A Modified Posterior Approach to the Nerve Transfer of the Spinal Accessory Nerve to the Suprascapular Nerve
Lenny L Rivera, MD1, Ruben Tresgallo, MD1, Rafael Baella, MD1, Gerardo Caussade-Silvestrini, MS2 and Christian Foy, MD3, (1)University of Puerto Rico, Medical Sciences Campus, San Juan, PR, (2)University of Puerto Rico, San Juan, PR, (3)University of Puerto Rico, School of Medicine, San Juan, Puerto Rico
Brachial plexus injuries may occur at any age after birth complications or trauma. Most are accompanied by severe to total loss of shoulder function. Dual neurotization consisting of spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) and radial nerve transfer to the axillary nerve, provide an excellent method for reconstruction of shoulder stability and function. However, transfer of the SAN to the SSN is a challenging procedure and we therefore propose a modification for the posterior approach to the SSN that decreases length of surgery and may ease identification of the SSN.
Materials and Methods:
We conducted a retrospective study where we analyzed postoperative results of 13 patients who suffered brachial plexus injuries during birth or after any kind of trauma and then underwent SAN to SSN transfer and radial nerve to axillary nerve transfer. All patients treated from September 2018 to November 2022 were included. Each SAN to SSN transfer was performed via a modification of the traditional posterior approach consisting of elevation of the supraspinatus muscle from the supraspinous fossa of the scapula. To better illustrate this modified approach, a cadaveric dissection was performed. For patients 18 years and older, DASH questionnaire results, medical research council (MRC) grading system and shoulder range of motion at last follow up were obtained. For younger patients, MRC grading system and shoulder range of motion were obtained. Our results were then compared to those reported in the literature.
Six patients treated after obstetric brachial plexus injuries and 7 patients treated after suffering traumatic total brachial plexus injuries were included. Shoulder abduction, forward flexion and external rotation improved in all 13 patients. Patients treated after obstetric brachial plexus injuries demonstrated an average of 101 degrees of active forward flexion (range 85-125), 93 degrees of active abduction (range 86-114) and 15 degrees of active external rotation (range 7-26); average MRC grade was 4 (±1). All other adult patients treated after suffering total brachial plexus injuries, demonstrated an average of 53.3 degrees of active forward flexion (range 85-125), 46.6 degrees of active abduction (range 10-124) and 22.5 degrees of active external rotation (range 6-61); average DASH score was 50.83 while MRC grade was 3.6 (±1.5).
The modified posterior approach to the SSN lessens the length of surgery without significantly compromising patientâ€™s functional outcomes. Pediatric patients treated after obstetric brachial plexus injuries demonstrated superior outcomes when compared to adult patients.
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