the paper. ABL and GB both collected and
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analyzed data. All authors read and approved the final
manuscript.
References
1. Fiddian NJ, King RJ: The winged scapula. Clin Orthop Relat Res
1984:228-236.
2. Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M:
Serratus anterior paralysis in the young athlete. J Bone Joint
Surg Am 1979, 61(6A):825-832.
3. Overpeck DO, Ghormley RK: Paralysis of the serratus magnus
muscle caused by lesions of the long thoracic nerve. JAMA
1940, 114:1994-1996.
4. Leffert RD: Pectoralis major transfer for serratus anterior
paralysis. Orthop Trans 1993, 16:761-766.
5. Kuhn JE, Plancher KD, Hawkins RJ: Scapular Winging. J Am Acad
Orthop Surg 1995, 3(6):319-325.
6. Pecina MM, Krmpotic-Nemanic J, Markiewicz AD: Long thoracic
nerve compression. In Tunnel Syndromes 3rd edition. Edited by:
Pecina MM, Krmpotic-Nemanic J, Markiewicz AD. Boca Raton, Fl ,
CRC Press; 2001:73-77.
7. Pugliese GN, Green RF, Antonacci A: Radiation-induced long tho-
racic nerve palsy. Cancer 1987, 60(6):1247-1248.
8. Schultz JS, Leonard JA Jr.: Long thoracic neuropathy from ath-
letic activity. Arch Phys Med Rehabil 1992, 73(1):87-90.
9. Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop
Relat Res 1999:17-27.
10. Warner JJ, Navarro RA: Serratus anterior dysfunction. Recogni-
tion and treatment. Clin Orthop Relat Res 1998:139-148.
11. Gozna ER, Harris WR: Traumatic winging of the scapula. J Bone
Joint Surg Am 1979, 61(8):1230-1233.
12. Horwitz MT, Tocantins LM: An anatomical study of the role of
the long thoracic nerve and the related scapular bursae in
the pathogenesis of local paralysis of the serratus anterior
muscle. Anat Rec 1938, 71:375-385.
13. Leffert RD: Nerve injuries about the shoulder. In The shoulder
Edited by: Rowe CR. New York, N.Y. , Churchill-Livingstone;
1988:435-454.
14. Leffert RD: Neurological problems. In The shoulder Volume 2. 3rd
edition. Edited by: Rockwood CA, Matsen FAIII. Philadelphia, PA ,
W.B. Saunders; 1990:750-773.
15. Iceton J, Harris WR: Treatment of winged scapula by pectoralis
major transfer. J Bone Joint Surg Br 1987, 69(1):108-110.
16. Hawkins RJ, Willis RB, Litchfield RB: Scapulothoracic arthrodesis
for scapular winging. In Surgery of the shoulder Edited by: Post M,
Morrey BF, Hawkins RJ. St. Louis, MO , Mosby Year Book;
1990:356-359.
17. Duncan MA, Lotze MT, Gerber LH, Rosenberg SA: Incidence,
recovery, and management of serratus anterior muscle
palsy after axillary node dissection. Phys Ther 1983,
63(8):1243-1247.
18. Birch R, Bonney G, Wynn Parry CB: Entrapment neuropathy. In
Surgical disorders of the peripheral nerves Edited by: Birch R, Bonney G,
Wynn Parry CB. New York, NY , Churchill Livingstone;
1998:245-292.
19. Disa JJ, Wang B, Dellon AL: Correction of scapular winging by
supraclavicular neurolysis of the long thoracic nerve. J Recon-
str Microsurg 2001, 17(2):79-84.
20. Skillern PG: Serratus magnus palsy with proposal of a new
operation for intractable cases. Ann Surg 1913, 57:909-915.
21. Novak CB, Mackinnon SE: Surgical treatment of a long thoracic
nerve palsy. Ann Thorac Surg 2002, 73(5):1643-1645.
