Suprascapular nerve release for treatment of shoulder and periscapular pain following intracranial spinal accessory nerve injury

Report of 3 cases

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Iatrogenic injury to the spinal accessory nerve is one of the most common causes of trapezius muscle palsy. Dysfunction of this muscle can be a painful and disabling condition because scapular winging may impose traction on the soft tissues of the shoulder region, including the suprascapular nerve. There are few reports regarding therapeutic options for an intracranial injury of the accessory nerve. However, the surgical release of the suprascapular nerve at the level of the scapular notch is a promising alternative approach for treatment of shoulder pain in these cases. The author reports on 3 patients presenting with signs and symptoms of unilateral accessory nerve injury following resection of posterior fossa tumors. A posterior approach was used to release the suprascapular nerve at the level of the scapular notch, transecting the superior transverse scapular ligament. All patients experienced relief of their shoulder and scapular pain following the decompressive surgery. In 1 patient the primary dorsal branch of the C-2 nerve root was transferred to the extracranial segment of the accessory nerve, and in the other 2 patients a tendon transfer (the Eden–Lange procedure) was used. Results from this report show that surgical release of the suprascapular nerve is an effective treatment for shoulder and periscapular pain in patients who have sustained an unrepairable injury to the accessory nerve.

Abbreviations used in this paper: CN = cranial nerve; CPA = cerebellopontine angle; MRC = Medical Research Council.

Article Information

Address correspondence to: Leandro Pretto Flores, M.D., SQN 208, Bloco F, Apartamento 604, Asa Norte, Brasília Distrito Federal, Brazil 70853-060. email: leandroprettoflores@hotmail.com.

© AANS, except where prohibited by US copyright law.

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    Operative photograph of the posterior approach to the suprascapular nerve, on the left side. The patient was placed in the supine position and the head was rotated to the contralateral side. A bolster was placed under the shoulder to elevate it off the operating table. A transverse incision was made midway between the spine of scapula and the clavicle, at the midline of the suprascapular fossa. The trapezius (Tr) muscle was split in the direction of its fibers and the supraspinatus muscle (SS) was retracted inferiorly. A right clamp was inserted under the superior transverse scapular ligament (asterisk), before its complete division. A small Penrose drain is encircling the suprascapular nerve, proximally to the superior transverse scapular ligament.

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    Schematic drawing demonstrating the proposed mechanism involved in the origin of the shoulder pain in cases of spinal accessory nerve injury. Left: Normal anatomy of the scapular region. The spinal accessory nerve exits the cranial base at the level of the jugular foramen and runs inferiorly to innervate the trapezius muscle. The suprascapular nerve receives fibers from C-5 and C-6 nerve roots, passes deep to the omohyoid and trapezius muscles to reach the scapular notch. The nerve crosses beneath the superior transverse scapular ligament and, after providing branches to the supraspinatus muscle, travels inferolaterally to wrap around the spine of the scapula (spinoglenoid notch). After exiting this fibroosseous tunnel, the nerve gives branches to innervate the infraspinatus muscle. Right: An intracranial injury of the accessory nerve promotes a progressive atrophy of the trapezius muscle, especially its upper and middle segment. The inferior segment of the muscle might keep some residual innervation by branches derived from the cervical plexus. The scapula loses its stability, and its upper segment rotates laterally and downward, and its distal segment translates medially (arrow). In this distorted position, the entire scapular system may exert traction on the suprascapular nerve, which is anatomically anchored at the level of the scapular notch (inset).

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