A modified, less invasive posterior subscapular approach to the brachial plexus: case report and technical note

The traditional posterior subscapular approach offers excellent exposure of the lower brachial plexus and has been successfully used in patients with recurrent thoracic outlet syndrome after an anterior operation, brachial plexus tumors involving the proximal roots, and postirradiation brachial plexopathy, among others. However, this approach also carries some morbidity, mostly related to the extensive muscle dissection of the trapezius, rhomboids, and levator scapulae. In this article, the authors present the surgical technique and video illustration of a modified, less invasive posterior subscapular approach, using a small, self-retaining retractor and only a partial trapezius and rhomboid minor muscle dissection. This approach is likely to result in decreased postoperative morbidity and a shorter hospital stay.

Gilliatt-Sumner Hand Revisited: A 25-year Experience

OBJECTIVE: Thirty-three patients with true neurogenic thoracic outlet syndrome, or Gilliatt-Sumner hand, underwent surgical treatment at Louisiana State University during a 25-year period. This study retrospectively evaluated the outcome referable to pain and motor function in these patients. METHODS: All patients had the typical Gilliatt-Sumner hand, secondary to compression of C8, T1, and/or lower trunk. Nineteen patients underwent an anterior supraclavicular approach, and 15 patients underwent a posterior subscapular approach to the brachial plexus. Nerve action potential recordings showed plexus involvement close to the spine, at the level of the junction of the spinal nerves to the lower trunk. RESULTS: Pain, present in 22 patients, improved in 21. Mild motor deficit improved in 12 of 14 patients. Severe motor deficit improved partially in 14 of 20 patients. CONCLUSION: The diagnosis of true neurogenic thoracic outlet syndrome provides a clear operative indication. Surgical decompression needs to involve the medial portion of the plexus, and especially the spinal nerves. An anterior supraclavicular approach is preferred in most cases. If there is a large cervical rib or there has been a prior anterior operation, then a posterior subscapular approach is indicated.

The nasal valve: a physiological and clinical study

Fifteen subject underwent nasal pressure gradient studies to determine the resistance profile of the nose. Seventy-nine per cent of nasal resistance to airflow occurred in the segment 0 cm.−2.8 cm. from the posterior margin of the anterior nares. The greater part of this resistance (43 per cent) occurred in the segment 1.5 cm.−2.8 cm. within the nose, and this area approximated to the site of the pyriform aperture.Eighteen patients underwent a trial of radical trimming of the turbinates (12 patients) versus anterior trimming of the inferior turbinates (6 patients). Both operations produced a similar fall in nasal resistance to airflow, confirming that the region of the pyriform aperture was the site of maximum nasal resistance.Whereas the radical operation significantly reduced the sensation of nasal obstruction, the anterior operation did not.The results of the study are discussed with reference to previous work on the subject.