Although minimally invasive techniques are typically tried before operative treatments, some patients may ultimately need surgery to relieve their shoulder pain. 29 Despite the . The suprascapular nerve is a peripheral nerve of the shoulder and arm. It receives nerve fibers that originate in the nerve roots C5 and C6 (and sometimes C4). Arthroscopic suprascapular nerve decompression: Indications and surgical technique. Ergnen T, Beyaz SG. Treatment varies depending on the location and etiology of entrapment, which can be described as compressive or traction lesions. The patient can present with point tenderness at the suprascapular or spinoglenoid notch, depending on the location of the injury. [8], In rare cases, systemic conditions like systemic lupus erthymatosus and rheumatoid arthritis can result in suprascapular nerve palsy. The ulnar nerve can become entrapped at the wrist in the Guyon canal, which is a fibro-osseous tunnel bordered by the hook of hamate and the pisiform (Figure 5).44 Occupational causes include activities that put pressure on the volar surface of the wrist, such as operating a jackhammer, cycling (i.e., cyclist's palsy), or weight-lifting. Radial Nerve. After a distance of about 2/3 of the clavicle has been reached, the incision is extended posteriorly to the spine of the scapula, perpendicular to the clavicle.37 The origin of the SSN on the upper trunk of the brachial plexus can be found under the posterior belly of the omohyoid. Endoscopy allows the nerve to be seen clearly, but with that comes a more invasive process. Federal government websites often end in .gov or .mil. However, surgery becomes the primary treatment modality when those fail, particularly if the patient has an identifiable and reversible nerve compression cause.10 In general, there are two modalities to treat SNES arthroscopic decompression and open decompression. If an X-ray cannot visualize the suprascapular notch, CT can be used for higher resolution assessment.9, MRI is supported in the literature as the ideal imaging modality for analyzing nerves and lesions of the nervous system.12 MRI can visualize vascular and bony abnormalities, as well as soft tissue lesions and ganglion cysts.7,8 Sotereanos et al. Clinical outcomes of suprascapular nerve decompression: a systematic review. Other causes include fractures, lipomas, ganglion cysts, and systemic diseases (e.g., diabetes mellitus, rheumatoid arthritis, hypothyroidism) that cause localized edema.38,45, Findings of ulnar nerve entrapment include atrophy of the hypothenar, lumbrical, and interosseous muscles.38 Motor dysfunction is less common because of the deep nature of the motor branch, but it results in weakness of abduction and adduction of the fingers as well as the pincer mechanism.46 The Froment sign (Figure 6) can be observed with ulnar nerve entrapment at any anatomic location, but it is more common when injury occurs to the deep branch at the wrist.38,46 Sensory disturbances occur over the hypothenar eminence, the fifth digit, and half of the fourth digit.38, The primary diagnostic tests for evaluation of nerve injury and entrapment include electrodiagnostic tests, subdivided into nerve conduction studies and electromyography (EMG), and imaging, which includes magnetic resonance imaging and ultrasonography. Physical exams should include an inspection of the shoulder. The suprascapular nerve stretch test (Fig. The course of the nerve through narrow osseoligamentous structures renders it susceptible to compressional and traction injuries at the suprascapular and spinoglenoid notches. J Shoulder Elbow Surg. Treatment of Labral Tears with Associated Spinoglenoid Cysts without Cyst Decompression. A meta-analysis. . The suprascapular nerve is a mixed (sensory and motor) nerve that branches from the upper trunk of the brachial plexus. It is derived from the ventral rami of cervical nerves C5-C6. When there is any sort of disruption within the suprascapular nerve, the muscles it supplies (supraspinatus and infraspinatus) lose their innervation, which causes the signs and symptoms seen with a suprascapular nerve palsy. Its nerve roots are C5 and C6. Shupeck M, Onofrio BM. Aguirre K, Mudreac A. Anatomy, Shoulder and Upper Limb, Shoulder. Peruto CM, Ciccotti MG, Cohen SB. Author disclosure: No relevant financial affiliations. This is common in athletes involved in repeated overhead activities. While the underlying etiology of SSN neuropathy remains elusive, multiple compression, traction, and inflammatory pathophysiologic cascades have been