22. Tomaino MM: Neurophysiologic and clinical outcome follow-
ing medial pectoral to long thoracic nerve transfer for scapu-
lar winging: a case report. Microsurgery 2002, 22(6):254-257.
23. Birch R, Bonney G, Wynn Parry CB: Results. In Surgical disorders of
the peripheral nerves Edited by: Birch R, Bonney G, Wynn Parry CB.
New York, NY , Churchill Livingstone; 1998:235-243.
24. Zancolli E, Cozzi EP: The brachial plexus: funicular topography
of the undivided parts. In Atlas of surgical anatomy of the hand New
York , Churchill Livingstone; 1992:570-576.
25. Ferry A: Results of treatment of anterior serratus paralysis. In
Surgery of the shoulder
Edited by: Post M, Morrey BF, Hawkins RJ. St.
Louis, MO , Mosby Year Book; 1990:325-329.
26. Sostarko M: Neurophysiology and electrodiagnosis of com-
pression syndromes. In Tunnel Syndromes 3rd edition. Edited by:
Pecina MM, Krmpotic-Nemanic J, Markiewicz AD. Boca Raton, Fl ,
CRC Press; 2001:13-27.
27. Friedenberg SM, Zimprich T, Harper CM: The natural history of
long thoracic and spinal accessory neuropathies. Muscle Nerve
2002, 25(4):535-539.
28. Depalma MJ, Pease WS, Johnson EW, Kadyan V: A novel technique
for recording from the serratus anterior. Arch Phys Med Rehabil
2005, 86(1):17-20.
29. Bertelli JA, Ghizoni MF: Long thoracic nerve: anatomy and func-
tional assessment. J Bone Joint Surg Am 2005, 87(5):993-998.
30. McComas AJ, Jorgensen PB, Upton AR: The neurapraxic lesion: a
clinical contribution to the study of trophic mechanisms. Can
J Neurol Sci 1974, 1(3):170-179.
31. Lundborg G, Dahlin LB: The pathophysiology of nerve compres-
sion. Hand Clin 1992, 8(2):215-227.
... Ultrasound of the LTN in the context of winged scapula provides a direct view of the nerve, a more accurate diagnostic approach and plays a role in selecting treatment option. In a study of 47 patients with winged scapula of various origins, Nath et al. showed that in 94% of patients for which nerve release was done, compression was clearly visible where the LTN emerges from the middle scalene muscle [17]. Thus, using ultrasound to identify the level of nerve injury could be an argument to take into account when determining the neurolysis indication. ...
Article
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Purpose: The purpose of this study was to analyze the potential of ultrasound with a high frequency probe (24-MHz) in the assessment of the long thoracic nerve (LTN) and describe ultrasonographic landmarks that can be used for standardization. Material and methods: Ultrasonography analysis of the LTN was done on 2 LTNs in a cadaver specimen and then on 30 LTNs in 15 healthy volunteers (12 men, 3 women; mean age, 28.8±3.8 [SD] years; age range: 24-39 years) by two independent radiologists (R1 and R2) using a 24-MHz probe. Interrater agreement was assessed using Kappa test (K) and intraclass correlation coefficient (ICC). Results: In the cadaver, dissection confirmed that the India ink was injected near the LTN in the middle scalene muscle. In volunteers, visibility of the LTN above the clavicle was highly reproducible for the branches arising from C5 (R1: 87% [26/30]; R2: 90% [27/30]; K=0.83) and from C6 (R1: 100% [30/30]; R2: 97% [29/30]; K=0.94). Where the nerve emerged from the middle scalene muscle, the mean diameter was 0.85±0.24 (SD) mm (range: 0.4-1.6mm) for R1 and 0.9±0.23 (SD) mm (range: 0.4-1.7mm) for R2 (ICC: 0.96; 95% CI: 0.92-0.98%). Along the thoracic wall, where LTN run along the lateral thoracic artery, the mean diameter was 0.83±0.19 (SD) mm (range: 0.5-1.27mm) for R1 and 0.89±0.21 (SD) mm (range: 0.6-1.2mm) for R2 (ICC: 0.86; 95% CI: 0.72-0.93%). Conclusion: The LTN can be analyzed with ultrasound using high-frequency probe by using the C5 and C6 roots, the middle scalene muscle above the clavicle and the lateral thoracic artery on the chest wall as landmarks.
