Download Long Thoracic Nerve

Differential diagnosis of nerve
pathologies in the shoulder
Sumit Bassi M.D.
Sports Medicine Fellow Summa Health.
Disclosures
Disclosure:Financial— No relevant financial relationship exists.
Nonfinancial— Member of American Medical Society of Sports
Medicine.
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Case
19 y/o right handed male baseball player, with right anterior
shoulder pain.
Shoulder Dislocation sensation while sliding head first into
third base.
ER work up - No fracture or any signs of dislocation on x-ray
imaging.
Numbness and tingling which lasted 24 hours after injury.
After 2 weeks of rest, he noticed some weakness with bench
press and deltoid flies.
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Office visit
Presents with complaints of on and off dull ache in shoulder
Worsens with movement, overhead activities, and aggravated
by sleeping on same side.
No radiating pain, swelling, bruising, or tingling. Patient
describes pain as an on and off dull ache.
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Physical Exam
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Another picture
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Another picture
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Inspection from the back
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Right shoulder Physical exam
ROM: Active - Abduction-120 degrees.
- Flexion- 120-130 degrees.
- Internal Rotation- 70 degrees
- External Rotation- 50 degrees
: Passive- Normal ROM
Strength testing against resistance:
-:Supraspinatus- Decreases strength.
-:External rotation- Decreased strength.
-:Internal rotation - Normal strength.
Exam of the right shoulder
Abduction- Decreased strength against resistance
Subscapularis- Normal strength against resistance
Biceps- Normal strength against resistance.
Impingement tests:- Negative
Sensory exam- grossly normal.
Pulse- Normal
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Further Testing
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Imaging
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Axial view
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Differential
Parsonage Turner Syndrome
Long thoracic nerve injury
C7 radiculopathy
Spinal accessory nerve injury
Fascioscapulohumeral dystrophy (FSHD)
Scapulodysrythmia
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Final diagnosis
Traumatic long thoracic and spinal accessory nerve injury.
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Common nerves affected around the
shoulder
Axillary Nerve - supplies the Deltoid muscle. Most commonly
stretched with shoulder disclocations.
Long Thoracic Nerve - supplies Serratus Anterior muscle and can
cause Winging of the shoulder
Suprascapular Nerve - supplies supraspinatus and infraspinatus
muscles and can be entrapped or diseased.
Musculocutaneous Nerve - supplies the Biceps muscle and can
rarely be injured at surgery
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Long thoracic nerve injury
The long thoracic nerve is a pure motor nerve that arises from
the fifth, sixth, and seventh cervical nerve roots
The main causes of injury to the long thoracic nerve are the
following
●Neuralgic amyotrophy
●Trauma or compression
●Stretch or traction from repetitive activities
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Long Thoracic nerve innervating serratus
anterior muscle
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Treatment and Prognosis of Long
Thoracic nerve injury
Management and prognosis varies according to the mechanism
of nerve injury
Recovery from neuralgic amyotrophy occurs slowly over one to
three years
Most cases of long thoracic nerve injury caused by carrying or
by repetitive activity are incomplete and resolve spontaneously
within 6 to 24 months
For those who do not experience functional recovery, surgical
procedures may be an option, which is fascial grafts( transfer of
sternal head of pectoralis major)
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Medial and lateral winging of Scapula
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Medial winging- Long thoracic nerve
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Lateral winging- Spinal accessory nerve
or dorsal scapular nerve
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Medial and lateral winging
medial winging
usually seen in young athletic patient
far more common
lateral winging
– history of neck surgery (lateral is usually iatrogenic)
On physical exam:medial winging
medial spine of scapula moves upward and medial
lateral winging
medial spine of scapula moves downward and lateral
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Spinal Accessory nerve injury
The spinal accessory nerve is a cranial nerve that is derived
from the upper cervical nerve roots and innervates the
sternocleidomastoid and trapezius muscles, the latter of which
primarily functions as a shoulder stabilizer.
The most common causes of isolated spinal accessory
neuropathy include biopsy of the cervical lymph nodes in the
posterior triangle and local surgery, such as radical neck
dissection
Blunt injuries to the nerve are also common (eg, due to sports
or combat).
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Treatment and prognosis of Spinal
accessory nerve injury
Non operative care- observation and trapezius strengthening.
Operative treatment includes- nerve explorations or muscle
transfer (lateralize levator scapulae and rhomboids, transfer from
medial border to lateral border).
The prognosis will vary by cause
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Overview of the nerves innervating the
shoulder
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Suprascapular nerve entrapment at
suprascapular notch.
Compression can be from:- Ganglion cyst(often associated
with labral tears)
:- Transverse scapular ligament entrapment
:- Callus formation after a fracture
Presentation
:-symptoms
• deep, diffuse, posterolateral shoulder pain
:-physical exam
• pain with palpation of suprascapular notch
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Ganglion cyst at the suprascapular
notch
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Suprascapular nerve entrapment at
spinoglenoid notch
Compression can be due to
:- Posterior labral tears causing a cyst
:- Spinoglenoid ligament
:- Spinoglenoid notch ganglion
:- Traction injury seen in volleyball players and rowers
Presentation
:-symptoms
• deep, diffuse, posterolateral shoulder pain
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Spinoglenoid cyst
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Upper extremity myotomes
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Which nerve and site?
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What nerve and which muscle?
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What nerve and which muscle?
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Work up
When to get a MRI vs EMG?
When to send for physical therapy?
When to send for surgical intervention?
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