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Ann Thorac Surg 2002;73:1643-1645
© 2002 The Society of Thoracic Surgeons

Case report

Surgical treatment of a long thoracic nerve palsy

Christine B. Novak, MS, PTa, Susan E. Mackinnon, MD*a

a Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri, USA

Accepted for publication September 25, 2001.

* Address reprint requests to Dr Mackinnon, Division of Plastic and Reconstructive Surgery, Suite 17424, East Pavilion, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110, USA
e-mail: mackinnons{at}msnotes.wustl.edu


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
A 17-year-old patient presented with a long thoracic nerve palsy following an idiopathic onset of weakness to the serratus anterior muscle. With no evidence of recovery 3.5 months following onset of serratus anterior weakness, the patient underwent a thoracodorsal to long thoracic nerve transfer to reinnervate the serratus anterior muscle. Follow-up examination 6.5 years following the nerve transfer revealed no scapular winging, full range of motion of the shoulder and no reported functional shoulder restriction. We conclude that a thoracodorsal to long thoracic nerve transfer results in good functional recovery of the serratus anterior muscle.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Injury to the long thoracic nerve can result in a severe loss of shoulder function, particularly shoulder flexion because of a loss of scapular stabilization and scapular rotation [1, 2]. In cases of a proximal laceration or when the level of the injury cannot be identified, as occurs in a closed traction injury or a brachial plexus neuritis, surgical reconstruction options to restore serratus anterior muscle function are limited. The reported surgical reconstructions include late reconstructions that use muscle, tendon, or fascial flap reconstruction to restrict winging of the inferior angle of the scapula [1]. The optimal surgical reconstruction to maximize function is to reinnervate the serratus anterior muscle. Nerve transfers permit the coaptation of an uninjured nerve to the injured nerve thus placing an innervated nerve source close to the target muscle [3, 4]. This study reports the results of a patient following a thoracodorsal to long thoracic nerve transfer for the treatment of a long thoracic nerve palsy.

A 17-year-old, right-hand dominant man presented on July 19, 1994 with right shoulder weakness and scapular winging. He reported that a month before he was working out excessively with weight training and developed pain in the right shoulder region. The next day he awoke with severe pain and restriction of his shoulder movement. The following day, the pain subsided and he remained with restriction of his shoulder movement and scapular winging. He does not recall any other trauma. His past medical history is unremarkable and he takes no medications on a regular basis.

Physical examination revealed right scapular winging with shoulder flexion and less pronounced winging with shoulder abduction. Active shoulder abduction and flexion range of motion were 90 degrees and full passive shoulder range of motion was present. Electromyography 6 weeks following the onset of weakness revealed fibrillations and positive sharp waves in the right serratus anterior muscle. All other muscles including the right deltoid, biceps brachii, triceps, trapezius, infraspinatus, and latissimus dorsi revealed no abnormal muscle activity. On September 6, 1994 there was no clinical evidence of improvement and the electromyographic studies were repeated and revealed a decrease in spontaneous muscle activity (positive sharp waves and fibrillations) with no evidence of muscle reinnervation.

On September 30, 1994, the patient underwent surgical exploration of the long thoracic nerve and a thoracodorsal to long thoracic nerve transfer (Fig 1). Under general anesthesia, the right arm and anterior chest were prepped and a longitudinal incision was made along the free border of the latissimus dorsi muscle. The long thoracic nerve was identified and intraoperative nerve stimulation was performed with no recording along the long thoracic nerve. An appropriate size of a branch of the thoracodorsal nerve was divided and transferred to the long thoracic nerve using 9-0 microsutures and an epineurial nerve repair. The long thoracic nerve was exposed along the chest wall as proximal as possible to ensure that the majority of the serratus anterior muscle was innervated. A bulky dressing was applied and patient was immobilized in shoulder adduction and internal rotation for 2 weeks. Range of motion and physical therapy were instituted after that time.



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  		Fig 1. Schematic drawing of a branch of the thoracodorsal nerve transferred to the long thoracic nerve.