previously considered. Currently, there is no definitive best position, and it is up to the surgeon based on their experience and training.2224 Arthroscopic decompression surgery is considered a safe and effective treatment modality for suprascapular nerve entrapment.25 In one review, researchers found that out of 269 operations, 2 reported complications superficial infection and adhesive capsulitis.26 The few large retrospective analyses of arthroscopic decompression outcomes show that most patients included in the study parameters have a statistically significant improvement in various outcome measures, including a range of motion, shoulder pain, and strength.2629, The following arthroscopic decompression surgical description will be based on the beach-chair position. Surgical decompression of the suprascapular nerve is performed along with repair of the contributing shoulder pathology (if present).[7]. Fabre T, Piton C, Leclouerec G, Gervais-Delion F, Durandeau A. Entrapment of the suprascapular nerve. Acta Orthop Scand. The suprascapular nerve is a mixed nerve of the upper limb. Electrodiagnostic testing should be used as an adjunct to physical examination and imaging to help confirm the diagnosis of peripheral nerve injury, establish the severity of injury, and monitor progression of nerve damage. Radiation to the lateral arm, neck, or anterior thorax has also been observed. If non-operative treatment fails to relieve suprascapular neuropathy, minimally invasive treatment options exist, such as suprascapular nerve injection, neurostimulation, cryoneurolysis, and pulsed radiofrequency. This trauma can be a direct force or indirectly through damage to the vascular supply to the nerve. The rest of the stimulator can be attached to different body areas, such as the thorax and buttocks. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. Corresponding Author Christopher Lee, MD St.Joseph Hospital & Medical Center Department of Internal Medicine 500 West Thomas Rd Phoenix, AZ 85013 Chrislee0621@gmail.com. Clin Anat. Supraspinatus atrophy is best appreciated by examining the superior border of the patient shoulders from behind, noting any bilateral asymmetry.7 Infraspinatus atrophy can be best assessed while looking down at the scapula with the patient seated closely in front of the physician. official website and that any information you provide is encrypted [3], Trauma to the shoulder resulting from fractures of scapula, clavicle and proximal humerus can significantly damage the suprascapular nerve. Diagnosing Suprascapular Neuropathy in Patients With Shoulder [ 41] Spinoglenoid notch cysts can be identified with ultrasound,. Carpal tunnel syndrome is the most common with a prevalence of 3% in the general population (15% in the workforce).1 Cubital tunnel syndrome is also relatively common, with one U.S. metropolitan area reporting a prevalence of 1.8% to 5.9%.2 Overall prevalence of peripheral neuropathies in the general population is unclear. The anterior interosseous nerve is the motor-only nerve for deep muscles of the forearm. (ICCs) for test-retest reliability of goniometric AROM measurements of the shoulder have been estimated to be .64 to .69. See permissionsforcopyrightquestions and/or permission requests. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Further nerve damage can cause extensive muscle atrophy and weakness that may not be reversible, so non-operative treatment should be closely monitored to ensure that surgery is not indicated.10. Suprascapular Nerve Decompression With Rotator Cuff - ScienceDirect Copyright 2023 American Academy of Family Physicians. Suprascapular Artery: Anatomy, Function, and Significance - Verywell Health Suprascapular nerve - Wikipedia Spinal Accessory Nerve. Iatrogenic nerve injuries in shoulder surgery. Peripheral Nerve Entrapment and Injury in the Upper Extremity [7], Non-steroidal anti-inflammatory drugs and anaesthetic injections (nerve block) are used to conservatively manage the pain. Proximally, middle to distal third humeral shaft fractures are the most common cause of traumatic injury.40 The most common compressive cause results from sustained pressure on the posterior arm at the location of the radial groove, where the nerve lies directly on periosteum and is not protected by muscle. government site. Treatment of suprascapular nerve compression at the suprascapular notch requires decompression of a cyst when present. Cross-body adduction and internal rotation may increase pain. The opinions and assertions contained herein are the