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

Case report

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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.

Abbreviations used in this paper: LTN = long thoracic nerve; ROM = range of motion; TDN = thoracodorsal nerve.

Article Information

Address correspondence to: Susan E. Mackinnon, M.D., Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, Missouri 63110. email:mackinnons@wustl.edu.

Please include this information when citing this paper: published online June 24, 2011; DOI: 10.3171/2011.5.JNS101615.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative examination showing shoulder flexion at 90° (A), end range (B), and shoulder extension at 90° (C). Winged scapula is noted on the right in each photo.

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    Illustration of the two-level nerve transfer procedure to restore LTN function. Dashed lines = anatomical reference to the clavicle. A: Nerve transfers to restore LTN function occurred at 2 levels to reinnervate both proximal and distal parts of the serratus anterior muscle. B: Proximally, pectoral nerve fascicles were neurolysed from the middle trunk and transferred to reinnervate the upper portion of LTN. C: Distally, a branch of the TDN was transferred to reinnervate the lower potion of the LTN.

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    Proximal nerve transfer to restore LTN function using pectoral nerve fascicles as donors. A: Two pectoral nerve fascicles were neurolysed from the identified middle trunk through a right-sided supraclavicular incision. Two branches of the LTN were identified lateral to the middle trunk. B: Two pectoral nerve fascicles were transferred to reinnervate 2 branches of the proximal LTN. C: Nerve anastomosis was accomplished with good size match by neurotizing each pectoral fascicle with an individual branch of the LTN.

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    Distal nerve transfer to restore LTN function using a branch of the TDN as a donor. A: The LTN and the TDN were identified through an incision made below the right axilla. The LTN was identified superficial to the serratus anterior while the TDN was identified deep to the latissimus dorsi. B: The TDN was transferred to reinnervate the distal LTN.

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    Postoperative examination at 14 months showing shoulder abduction at 90° (A), end range (B), and shoulder adduction at 90° (C).

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