... 1,2,4 Scapular winging due to paralysis of the serratus anterior muscle is accentuated by forward elevation and-particularly-by pushing against a wall, and the entire scapula is displaced more medially and superiorly. 2 The compensatory muscular activity required for shoulder stability induces secondary shoulder pain. 5 The diagnosis is often delayed, as the clinical presentation may mimic the symptoms of shoulder joint or rotator cuff pathology. Although physical therapy resolves the pain and improves the function of the arm, mild endurance defi cits and asymptomatic scapular winging may persist. ...
... We and other investigators have previously shown that decompression and neurolysis and nerve transfer have significantly improved both upper and lower extremity functional movements in brachial plexus injury (BPI), winging scapula, and foot drop patients [28][29][30][31][32]. We have used these surgical techniques successfully for the patient in this study report. ...
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BACKGROUND: Acute flaccid myelitis is an emerging polio-like illness mostly affecting young children, characterized by rapid onset of extremity weakness and paralysis in 1 or more limbs. Certain viruses, including enteroviruses such as EV-68, EV-71, poliovirus, and West Nile virus, can cause this disorder. The largest known outbreak of EVD68 in the United States was in the summer of 2014, causing severe respiratory illness and acute flaccid myelitis, mainly in young children. Furthermore, the US Centers for Disease Control and Prevention noted an increase in the number of patients with clinical symptoms of acute flaccid myelitis in 2018, and 134 confirmed cases by December 2018 were reported in the USA. CASE REPORT: The patient in our present study was a 5-year-old female who had significant weakness and paralysis in all 4 extremities due to acute flaccid myelitis. EV-D68 had caused this disorder in this patient in August 2014. Conservative management had not helped her condition. Specific areas of concern were both shoulders and biceps, and the femoral and peroneal nerves in both sides. Of these, the right shoulder function was the worst, at less than grade 3. The patient also had marked atrophy and weakness of the right quadricep muscles. The patient underwent surgical treatment and had steady improvements in all 4 extremity functional movements. CONCLUSIONS: We demonstrated that decompression, neurolysis, and nerve transfer surgical procedures can be used successfully to correct the paralyzed upper and lower extremity movements in acute flaccid myelitis patients.
... We 8-10 and other investigators [15][16][17] have demonstrated that surgical release of LTN and spinal accessory nerve 18 as a simple and effective treatment that significantly improves winging scapula and shoulder AROM, [8][9][10] which relieves pain and provides complete motor recovery, 15 when performed within the first 12 months of the paralysis. 15 In addition, in our previously published meta-analysis report, 8 we compared and analyzed the outcomes of long thoracic or spinal accessory nerve decompression and neurolysis with muscle transfer procedures and found that nerve surgical procedures are effective techniques in correcting winging scapula in comparison with muscle and tendon transfer operations. ...