private views of the authors and are not to be construed as the official policy or position of the U.S. Air Force, the Department of Defense, or the U.S. government. It is noted that injuries at the location of the suprascapular notch tend to be more severe in presentation than the spinoglenoid notch pathologies. Open Anterior Release of the Superior Transverse Scapular Ligament for Decompression of the Suprascapular Nerve DuringBrachial Plexus Surgery. Using anesthetic medications with steroids such as bupivacaine and methylprednisolone acetate can be useful in managing neuropathy.11 Most injections are performed at the area of the suprascapular notch, with an ultrasound-guided probe to assist in capturing the nerve instead of the vascular structures nearby. Anterior Supraclavicular Approach to the Brachial Plexus. The suprascapular nerve can be identified under ultrasound, and can be used to screen for parascapular ganglia or masses. In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and includes patient education, relative rest, and activity modification. If SN blocks do not provide therapeutic relief, another method would include neurostimulation. Ganglion cysts may protrude in the infraspinous fossa, thereby compressing the SN after innervating the supraspinatus, thereby only causing atrophy of the infraspinatus. The long thoracic nerve is vulnerable to traction injury at its nerve roots located at the middle scalene.20 Other mechanisms of injury include direct blows to the nerve as it exits the pectoralis muscle at the fourth or fifth rib, repetitive stretching (e.g., throwing a baseball, serving a volleyball), or iatrogenic damage (e.g., during a radical mastectomy).20,21 Injury to this nerve is the most common cause of scapular winging.20,21. The patient will be placed supine on the operating table, with the back at 60 to 90 degrees, head secured, and the operative arm resting on a padded Mayo stand or in an arm-positioning device.30 Often, traction is placed on the arm to distract the humeral head from the acromion and better visualize the transverse scapular notch.18,31. sharing sensitive information, make sure youre on a federal https://www.youtube.com/watch?v=WnTVWnTFymA, Expert opinion and clinical practice guideline, Disease-oriented evidence, expert opinion, Patient-oriented evidence in systematic review, expert opinion, randomized controlled trial, case series, Cochrane review, Flexor carpi radialis, flexor carpi ulnaris, Extensor carpi radialis brevis, extensor carpi radialis longus, Flexor digitorum profundus, flexor digitorum superficialis, Extensor digitorum, extensor indicis, extensor digiti minimi, Lateral shoulder region paresthesia, shoulder movement weakness in all planes, difficulty with overhead activities, Physical therapy, monitoring recovery with serial examination vs. electromyography and nerve conduction studies, No electrophysiologic improvement after 3 to 4 months of conservative treatment, Physical therapy, avoidance of aggravating activities, Penetrating trauma resulting in nerve transection, no improvement after 18 to 24 months of conservative treatment, Median nerve at the elbow or forearm anterior interosseous nerve branch, No pain; thumb weakness; unable to make OK sign; if patient is unable to make OK sign but has sensory deficits, consider a proximal median nerve injury, Flexor pollicis longus, flexor digitorum profundus, Space-occupying lesion, no improvement after 3 to 4 months of conservative treatment, Median nerve at the elbow (pronator syndrome), Aching pain in the proximal volar forearm; palm, thumb, or index finger paresthesia, Thumb, index and middle fingers, and radial side of ring finger, Varied but may include weakened grip strength, Avoidance of aggravating activities, rest, trial of NSAIDs, steroid injection, Median nerve at the wrist (carpal tunnel syndrome), Pain in the wrist and hand, occasionally radiating to the forearm; paresthesia in the first three digits; weak grip strength due to weakness of thumb abduction and opposition resulting in difficulty with tasks such as opening doors; thenar eminence atrophy in advanced disease, Abductor pollicis brevis, first or second lumbrical, Splinting, physical therapy, yoga, and acupuncture for the short term, Early surgery: evidence of moderate to severe median nerve damage on electromyography, Radial nerve at the elbow (posterior interosseous nerve), Weakness in finger extension, weakness of ulnar deviation, wrist extension can be maintained (because of sparing of extensor carpi radialis