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Total Subperiosteal Approach to Suprascapular Nerve Decompression: A Technique to Relieve Entrapment by the Superior Transverse Suprascapular Ligament

de Jesus, Ramon A. M.D.; Xu, Jie B.S.; Ferrari, Jonathan B.S.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 35e-36e
doi: 10.1097/PRS.0b013e3181905739
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Sir:

Chronic shoulder pain and dysfunction secondary to suprascapular neuropathy due to nerve entrapment under the superior transverse scapular ligament can be cured with surgical nerve decompression.1 The three main approaches to suprascapular nerve decompression are the anterior, superior, and posterior, with the most common technique being variations of a posterior approach.1,2 With the conventional posterior approaches, blunt or sharp dissection of the supraspinatus and trapezius muscles and their retraction3–5 afford a poor view of the superior transverse scapular ligament. Today, we introduce a new subperiosteal variation of the posterior approach that provides an unobstructed view of the ligament, which facilitates its successful and safe resection.

The total subperiosteal technique was performed on a 62-year-old man with chronic right shoulder pain and confirmed suprascapular nerve compression via physical examination, lidocaine block, and electromyogram. Surgical intervention began with a skin incision made posteriorly, 1 cm cephalad and 7 cm in length, parallel to the spine of scapula. Fiber splitting and dissection of the trapezius as described by Fabre et al.5 were deferred in favor of subperiosteal elevation of the trapezius to expose the underlying supraspinatus muscle. Post and Mayer3 and Topper4 described blunt dissection with posterior retraction of the supraspinatus muscle, but continuing a subperiosteal approach proves more practical. While preserving the tendinous origin of the supraspinatus muscle at the supraspinatus fossa, subperiosteal dissection of the supraspinatus muscle continued cephalad and laterally, with retraction of the muscle superiorly to expose the suprascapular notch.

A fat pad surrounds the suprascapular nerve as it traverses the suprascapular notch, impeding visualization of the superior transverse scapular ligament.4 This structure can be easily retracted by a Woody Woodsen elevator, as suggested by Topper,4 and an unobstructed visualization of the suprascapular notch, nerve, and vessels can be obtained. This proves much safer than attempting to locate the ligament with an index finger.5 In our case, superior transverse scapular ligament compression of the suprascapular nerve (Fig. 1) was alleviated by using a 3-mm narrow rongeur to resect the ligament at its bony attachments (Fig. 2). A nerve hook was used to retract and protect the suprascapular vessels and nerve during resection. The supraspinatus muscle was allowed to recede back into its fossa, and both trapezius and supraspinatus muscles were reattached at the spine of the scapula.

Fig. 1.
Fig. 1.:
Cephalad retraction of the supraspinatus and trapezius muscles after subperiosteal dissection exposes the superior transverse scapular ligament (arrow).
Fig. 2.
Fig. 2.:
Suprascapular nerve decompression after removal of the superior transverse scapular ligament at its bony attachment (arrow).

The total subperiosteal technique avoids direct dissection of the trapezius and supraspinatus muscles, which minimizes intraoperative muscle injury. Because of this, rehabilitation can be hastened, resulting in a quicker return to a patient's baseline function. In addition, this technique provides unobstructed visualization of the superior transverse scapular ligament and safe retraction of surrounding neurovascular structures, thereby allowing controlled, safe release of the suprascapular nerve. In cases of isolated infraspinatus muscle involvement, this technique also allows for distal suprascapular nerve survey for compression at the spinoglenoid notch. Lastly, with increased use and subsequent proficiency in this technique, minimization of total surgical incision length and tissue disruption will occur and augment the overall benefit of reduced muscle fiber disruption.

Ramon A. de Jesus, M.D.

Jie Xu, B.S.

Jonathan Ferrari, B.S.

Department of Surgery

Union Memorial Hospital

Baltimore, Md.

REFERENCES

1. Shupeck M, Onofrio BM. An anterior approach for decompression of the suprascapular nerve. J Neurosurg. 1990;73:53–56.
2. Weinfeld AB, Cheng J, Nath RK, Basaran I, Yuksel E, Rose JE. Topographic mapping of the superior transverse scapular ligament: A cadaver study to facilitate suprascapular nerve decompression. Plast Reconstr Surg. 2002;110:774–779.
3. Post M, Mayer J. Suprascapular nerve entrapment, diagnosis and treatment. Clin Orth. 1987;223:126–136.
4. Topper SM. The utility of spine surgery instrumentation in decompression of the suprascapular notch. Am J Orthop. 1998;27:151–152.
5. Fabre T, Piton C, Leclouerec G, Gervais-Delion F, Durandeau A. Entrapment of the suprascapular nerve. J Bone Joint Surg (Br). 1999;81:414–419.

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