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Introduction: In teens, athletes, in general, have been found to have shoulder pain and or winging scapula resulting from long thoracic or spinal accessory nerve injuries. Accident (fall) and stretch injuries due to overuse and poor sports techniques mainly cause these injuries that affect their upper extremity movements and functions. Here, we report a significant improvement in scapula winging and shoulder active range of motion in 16 teen patients after long thoracic nerve decompression and neurolysis. Patients and Methods: This was a retrospective study of 16 teen patients who had severe winging scapula and poor shoulder movements and function. Therefore, they underwent decompression and neurolysis of long thoracic nerve with us, between 2005 and 2016. The average patient age was 17 years (range, 14-19 years). These patients had been suffering from paralysis for an average of 15 months (range, 2-48 months). All patients underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm the long thoracic nerve injury. Results: Scapula winging was severe in 10 of 16 patients (63%), moderate in 2 patients (12%), and mild in 4 patients (25%) in our present study. Mean shoulder abduction (128°) and flexion (138°) were poor preoperatively. Shoulder abduction and flexion improved to 180° in 15 patients (94%) and good (120°) in 1 patient (6%) at least 2 months after surgery. In 11 patients (69%), the winged scapula was completely corrected postsurgically and it was less prominent in other 5 patients. Conclusion: Long thoracic nerve decompression and neurolysis significantly improved scapular winging in all 16 teen patients in our present study, producing “excellent” shoulder movements in 15 patients (94%) and “good” result in 1 patient (6%).
... This was a retrospective study of 16 teen patients who had winging scapula and therefore underwent LTN decompression between 2005 and 2016, as described in our previous publications. 9,10 The average patient age was 17 years (range, 14-19 years). Patients had been suffering from paralysis for an average of 1.3 years (range, 2-48 months). ...
Article
Introduction: In teens, athletes, in general, have been found to have shoulder pain and or winging scapula resulting from long thoracic or spinal accessory nerve injuries. Accident (fall) and stretch injuries due to overuse and poor sports techniques mainly cause these injuries that affect their upper extremity movements and functions. Here, we report a significant improvement in scapula winging and shoulder active range of motion in 16 teen patients after long thoracic nerve decompression and neurolysis. Patients and Methods: This was a retrospective study of 16 teen patients who had severe winging scapula and poor shoulder movements and function. Therefore, they underwent decompression and neurolysis of long thoracic nerve with us, between 2005 and 2016. The average patient age was 17 years (range, 14-19 years). These patients had been suffering from paralysis for an average of 15 months (range, 2-48 months). All patients underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm the long thoracic nerve injury. Results: Scapula winging was severe in 10 of 16 patients (63%), moderate in 2 patients (12%), and mild in 4 patients (25%) in our present study. Mean shoulder abduction (128°) and flexion (138°) were poor preoperatively. Shoulder abduction and flexion improved to 180° in 15 patients (94%) and good (120°) in 1 patient (6%) at least 2 months after surgery. In 11 patients (69%), the winged scapula was completely corrected postsurgically and it was less prominent in other 5 patients. Conclusion: Long thoracic nerve decompression and neurolysis significantly improved scapular winging in all 16 teen patients in our present study, producing “excellent” shoulder movements in 15 patients (94%) and “good” result in 1 patient (6%).
... traktion og tryk (f.eks. fra en tung rygsaek), penetrerende laesioner, lejringsskader under en operation eller iatrogen påvirkning under operationer i aksillen [25,26] såvel som ved neuritis pga. virale/toksiske eller andre systemiske neuropatier. ...
Article
A well-functioning scapula provides a stable base for the humerus and allows free motion of the arm through a smooth glide over the posterior thoracic wall. This is possible through intimate interaction between anatomy and muscles. This can be disturbed by painful conditions, nerve dysfunctions, over-/underperformance of muscles, anatomic variations and trauma. In this review, we describe anatomy, biomechanics and different pathologies of the scapula: muscular imbalances, nerve dysfunctions, snapping scapula, tumours and fractures. We discuss, how the different conditions are diagnosed and treated.
... Sports related injuries have been reported related to football, bowling, gymnastics, soccer and hockey (Martin and Fish 2008). Repeated weight lifting and throwing have also been reported to produce long thoracic nerve compression at the level of the middle scalene (Nath et al. 2007). Hester et al. (2000) describes a fascial sling which may entrap the long thoracic nerve at the level of the brachial plexus as the long thoracic nerve travels with the plexus through the axillary sheath (Olamakin and Karl 2016) Laulan et al. (2011) report that the long thoracic nerve may be compressed under branches of the thoracodorsal artery. ...
