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

Abstract

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.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy

“…The proposed clinical decision-making algorithm presented in this article takes into consideration the work of other surgeons by including both proximal and chest-level decompression, as well as advances in nerve transfers to improve function in this patient population. 4,5,10,19,20,23,24 Further evaluation and refinement of the algorithm is ongoing as we treat more patients with a multilevel surgical approach.…”

“…23 Ray et al reported the first 2-level nerve transfer for the long thoracic nerve palsy in a patient with isolated long thoracic nerve palsy. 19 In this case, the patient had a proximal medial pectoral nerve to long thoracic nerve transfer and a distal thoracodorsal to long thoracic nerve transfer. 19 There is no consensus in the literature regarding the best management of isolated long thoracic nerve palsy.…”

“…19 In this case, the patient had a proximal medial pectoral nerve to long thoracic nerve transfer and a distal thoracodorsal to long thoracic nerve transfer. 19 There is no consensus in the literature regarding the best management of isolated long thoracic nerve palsy. Using our clinical experience, we have devised a clinical and surgical algorithm to simplify the management of these complicated patients.…”

“…This can be achieved with long thoracic nerve decompression (in the setting of conduction block) 4,[10][11][12][13][14]20,22 or by nerve transfers that reinnervate the serratus anterior muscle. 15,19,23,24 Nerve transfers allow nearby healthy axons to reinnervate the injured serratus anterior muscle close to the motor endplates and prior to atrophy. 15 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.…”

Direct transfer of C7 pectoral fascicles to the suprascapular nerve in C5/C6 brachial plexus palsies: an anatomical study

“…Based on the anatomical features, the expendability of C7 pectoral fascicles within the brachial plexus can be understood (David et al., 2010). Many authors have reported the clinical use of pectoral fascicles as donors in BPI reconstruction, without significant postoperative deficits (Maldonado and Spinner, 2017; Ray et al., 2011and 2012; Songcharoen et al., 2001; Wang et al., 2012; Yin et al., 2012). By harvesting a single C7 motor fascicle as we describe, the risk of a postoperative deficit appears to be low.…”