longus), pain is rare, Extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis, supinator, Rest, activity modification, splinting, stretching, NSAIDs; steroid injection can be therapeutic and diagnostic, Significant motor weakness is present, no improvement after 3 to 4 months of conservative treatment, Radial nerve at the elbow (superficial radial nerve), Pain 3 cm to 4 cm distal to lateral epicondyle, often causes pain at night, Radial nerve at the spiral groove (radial neuropathy [Saturday night palsy]), Weakness in finger and wrist extension, paresthesia of forearm and hand, Brachioradialis (elbow flexion); extensor carpi radialis longus; branches distally include superficial radial nerve and posterior interosseous nerve, which can also be affected, Avoidance of repeat compression, physical therapy nearly 100% effective at 6 months based on small observational study, cock-up splint for normal hand function, Fracture of the humerus resulting in nerve compromise, Radial nerve at the wrist (handcuff neuropathy), Pain and paresthesia of the hand; if motor findings are present, consider a higher radial nerve lesion, Eliminate external compression, steroid injection, Surgery rarely required, no improvement after 3 to 4 months of conservative treatment, Weakness in shoulder abduction (> 180 degrees), scapular winging, Trapezius (shoulder shrug) and sternocleidomastoid, Transient paresthesia and weakness from neck or shoulder traveling down the arm, Evidence of anatomic abnormalities (foraminal stenosis) predisposing to repeat injury, Weakness in shoulder flexion, abduction, external rotation, Supraspinatus (shoulder abduction) and infraspinatus (external rotation of the shoulder), Physical therapy to maintain range of motion, activity modification to limit overhead activities, Early surgery for space-occupying lesion (i.e., ganglion cyst), Ulnar nerve at the elbow (cubital tunnel syndrome), Pain, paresthesia, numbness in the fourth and fifth digits; weakness in finger abduction, thumb abduction, and thumb-index pincer; positive Tinel sign at the cubital tunnel; weak wrist flexion not due to the median nerve innervation of flexor carpi radialis and flexor digitorum superficialis, which compensate for loss of flexor carpi ulnaris, Hypothenar eminence, fifth finger, and ulnar side of fourth finger, Intrinsic hand muscles, flexor carpi ulnaris, Activity modification, NSAIDs, elbow pads, physical therapy, night splinting in 45 degrees of extension with neutral forearm, steroid injection, No improvement after 3 to 4 months of conservative treatment, Ulnar nerve at the wrist (cyclist's palsy), Atrophy of intrinsic hand muscles (hypothenar, lumbrical, interosseous); pain, paresthesia, numbness of the hand; positive Froment sign (, Patient education, activity modification, padding on handlebars, splinting, physical therapy, and NSAIDs; steroid injection not indicated because causes are usually related to structural or mechanical abnormality; drain ganglion cyst if this is the cause, Management of anatomic cause (e.g., ganglion cyst, lipoma, hook of hamate fracture), no improvement after 2 to 4 months of conservative treatment, Fat-suppressed highly T2-weighted images demonstrate nerve pathology the best, Carpal tunnel syndrome: evaluate persistent nerve distress and/or inadequate surgical release, Posterior interosseous nerve: thickened superficial head of supinator (most common entrapment point of posterior interosseous nerve), denervation of the supinator muscle, Cubital tunnel syndrome: perform with extended elbow, shows nerve enlargement, external compression by loose bodies or space-occupying lesions, and regional inflammatory and denervation changes, Use high-resolution (15 to 18 MHz) transducers, Carpal tunnel syndrome: assess nerve thickness within the carpal tunnel and pronator quadratus for a change greater than 2 mm, Posterior interosseous nerve: superficial nerve is easy to visualize, enlargement and hypoechogenicity of the nerve can be seen, Cubital tunnel syndrome: nerve appears enlarged and hypoechoic, loss of normal fibrillar appearance; comparison of cross section to contralateral side, shows dynamic snapping of nerve. Clinical outcomes of suprascapular nerve decompression: a systematic review. When positive, it will induce paresthesia and pain.22. The suprascapular nerve's roots emerge from the fifth and sixth cervical vertebrae (C5 and C6) in your neck. The suprascapular nerve is a mixed nerve, meaning that it gives both sensory & motor supply to the suprascapular region. Bhatia S, Chalmers PN, Yanke AB, Romeo AA, Verma NN. 2011 Mar;20(2 Suppl):S9-13. . . Full range of motion should be maintained at the shoulder to prevent adhesive capsulitis. It is also useful for the diagnosis and treatment of chronic shoulder pain secondary to bursitis, arthritis, degenerative joint and rotator cuff disease. Georgetown University School of Medicine, Washington DC, 2 Suprascapular nerve palsy is a relatively uncommon cause of shoulder pain and dysfunction, but can lead to significant disability. 