Dorsal approach in spinal accessory to suprascapular nerve transfer in brachial plexus injuries: technique details

Abstract

Transfer of spinal accessory nerve to suprascapular nerve is an acceptable technique in the restoration of shoulder functions in devastating brachial plexus injuries. Conventionally, these transfers have been performed by anterior approach with several modifications. With anterior approach dissection of spinal accessory nerve is tedious because nerve lies deep in the fatty tissue, rich in lymphatic vessels and blood vessels. Distal suprascapular nerve injuries may also be missed when plexus exploration and nerve transfer have been performed through anterior approach. We describe a new approach in the exposure of target nerves through a transverse incision placed over the scapular spine. Anatomic dissections were performed on 3 cadavers through dorsal approach. For this purpose a 12 to 15 cm long transverse incision was made over the spine of scapula. Trapezius muscle was detached from the spine and reflected upwards. Distal part of spinal accessory nerve was identified on the anterior surface of trapezius muscle. Suprascapular nerve was taped near the suprascapular notch. Both the nerves were in close vicinity and a direct transfer was possible. Thereafter this technique was clinically tried in 24 consecutive cases of brachial plexus injuries. In all of the cases, the spinal accessory and suprascapular nerves were distinctly located under direct vision and a direct coaptation of both the target nerves was possible. In 2 cases with C5 to T1 root avulsion injuries suprascapular nerve was also injured near the suprascapular notch. This approach allowed a direct transfer of spinal accessory to suprascapular nerve in a relatively safe zone and helped in the identification of other injuries of suprascapular nerve. Since distal part of spinal accessory nerve was used in transfer, function of upper trapezius remained intact.

Keywords

Brachial plexus injuries - Dorsal approach - Nerve transfer - Spinal accessory nerve - Suprascapular nerve

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