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Objectives The purpose of this study was to describe a new technique to record long thoracic nerve conduction velocity through the axilla as well as to assist in establishing normative values for latency and amplitude of the long thoracic nerve and to evaluate side to side, gender and BMI differences. Methods 26 healthy subjects (12 males/14 females) participated in the study with data collected bilaterally resulting in 52 limbs studied. Surface recording was over the serratus anterior muscle with the recording electrode located on the rib closest to a distance within a standardized range of 22 to 24 cm distal to the acromion. Stimulation was delivered at the mid axillary line, then again in the supraclavicular region. A caliper was used to measure the distance between the two stimulation sites in order to calculate the nerve conduction velocity. Results The normal value (mean + 2 SD) for distal latency is < 2.7 msec, while the normal value for velocity (mean- 2 SD) is > 61.0 m/s. Absolute amplitude values were not calculated. Side to side difference normal values for distal latency, amplitude and velocity are 0.7 msec, 70.3% and 8.5% respectively. A two way analysis of variance (ANOVA) revealed a significant gender and BMI difference in both distal (0.02) and proximal amplitude (0.05) means. There was no significant interaction between gender and BMI for latency or velocity values for either stimulation site. Conclusions The distal latency values are not significantly different from those reported previously, however long thoracic nerve conduction velocity has not been described before and would be an appropriate way to monitor velocity through the proximal portions of the brachial plexus. Men who qualified as overweight with a BMI greater than 25 demonstrated a larger amplitude when compared with average weight men and women. In contrast women with BMI greater than 25 demonstrated a much smaller amplitude when compared with overweight men and average weight men and women. Significance Absolute amplitude normal values are not reported as BMI may impact the ability to record an accurate amplitude for both men and women. Side to side differences may be a more appropriate way to assess amplitude.
Chapter
This chapter discusses dysfunction of the long thoracic nerve, its clinical presentation, causes, investigation and management.
Chapter
Please confirm if hierarchy of section headings is correctly identified and given.
Article
Scapular winging is a painful and debilitating condition. The composite scapular motion of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. The most common causes reported in the literature for scapular winging are dysfunction of the serratus anterior from long thoracic nerve injury causing medial winging or dysfunction of the trapezius from spinal accessory nerve injury causing lateral winging. Most reviews and teaching focus on these etiologies. However, acute traumatic tears of the serratus anterior, trapezius, and rhomboids off of the scapula are important and under-recognized causes of scapular winging and dysfunction. This article will review the relevant anatomy, etiology, clinical evaluation, diagnostic testing, and treatment of scapular winging. It will also discuss the differences in diagnosis and management between scapular winging arising from neurogenic causes and traumatic muscular detachment.
Article
Unusual winging of the scapula is a deformity which is fairly well recognized as secondary in some instances to paralysis of the serratus magnus muscle. Description of this syndrome was first made by Velpeau¹ in 1825. Sir Charles Bell² in 1827 described the nerve supply of the serratus magnus muscle. The condition has been described by various writers since the time of Velpeau and Bell, notably by Marchessaux³ in 1840 and by Duchenne¹ in 1867. Several methods of treatment have been suggested from time to time and several operative procedures have been offered. In order to estimate the relative incidence of this condition and to aid in our ability to prognosticate the end result in an instance of the disease newly seen, this study was undertaken. The function of the serratus magnus muscle is mainly to aid in fixing the scapula to the thorax when the
Article
The basic pathophysiology of an acute and chronic nerve compression lesion is complex. Compression of a peripheral nerve induces marked changes in intraneural microcirculation and nerve fiber structure, impairment of axonal transport, and alterations in vascular permeability, with edema formation and deterioration of nerve function. The peripheral nerves of subjects with underlying neuropathies are more susceptible to compression injury.