7,9 It also allows the physician . Suprascapular nerve injury is experiencing an increase in clinical significance due to its role in shoulder pain and upper limb weakness. Chronic shoulder pain has plagued numerous patients throughout the world, and each person is unique in regards to their shoulder anatomy, physiology, pain response, and pathology. The first is posterior to the clavicle, occurring with clavicular fractures. [7], The most common clinical sign of suprascapular nerve palsy is atrophy of the supraspinatus and/or infraspinatus muscles. Suprascapular Nerve. A detailed history and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies can help confirm the clinical diagnosis and is indicated if conservative management is ineffective. Subtle weakness can be detected by attempting to break apart the thumb and second digit while the patient makes an OK sign22 (see a video about the anterior interosseous nerve). With findings of severe weakness or multiple nerve involvement, imaging should be performed immediately; otherwise, it can be initiated after six to eight weeks of conservative treatment.4750 A summary of imaging indications is provided in Table 3.4749, Electrodiagnostic testing is helpful to confirm the diagnosis, determine severity, and monitor progression of nerve damage.50 This can be especially helpful in presurgical planning for more common nerve entrapments, such as carpal tunnel syndrome and cubital tunnel syndrome.51,52 Nerve conduction studies evaluate the speed and time of conduction across the nerve; EMG measures the tested muscle's response to stimulation.50 Changes to both nerve conduction studies and EMG will occur depending on the chronicity and degree of injury, so they should be ordered simultaneously.5052 The ability of EMG or nerve conduction studies to detect nerve injury is variable and requires subjective interpretation; they are best used as an adjunct to physical examination and imaging.50, Magnetic resonance imaging and ultrasonography are used for evaluating deeper soft tissue pathology and bony abnormality compressing a nerve or for increased signal and nerve thickness indicative of nerve injury.40,53 Magnetic resonance imaging can identify local muscular atrophy consistent with denervation.53 Ultrasonography can evaluate for a variety of changes that occur in peripheral nerve entrapment syndromes.47,48 A useful point-of-care application of ultrasonography is determining specific sites of entrapment by compression with the ultrasonography transducer to recreate symptoms.47,48 Specifically, ultrasonography is helpful in the diagnosis of carpal tunnel syndrome; one meta-analysis found that a cross-sectional area of the median nerve at the carpal tunnel inlet of 9 mm2 or more is 87.3% sensitive and 83.3% specific for carpal tunnel syndrome.49 Accurate interpretation is dependent on sonographer experience, and correlation to EMG has yet to be shown.49, In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and includes patient education, relative rest, and activity modification.1322,2931,3335,37,38 Physical therapy, yoga, and acupuncture may be helpful, although conclusive evidence is lacking.1322,2931,3335,37,38 Surgical options include nerve decompression, exploration for anatomic causes and treatment, or nerve transfers.54,55 Despite low complication rates, these procedures are often associated with lack of full resolution of symptoms, even when patients complete a rehabilitation program.54,55 Carpal tunnel syndrome is one of the few entrapment neuropathies to have evidence-based treatment.1316,2428 Conservative treatment options and surgical indications for each of the nerves are listed in Table 2.1338, This article updates a previous article on this topic by Neal and Fields.12. Pain is exacerbated by extending the elbow, pronating the forearm, and flexing the wrist.30, Posterior interosseous nerve syndrome results in motor-only weakness. An official website of the United States government. The scapula forms the osseous portion of the notch. 