Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries

Object There is insufficient information in the neurosurgical literature regarding the long thoracic nerve (LTN). Many neurosurgical procedures necessitate a thorough understanding of this nerve's anatomy, for example, brachial plexus exploration/repair, passes for ventriculoperitoneal shunt placement, pleural placement of a ventriculopleural shunt, and scalenotomy. In the present study the authors seek to elucidate further the surgical anatomy of this structure. Methods Eighteen cadaveric sides were dissected of the LTN, anatomical relationships were observed, and measurements were obtained between it and surrounding osseous landmarks. The LTN had a mean length of 27 ± 4.5 cm (mean ± standard deviation) and a mean diameter of 3 ± 2.5 mm. The distance from the angle of the mandible to the most proximal portion of the LTN was a mean of 6 ± 1.1 cm. The distance from this proximal portion of the LTN to the carotid tubercle was a mean of 3.3 ± 2 cm. The LTN was located a mean 2.8 cm posterior to the clavicle. In 61% of all sides the C-7 component of the LTN joined the C-5 and C-6 components of the LTN at the level of the second rib posterior to the axillary artery. In one right-sided specimen the C-5 component directly innervated the upper two digitations of the serratus anterior muscle rather than joining the C-6 and C-7 parts of this nerve. The LTN traveled posterior to the axillary vessels and trunks of the brachial plexus in all specimens. It lay between the middle and posterior scalene muscles in 56% of sides. In 11% of sides the C-5 and C-6 components of the LTN traveled through the middle scalene muscle and then combined with the C-7 contribution. In two sides, all contributions to the LTN were situated between the middle scalene muscle and brachial plexus and thus did not travel through any muscle. The C-7 contribution to the LTN was always located anterior to the middle scalene muscle. In all specimens the LTN was found within the axillary sheath superior to the clavicle. Distally, the LTN lay a mean of 15 ± 3.4 cm lateral to the jugular notch and a mean of 22 ± 4.2 cm lateral to the xiphoid process of the sternum. Conclusions The neurosurgeon should have knowledge of the topography of the LTN. The results of the present study will allow the surgeon to better localize this structure superior and inferior to the clavicle and decrease morbidity following invasive procedures.

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Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report

The Journal Of Hand Surgery ◽

10.1016/j.jhsa.2010.05.024 ◽

2010 ◽

Vol 35 (9) ◽

pp. 1427-1431 ◽

Cited By ~ 3

Author(s):

Tetsuya Yamada ◽

Kazuteru Doi ◽

Yasunori Hattori ◽

Shushi Hoshino ◽

Soutetsu Sakamoto ◽

...

Keyword(s):

Case Report ◽

Brachial Plexus ◽

Shoulder Function ◽

Long Thoracic Nerve ◽

Thoracic Nerve

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Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury

Journal of Shoulder and Elbow Surgery ◽

10.1016/j.jse.2020.03.052 ◽

2020 ◽

Vol 29 (12) ◽

pp. 2595-2600

Author(s):

Kiminori Yukata ◽

Kazuteru Doi ◽

Toshitaka Okabayashi ◽

Yasunori Hattori ◽

Sotetsu Sakamoto

Keyword(s):

Brachial Plexus ◽

Nerve Palsy ◽

Brachial Plexus Injury ◽

Long Thoracic Nerve ◽

Thoracic Nerve

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Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: A case report

Microsurgery ◽

10.1002/micr.10046 ◽

2002 ◽

Vol 22 (6) ◽

pp. 254-257 ◽

Cited By ~ 24

Author(s):

Matthew M. Tomaino

Keyword(s):

Case Report ◽

Clinical Outcome ◽

Nerve Transfer ◽

Long Thoracic Nerve ◽

Thoracic Nerve ◽

Scapular Winging

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Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy

Hand ◽

10.1177/1558944717733306 ◽

2017 ◽

Vol 13 (6) ◽

pp. 689-694 ◽

Cited By ~ 4

Author(s):

Shelley S. Noland ◽

Emily M. Krauss ◽

John M. Felder ◽

Susan E. Mackinnon

Keyword(s):

Decision Making ◽

Nerve Stimulation ◽

Nerve Palsy ◽

Clinical Decision Making ◽

Treatment Algorithm ◽

Nerve Transfer ◽

Clinical Decision ◽

Serratus Anterior ◽

Long Thoracic Nerve ◽

Thoracic Nerve

Background: Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management. Methods: In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed. Results: In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months. Conclusions: A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.