Article
Injury to the long thoracic nerve causing paralysis or weakness of the serratus anterior muscle can be disabling. Patients with serratus palsy may present with pain, weakness, limitation of shoulder elevation, and scapular winging with medial translation of the scapula, rotation of the inferior angle toward the midline, and prominence of the vertebral border. Long thoracic nerve dysfunction may result from trauma or may occur without injury. Fortunately, most patients experience a return of serratus anterior function with conservative treatment, but recovery may take as many as 2 years. Bracing often is tolerated poorly. Patients with severe symptoms in whom 12 months of conservative treatment has failed may benefit from surgical reconstruction. Although many surgical procedures have been described, the current preferred treatment is transfer of the sternal head of the pectoralis major tendon to the inferior angle of the scapula reinforced with fascia or tendon autograft. Many series have shown good to excellent results, with consistent improvement in function, elimination of winging, and reduction of pain.
Article
Ten cases of isolated, complete paralysis of the serratus anterior muscle were diagnosed in young athletes during a three-year period. One patient had recurrent partial paralysis of the serratus anterior muscle, the first such case reported. From studies on cadavera and clinical observations, we concluded that paralysis of the serratus anterior muscle results from a traction injury to the long thoracic nerve of Bell. Since full recovery usually occurs in an average of nine months, surgical methods of treatment should be reserved for patients in whom function fails to return after a two-year period. Non-strenuous use of the involved extremity with avoidance of the precipitating activity, followed by exercises designed to maintain the range of motion of the shoulder and to increase the strength of associated muscles, is advocated for treatment of acute or repetitive injuries to the long thoracic nerve of Bell.
Article
Fourteen patients with traumatic winging of the scapula were reviewed, all of whom had had injuries producing sudden depression of the shoulder girdle from either a direct blow to the top of the shoulder or downward traction on the arm. The diagnosis was commonly missed for a considerable interval. Seven patients recovered spontaneously within six months of injury. Three of the other seven patients were treated by reattachment of the insertion of the sternal portion of the pectoralis major muscle via a fascia lata graft to the lower pole of the scapula. In one of these patients a reoperation was needed, but all three ultimately recovered satisfactory function of the shoulder. Anatomical studies suggested that the injury results from compression of the long thoracic nerve against the second rib and not from entrapment of the nerve by the scalenus medius muscle.
Article
Four cases of long thoracic mononeuropathy associated with sports participation are presented. Each patient developed shoulder pain or dysfunction after an acute event or vigorous activity, and demonstrated scapular winging consistent with serratus anterior weakness. The diagnosis was confirmed with electromyography in each case. It is suggested that the athletic activity caused a stretch injury to the long thoracic nerve. Conservative management, consisting of range of motion exercises for the shoulder and strengthening of the serratus anterior muscle, resulted in a favorable outcome in all patients.
Article
We report the transfer of the sternal part of the pectoralis major to the lower pole of the scapula in 15 patients with winged scapula. At follow-up after 1 to 16 years nine had a satisfactory result and were gainfully employed, though in four of these re-operation had been necessary. Two patients had fair results; the transplant functioned, but they had limited voluntary control. Four were failures: two had had paralysis of other shoulder girdle muscles in addition to the serratus anterior. The indications for the operation are discussed.
Article
The incidence of long thoracic nerve palsy after radical mastectomy has been documented to be approximately 10%. No cases have been reported after the more recent treatment for breast cancer, lumpectomy with axillary dissection. This more recent surgical procedure is customarily followed by aggressive radiation therapy to the remaining breast tissue. This is the first case report of a patient with radiation-induced long thoracic nerve palsy. The patient was a young woman who underwent left breast quadrantectomy and axillary dissection for breast cancer. After radiation therapy, she had isolated left long thoracic nerve palsy. The diagnosis was confirmed by electrodiagnostic studies. Almost full recovery occurred after 5 months.