19. Zoltan JD. Electrodiagnostic testing is helpful to confirm the diagnosis, determine severity, and monitor progression of nerve damage. Patients with nerve injury typically present with pain, weakness, and paresthesia. Arthroscopic Suprascapular Nerve Decompression: Transarticular and Subacromial Approach. In this photograph, the nerve can be seen branching out on the superior surface of the infraspinatus. Because of the slow rate of axonal regeneration, recovery can take years, with complete recovery often unachievable. NCV and EMG studies are considered the gold standard for diagnosing SNES.7 These tests should be considered when MRI, ultrasound, and physical exam do not yield a diagnosis.6,10 Moen et al. Although rare in the general population, SNES increases significantly in high-risk populations.13 The suprascapular nerve (SN) originates from the superior trunk of the brachial plexus, where it passes deep to the trapezius toward the scapula to innervate the supraspinatus and infraspinatus muscles. In: StatPearls [Internet]. 2002;26(6):339-43. 7. Ultrasound-Guided Peripheral Nerve Procedures. Using the supraspinatus muscle as a guide, the suprascapular foramen is located via palpation of the superior border of the scapula. Avery BW, Pilon FM, Barclay JK. Ultrasonography can evaluate for a variety of changes that occur in peripheral nerve entrapment syndromes. The test is usually easier in sitting or standing. The transducer should be placed parallel to the scapular spine above the suprascapular notch.12 This treatment approach can be beneficial in delaying surgery until necessary or appropriate, as well as simply providing short-term or immediate relief of shoulder pain. is sufficient to relieve pressure on the nerve. is necessary to relieve pressure on the nerve.6,10 Injuries refractory to conservative treatment may require either arthroscopic or open surgery.7,11,13,14, The relationship between overhead activities and SNES has been well documented in the literature.13 Sports such as volleyball, tennis, and swimming increase the risk of dynamic entrapment caused by repetitive compression and subsequent swelling, fibrosis, and demyelination of the SN.13 The sling effect describes how certain maneuvers increase stress on the SN at the spinoglenoid ligament.13,14 Protraction and retraction of the scapula during the throwing motion puts significant pressure on the SN.1 Cadaveric studies have demonstrated that shoulder adduction and internal rotation increase tension at the inferior portion of the spinoglenoid ligament, directly superior to the SN.3,13 This motion, often seen in volleyball spikes and overhead serves, is thought to cause cumulative microtrauma and neuropathy of the SN.1,7,8,11,15 Around 33% of volleyball players suffer from SNES at some point in their careers.13 The greatest tension in the suprascapular ligament is seen during abduction and full rotation of the arm, which is a motion common to many overhead sports.7,12 Some researchers have also suggested that SNES can be caused by microemboli formation secondary to repeated compression trauma that damages the vasonervorum.4,13,16, Rotator cuff and labrum injuries are potential causes of SNES.1,7,13 Massive rotator cuff tears have been shown to increase tension on the SN at the suprascapular notch substantially and spinoglenoid notch as ruptured muscles retract medially.7 Paradoxically, some rare events of SNES have also been attributed to rotator cuff repair surgeries.6 Cadaveric studies have determined that significant (1-3cm) lateral translation of the rotator cuff during repair can increase tension on the SN.6,13,15, Following tears of the labrum, synovial fluid can leak into the surrounding tissue forming paralabral ganglion cysts.1,6 These cysts are formed by a one-way valve mechanism, which allows them to grow in size and compress nearby structures such as the SN.6 SNES from ganglion cysts most often occurs at the spinoglenoid notch; however, ganglion cysts can compress the SN at both the spinoglenoid notch or the suprascapular notch depending on the primary labral injury and size of the cyst.4,11, After branching from the superior trunk of the brachial plexus, the SN dives into the shoulder and passes through the suprascapular notch. Paolo Procacci Foundation, Via Tacito 7, Rome, Italy, 5Department of Orthopaedic Surgery, . Axonotmesis extends damage to the axon but preserves the connective tissue framework. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length.
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