Surgical technique
Open Anterior Release of the Superior Transverse Scapular Ligament for Decompression of the Suprascapular Nerve During Brachial Plexus Surgery

https://doi.org/10.1016/j.jhsa.2016.03.005Get rights and content

Reconstruction of the suprascapular nerve (SSN) after brachial plexus injury often involves nerve grafting or a nerve transfer. To restore shoulder abduction and external rotation, a branch of the spinal accessory nerve is commonly transferred to the SSN. To allow reinnervation of the SSN, any potential compression points should be released to prevent a possible double crush syndrome. For that reason, the authors perform a release of the superior transverse scapular ligament at the suprascapular notch in all patients undergoing reconstruction of the upper trunk of the brachial plexus. Performing the release through a standard anterior open supraclavicular approach to the brachial plexus avoids the need for an additional posterior incision or arthroscopic procedure.

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Indications

Many patients will recover spontaneously after a postganglionic neuropraxia or axonotmetic injury to the upper trunk of the brachial plexus. However, in patients with more severe injuries, such as a neuroma-in-continuity or neurotmesis, surgical intervention is indicated. If the physical examination, diagnostic imaging, and electrodiagnostic testing suggest a preganglionic injury or a neurotmetic injury, a nerve transfer is performed to coapt a branch of the spinal accessory nerve to the SSN.

To

Contraindications

If a patient presents in a delayed (9–12 mo) or late (over 12 mo) manner after injury, the likelihood of success with a nerve transfer is greatly diminished because of prolonged denervation of the target muscles and degeneration of the motor end plates. In these cases, nerve transfers can still be performed with a guarded prognosis up to approximately 12 months after injury for adult patients or up to 18 months after injury for pediatric patients. Alternatively, in these cases, tendon transfers

Surgical Anatomy

The SSN originates from the upper trunk of the brachial plexus, 2 to 3 cm above the clavicle. It is formed by the C5 and C6 spinal nerves4 at Erb’s point, just proximal to the division of the upper trunk into anterior and posterior divisions. The SSN runs superior to the brachial plexus. It passes caudally and posteriorly under the omohyoid and trapezius muscles, lateral to the scalenus medius, and through the suprascapular notch beneath the STSL.5 The SSN then passes through the supraspinatus

Surgical Technique

Most commonly, SSN decompression is performed via an open posterior approach8 or arthroscopically.9 We prefer to release the STSL at the suprascapular notch through an open anterior approach during brachial plexus reconstruction.

A standard supraclavicular approach to the brachial plexus is used.10 The patient is positioned supine with the neck turned to the contralateral side, away from the site of injury. The ipsilateral arm is positioned on an arm board and is fully prepped to allow

Postoperative Management

The patient's affected arm is immobilized in a sling and swath for 3 weeks after surgery. After 3 weeks, the immobilization is discontinued and the patient gradually increases range of motion exercises for the shoulder and elbow over the next 2 weeks under the guidance of a physiotherapist. Range of motion exercises are performed by the patient for all joints of the affected limb to maintain joint suppleness from the time of injury until reinnervation occurs, with a brief 3-week period of

Pearls and Pitfalls

When first learning to release the STSL, there is a tendency to explore too medially. Staying lateral can help facilitate this step of the operation.

When releasing the ligament from the anterior approach, it is important to continue to dissect deep to identify the ligament; it is found more posteriorly than one might initially expect.

Complications

The suprascapular artery typically travels above the SSN, passing superficially to the suprascapular notch and the STSL. Occasionally, the artery may travel with the SSN through the notch. The SSN, the suprascapualar artery, or both structures can be marked with vessel loops before ligament division. A headlight can be worn to improve illumination. If the artery is damaged during division of the STSL, bleeding can be difficult to control if the vessel retracts posteriorly. Careful dissection to

Discussion

Anterior open release of the STSL at the suprascapular notch allows decompression of the SSN at this common point of entrapment. The release adds approximately 5 minutes to the overall surgical time, is well visualized via an anterior supraclavicular approach, and is associated with minimal morbidity. It alleviates the concern of a possible double crush syndrome after nerve grafting or nerve transfer to the SSN. After SSN reconstruction, supraspinatus and infraspinatus muscle function,

Acknowledgments

The authors thank Tracy Xiang for contributions in the artistic rendering of the figures.

References (10)

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