Supraclavicular Long Thoracic Nerve Decompression for Traumatic Scapular Winging

Abstract

Scapular winging resulting from long thoracic nerve palsy is a painful, disabling condition often associated with periscapular weakness and decreased active shoulder range of motion. Observation, therapy, and symptomatic treatment have customarily been the recommended treatment, often with disappointing results. Recently, encouraging results have been reported following decompression of the long thoracic nerve. Six patients who underwent a supraclavicular long thoracic nerve decompression from 2008 to 2010 for painful posttraumatic scapular winging were identified retrospectively. Four males and two females with a mean age of 28 years at the time of surgery were treated for an average of 9 months following injury. Mean follow-up was 16 months following surgery. All patients had decreased pain, disability, and scapular winging, and improved shoulder range of motion. One patient had recurrence following a second injury. This procedure has resulted in good outcomes without the morbidity associated with tendon or nerve transfer.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy

“…The proposed clinical decision-making algorithm presented in this article takes into consideration the work of other surgeons by including both proximal and chest-level decompression, as well as advances in nerve transfers to improve function in this patient population. 4,5,10,19,20,23,24 Further evaluation and refinement of the algorithm is ongoing as we treat more patients with a multilevel surgical approach.…”

“…2,7,16 The optimal surgical treatment, however, would preserve the natural serratus anterior motor function. This can be achieved with long thoracic nerve decompression (in the setting of conduction block) 4,[10][11][12][13][14]20,22 or by nerve transfers that reinnervate the serratus anterior muscle. 15,19,23,24 Nerve transfers allow nearby healthy axons to reinnervate the injured serratus anterior muscle close to the motor endplates and prior to atrophy.…”

“…15 The second approach to the long thoracic nerve, the proximal or supraclavicular approach, has been published by several authors. 4,13,14,20 Disa et al first published their results after supraclavicular decompression of the long thoracic nerve in 4 patients. 4 Scapular winging was resolved in all patients.…”

“…Subsequently, Nath and Schippert published similar findings after supraclavicular decompression. 13,14,20 The third approach to the long thoracic nerve is a 2-level approach. Tomaino reported a medial pectoral to long thoracic nerve transfer in 1 patient with an isolated long thoracic nerve palsy.…”

“…Subsequently, Nath and Schippert published similar findings after supraclavicular decompression. 13,14,20…”