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Annie S. Dubuisson, David G. Kline and Steven S. Weinshel

A ccording to Hochberg, 4 the posterior subscapular approach was originally described in the 19th century by Simon and Estlander for use as a thoracoplasty procedure in the treatment of tuberculosis and thoracic empyema in the pre-antibiotic era. In 1962, Clagett 1 described the same approach as a method to resect the first rib for thoracic outlet syndrome (TOS). The procedure became a standard surgical approach for this disease until recently, when the transaxillary and supraclavicular approaches became more popular. The posterior subscapular approach to

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Clifford L. Crutcher II, David G. Kline and Gabriel C. Tender

T he posterior subscapular approach to the brachial plexus is safe and effective. 6 Its indications include: thoracic outlet syndrome (TOS) and recurrent TOS, 7 brachial plexus tumors involving the proximal roots, postirradiation brachial plexopathy, and proximal brachial plexus palsy. 3 The posterior approach is especially helpful for brachial plexus access in patients with previous irradiation to the neck or anterior chest wall, previous anterior neck surgery, or morbid obesity. 3 The advantages of this approach include ease of exposure, exposure of

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David G. Kline, Joseph Kott, George Barnes and Lester Bryant

United States, John Alexander popularized an apical thoracoplasty from the posterior, subscapular approach. 9 In 1962, Clagett 3 reported his experience with a similar posterior, subscapular approach for surgical amelioration of thoracic outlet syndrome. For a period of time this became the standard technique for first-rib resection. 2 In recent years, the transaxillary 10, 11 or infraclavicular 6, 7 approaches have become more popular than either the supraclavicular 1, 5 or the posterior approaches, but the latter is still in use by some surgeons. Thus, there

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David G. Kline, Thomas R. Donner, Leo Happel, Barbara Smith and Hans P. Richter

relatively safe surgical approach to the intraforaminal portion of the plexus and also to see if effective regeneration would result from graft repair at such a proximal level. Materials and Methods Previous clinical experience with a posterior subscapular approach to the first rib and the proximal brachial plexus 2, 3, 6, 8–10, 21 and preliminary work with several human and nonhuman primate cadavers provided ideas for a modified posterior laminotomy approach to the intraforaminal portion of the spinal nerve roots. 33 The principles of laboratory animal care as

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Thomas Carlstedt and Georg Norén

right arm innervated by the C7—T1 roots. She could not flex or extend the wrist or the fingers. There was considerable weakness in shoulder and elbow motion (C5–7). She had no sensation in the ulnar region of the hand and arm (C8—T1 dermatomes), reduced sensation in the third finger, but normal sensory function in the two radial fingers (C-6 dermatome). Operation The patient was operated on 8 days after the accident. The proximal portion of the brachial plexus was reached through a modified (midline incision) posterior subscapular approach. 6 Spinal nerves C5

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Aruna Ganju, Norbert Roosen, David G. Kline and Robert L. Tiel

one has experienced no change in pain status. Operative Approach and Technique An anterior supra- and/or infraclavicular approach to the brachial plexus was used for 82% of the 111 tumors that were surgically treated. A smaller percentage of patients (18%) underwent surgery performed via the posterior subscapular approach. Both of these approaches have been described extensively in earlier reports. 9, 14, 17, 18 The posterior approach was chosen under the following conditions: 1) the lower plexus roots (C-8 and T-1) or trunk were involved by tumor; 2

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Rishi N. Sheth and James N. Campbell

9. Cuypers PW , Bollen EC , van Houtte HP : Transaxillary first rib resection for thoracic outlet syndrome. Acta Chir Belg 95 : 119 – 122 , 1995 Cuypers PW, Bollen EC, van Houtte HP: Transaxillary first rib resection for thoracic outlet syndrome. Acta Chir Belg 95: 119–122, 1995 10. Dubuisson AS , Kline DG , Weinshel SS : Posterior subscapular approach to the brachial plexus. Report of 102 patients. J Neurosurg 79 : 319 – 330 , 1993 Dubuisson AS, Kline DG, Weinshel SS

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David G. Kline

, et al : Exploration of selected brachial plexus lesions by the posterior subscapular approach. J Neurosurg 49 : 872 – 880 , 1978 Kline DG, Kott J, Barnes G, et al: Exploration of selected brachial plexus lesions by the posterior subscapular approach. J Neurosurg 49: 872–880, 1978 10. Leffert RD : Brachial Plexus Injuries. New York : Churchill Livingstone , 1985 , pp 131 – 139 Leffert RD: Brachial Plexus Injuries. New York: Churchill Livingstone, 1985, pp 131–139 11. Nakaras A : The

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Daniel H. Kim, Yong-Jun Cho, Robert L. Tiel and David G. Kline

. Operative Techniques for Tumors An anterior supraclavicular and/or infraclavicular approach was performed in 83% of the 141 patients harboring benign tumors who were surgically treated at LSUHSC. A smaller percentage of patients (17%) underwent a posterior subscapular approach. 21, 33 The first step in the removal of nerve sheath tumors was to isolate and identify adjacent plexus elements and structures to prevent damage to them. The proximal and distal elements directly involved with the tumor were then isolated. Using microsurgical techniques, fascicles could be

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David G. Kline and Donald J. Judice

operative evidence of tumor involving the plexus. Instead, partial deficit and usually severe pain was secondary to irradiation damage to the plexus. Pain was sometimes eased by operation, but the deficit was seldom reversed and in several cases was inadvertently increased, presumably due to dissection and retraction of elements that had suffered extensive intraneural damage due to irradiation. In four instances, irradiation damage was primarily to the supraclavicular plexus, and exposure was gained by a posterior subscapular approach with resection of the first rib. The