 
Because the patient lived a long distance away, he did not return for follow-up. On March 16, 2001, the patient returned to the office for an onset of similar weakness to the left arm in September 2000. On the left arm, he had full range of motion of the shoulder with moderate scapular winging with shoulder flexion. Because he had full shoulder flexion of his left arm overhead, it was felt that the left serratus anterior was functioning but weak. He was referred to physical therapy for strengthening exercises and recommendation for an electromyographic study of the left serratus anterior. On his right arm, 6.5 years following a thoracodorsal to long thoracic nerve transfer, he had full shoulder flexion with no scapular winging. He reported no functional limitation to his shoulder or to the donor site (Fig 2).



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  		Fig 2. (A) At rest, the patient presents with no scapular winging on the right side following a thoracodorsal to long thoracic nerve transfer, but on the left side he has new weakness with scapular winging. (B) The patient was able to do full shoulder flexion and presents no scapular winging when returning from the overhead position. (C) The incision is noted at the free border of the latissimus dorsi muscle. Full shoulder flexion is achieved by the patient.

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Injury to the long thoracic nerve will result in a severe functional shoulder deficit with scapular winging [1, 2]. In laceration injuries, a long thoracic nerve repair will yield a good result if the nerve repair is performed in a timely fashion and the injury is not so proximal as to be affected by a prolonged period of muscle denervation. In closed injuries where the level of injury is difficult to identify, surgical repair of the nerve may not be possible. In this case report, the etiology is difficult to determine. If the injury is a result of the trauma of weight lifting, it would be difficult to identify the level of the injury. Because of the anatomic location and length of the long thoracic nerve, nerve reconstruction options are limited by the long span of the nerve and difficulty localizing the injured area. However, in this case, because of the relatively minor trauma and onset of severe pain, the differential diagnosis would include a neuritis. These cases result in an injury to the cell body and therefore nerve reconstruction distal to the cell body may not produce optimal muscle strength of the reinnervated muscle.

Functional muscle recovery requires an adequate number of motor axons to reach the target muscle and reinnervate muscle fibers within a critical period of time [5]. Nerve transfers permit a direct nerve to nerve coaptation closer to the target muscle, and guide the motor axons directly to the target muscle. Reports of the surgical outcome following nerve repair or grafts to the long thoracic nerve are scarce. To our knowledge, there are no patient reports following a thoracodorsal to long thoracic nerve transfer, however, surgical results of other nerve transfers to other muscles have yielded good reinnervation of the target muscle with good functional recovery [6]. The selection of a donor nerve is important in the restoration of function and to minimize loss of function from the donor nerve. In this case report, the patient did not report any loss of shoulder function. This may be due to the large number of muscles that provide shoulder internal rotation and adduction. However, if the patient required strong scapular depression, as is required with ambulation with crutches, he may note weakness in performing that task.

While in this case report, it is likely that the patient sustained a neuritis resulting in a long thoracic nerve palsy, a nerve transfer to the long thoracic nerve may be used to restore neural function with other etiologies including iatrogenic nerve injuries. In cases of a high injury to the long thoracic nerve or to a delayed recognition of an injury, a thoracodorsal to long thoracic nerve transfer will provide a source of nerve close to the target muscle. Given the location of the long thoracic nerve along the thorax, it may be susceptible to injury with video-assisted thoracoscopic surgery port site placement or axillary thoracotomy incisions. Because of the severe loss of shoulder function following a long thoracic nerve injury, care should be taken to avoid injury to this nerve. Other expendable motor nerves such as motor intercostal nerve could also be considered for transfer to the long thoracic nerve. Surgical intervention using a thoracodorsal to long thoracic nerve transfer to reconstruct the nerve and restore neural continuity will allow reinnervation of the serratus anterior muscle providing good muscle strength and shoulder function.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Warner J.J., Navarro R.A. Serratus anterior dysfunction. Recognition and treatment. Clin Orthop 1998;349:139-148.
  2. Wiater J.M., Flatow E.L. Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
  3. Mackinnon S.E., Novak C.B. Nerve transfers. Hand Clin 1999;15:643-666.[Medline]
  4. Mackinnon S.E., Dellon A.L. Surgery of the peripheral nerve. New York: Thieme, 1988.
  5. Fu S.Y., Gordon T. Contributing factors to poor functional recovery after delayed nerve repair: prolonged denervation. J Neurosci 1995;15:3886-3895.[Abstract]
  6. Narakas A.O. Neurotization in the treatment of brachial plexus injuries. In: Gelberman R.H., ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991:1329-1358.



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