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Aberrant Dual Origin of the Dorsal Scapular Nerve and Its Communication with Long Thoracic Nerve: An Unusual Variation of the Brachial Plexus

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2015/13620.6027 ◽

2015 ◽

Author(s):

Poonam Shilal

Keyword(s):

Brachial Plexus ◽

Long Thoracic Nerve ◽

Thoracic Nerve ◽

Dual Origin

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Occupational shoulder disability: functional recovery after decompression and neurolysis of the upper brachial plexus and the long thoracic nerve

International Journal of Occupational Medicine and Environmental Health ◽

10.13075/ijomeh.1896.01634 ◽

2021 ◽

Author(s):

Rahul Nath ◽

Alyssa Leal ◽

Chandra Somasundaram

Keyword(s):

Brachial Plexus ◽

Functional Recovery ◽

Long Thoracic Nerve ◽

Thoracic Nerve ◽

Shoulder Disability

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Two-level motor nerve transfer for the treatment of long thoracic nerve palsy

Journal of Neurosurgery ◽

10.3171/2011.5.jns101615 ◽

2011 ◽

Vol 115 (4) ◽

pp. 858-864 ◽

Cited By ~ 11

Author(s):

Wilson Z. Ray ◽

Mitchell A. Pet ◽

Michael C. Nicoson ◽

Andrew Yee ◽

Lorna C. Kahn ◽

...

Keyword(s):

Motor Nerve ◽

Nerve Transfer ◽

Shoulder Function ◽

Favorable Result ◽

Long Thoracic Nerve ◽

Therapy Regimen ◽

Thoracic Nerve ◽

Nerve Transfers ◽

Postoperative Physical Therapy ◽

Thoracodorsal Nerve

The authors report a case of long thoracic nerve (LTN) palsy treated with two-level motor nerve transfers of a pectoral fascicle of the middle trunk, and a branch of the thoracodorsal nerve. This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function. A detailed account of the postoperative physical therapy regimen is included, as this critical component of the favorable result cannot be overlooked. This case establishes the two-level motor nerve transfer as a new option for treating LTN palsy, and demonstrates that nerve transfers should be considered in the therapeutic algorithm of an idiopathic mononeuritis.

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Results of Distal Nerve Transfers in Restoration of Shoulder Function in C5 and C6 Root Avulsion Injury to the Brachial Plexus

Indian Journal of Neurotrauma ◽

10.1055/s-0037-1604050 ◽

2017 ◽

Vol 14 (01) ◽

pp. 021-025

Author(s):

Prem Bhandari

Keyword(s):

Brachial Plexus ◽

External Rotation ◽

Nerve Transfer ◽

Shoulder Function ◽

Shoulder Abduction ◽

Root Avulsion ◽

Long Thoracic Nerve ◽

Avulsion Injury ◽

Nerve Transfers ◽

Distal Nerve

Background The lack of shoulder function following brachial plexus injury is a debilitating condition. Nerve root avulsion injury precludes a direct nerve repair. Under these circumstances, distal nerve transfer is a well-established technique in the restoration of shoulder abduction and external rotation. Methods Thirty patients with C5 and C6 root avulsion injury were treated with distal nerve transfers in the period between February 2009 and December 2012.The average denervation period was 5.6 months. Shoulder function was restored by posterior transfer of distal part of the spinal accessory nerve into the suprascapular nerve and transfer of the long head triceps branch of radial nerve to the anterior branch of axillary nerve. An additional nerve transfer was performed in four patients with winged scapula by transferring a part of thoracodorsal nerve into the long thoracic nerve. Results Twenty-seven patients recovered shoulder abduction; 18 scored M4 and 9 scored M3. Range of abduction averaged 118 degrees (range, 90–170 degrees). Nineteen patients restored external rotation with an average of 53 degrees (range: 30–70 degrees). Three patients failed to recover shoulder abduction though the joint regained stability. External rotation remained severely restricted in 11 patients. At final follow-up, winging of scapula improved in three of four patients following reinnervation of the serratus anterior muscle. Conclusion Nerve transfers, when performed close to the target muscles, restore good range and strength of shoulder abduction in most patients with C5 and C6 root avulsion injuries. However, return in external rotation is not as good as the recovery in abduction.

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