Full exposure of the axillary and suprascapular nerves

Transfer of the Lower Trapezius as a Surgical Treatment for Combined Injuries to the Suprascapular and Axillary Nerves: A Case Report

Introduction:

Combined injuries to the suprascapular and axillary nerves can result in irreversible dysfunction of the shoulder joint, with reconstruction of shoulder external rotation being an essential component of an effective treatment. Transfer of the lower portion of the trapezius to the infraspinatus has been used, with success, to regain external rotation of the shoulder.

Case Report:

We present the case of a 45-year-old man with a chronic traumatic injury of the suprascapular and axillary nerves. In addition to a surgical transfer of the lower trapezius to the infraspinatus, we included a transfer of the latissimus dorsi and teres major, with a tensor fasciaelatae graft to the supraspinatus tendon insertion, to improve the muscular strength of shoulder elevation and abduction, as well as to improve external rotation. At 24-month post-surgery, the patient had recovered 170° of shoulder elevation, 170° of abduction, and 60° of external rotation.

Conclusion:

Early recovery after surgery was achieved, with excellent improvement of the range of shoulder motion. We report the transfer of the lower trapezius to the infraspinatus might provide a useful salvage procedure for patients with poor functional prognosis of a chronic suprascapular nerve injury.

Radial to axillary nerve neurotization for brachial plexus injury in children: a combined case series

OBJECT

Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed.

METHODS

A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used.

RESULTS

Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years).

CONCLUSIONS

Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.

Anterior deltopectoral approach for axillary nerve neurotisation

PURPOSE

To report outcome of axillary nerve neurotisation for brachial plexus injury through the anterior deltopectoral approach.

METHODS

Nine men aged 20 to 52 (mean, 27.8) years with brachial plexus injury underwent axillary nerve neurotisation through the anterior deltopectoral approach. Three of the patients had complete avulsion of C5-T1 nerve roots. The remaining 6 patients had brachial plexus injury of C5-C6 nerve roots, with associated subluxation of the glenohumeral joint, atrophy of the supraspinatus, deltoid and elbow flexors. They had no active shoulder abduction, external rotation, and elbow flexion. The pectoralis major and minor were cut and/or retracted to expose the underlying infraclavicular plexus. The axillary nerve was identified with respect to the available donor nerves (long head of triceps branch, thoracodorsal nerve, and medial pectoral nerve). In addition to the axillary nerve neurotisation, each patient had a spinal accessory nerve transferred to the suprascapular nerve for better shoulder animation.

RESULTS

Patients were followed up for 24 to 30 (mean, 26) months. In the 3 patients with C5-T1 nerve root injuries, the mean active abduction and external rotation were 63 and 20 degrees, respectively, whereas the mean abduction strength was M3 (motion against gravity). In the 6 patients with C5-C6 nerve root injuries, the mean active abduction and external rotation were 133 and 65 degrees, respectively, whereas the strength of the deltoids and triceps was M5 (normal) in all. In 4 patients with the pectoralis major cut and repaired, the muscle regained normal strength.

CONCLUSION

The anterior deltopectoral approach enabled easy access to all available donor nerves for axillary nerve neurotisation and achieved good outcomes.

Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries

Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5-T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.4° abduction at follow up of average 34.6 months. The shoulder recovery was good with 130° abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5-T1 avulsion injuries patients with an average of 64° shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries.

Axillary nerve repair in 99 patients with 101 stretch injuries

Object. The purpose of this paper was to analyze outcomes in patients at the Louisiana State University Health Sciences Center (LSUHSC) who presented with contusion—stretch injuries to the axillary nerve. These injuries resulted from shoulder injury either with or without fracture/dislocation. Although recovery of deltoid function can occur spontaneously, this was not always the case.

Methods. Severe deficits persisting for several months led the patients to undergo surgery. Operative categories included isolated axillary palsy (56 procedures), combined axillary and suprascapular palsies (11 procedures), axillary and radial palsies (14 procedures), and axillary palsy with another deficit, usually infraclavicular plexus loss (20 procedures). Deltoid function was evaluated pre- and postoperatively by applying the LSUHSC grading system. An anterior infraclavicular approach was usually followed during surgery, but in three patients an additional posterior approach was used.

Axillary lesions usually began in the proximal portion of the posterior cord. Although several patients had distraction of the nerve, lesions in continuity were found in more than 90% of cases. Intraoperative nerve action potential (NAP) recordings were performed to determine the need for resection. Most repairs were made using grafts, although in three patients with relatively focal lesions suture was used.

When an NAP was recorded across the lesion and neurolysis was performed, recovery was judged to be a mean Grade 4 according to the LSUHSC in 30 cases. Recovery following suture repairs was a mean Grade 3.8, whereas recovery after 66 graft repairs was a mean Grade 3.7. In cases in which suprascapular palsies were associated with axillary injuries, the former recovered but the latter did not necessarily do so without surgery. If the radial nerve was also injured, recovery of the triceps and brachioradialis muscles and wrist extension was usually obtained, but it was far more difficult to reverse the loss of finger and thumb extension. Although few in number, complications did occur and they are important.

Conclusions. Operative exploration of axillary contusion—stretch lesions is worthwhile in carefully selected cases. If indicated by inspection and intraoperative electrical studies, nerve repair can lead to useful function.

[Surgical management of traumatic lesions of the axillary nerve: 83 cases]

Axillary nerve injuries still go undiagnosed far too often despite their frequency. However the quality of the outcome depends on expert management and prompt surgery. To optimise the latter, we re-examined 83 operated cases of traumatic lesions of the axillary nerve. We analysed the neurological and functional recovery of these patients by means of a follow-up evaluation at 6 years postop. The results were classified by age, mechanism of injury, delay to surgery and the presence or otherwise of associated neurological or osteo-articular lesions. We highlighted that a high index of suspicion ought to exist in all cases of trauma to the shoulder in a patient aged more than 40, any injury associated with palsy of the long head of triceps and in the case of an osteo-articular lesion due to high-velocity trauma. A complete lack of shoulder abduction must always prompt a search for a lesion of the axillary nerve as well as a suprascapular nerve palsy or rotator cuff lesion. There are few literature reports of surgical management of this particular nerve injury. An early MRI scan as part of the management should improve results by a reduction in the delay before surgery. As a result of our investigation we conclude that a lesion of the axillary nerve without signs of recovery at 3 months should be referred to a centre specialized in peripheral nerve surgery.