ARTHROSCOPIC SUPRASCAPULAR NERVE RELEASE
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1 ARTHROSCOPIC SUPRASCAPULAR NERVE RELEASE Laurent Lafosse & Robert Fullick Alps Surgery Institute Annecy France DISCLOSURE Royalties Depuy Consultant Depuy Stock options ITS Stock options Orthospace 1
2 Background Thompson and Koppel, NEJM first described Suprascapular nerve entrapment at the SS notch. Background Rengachary et al., Neurosurgery the SSN is relatively constrained and fixed at the level of the suprascapular notch. 2
3 ANATOMY 3
4 ANATOMY ANATOMY D après MORIGGL et coll 4
5 SSN Dysfunction: Causes Primary 1. Idiopathic Secondary 1. Direct trauma 2. Traction injury (isolated trauma or massive, retacted cuff tear) 3. Repetitive over- use injury 4. Cysts or space- occupying lesions. 5
6 Patient Presentation Pain Posterior- superior shoulder Often Dull and achy in nature Worse with overhead activities Weakness and fatigue? History of trauma Patient Presentation Relatively uncommon High clinical suspicion! 6
7 Physical Exam Supra and Infraspinatus atrophy Physical Exam Supra and Infraspinatus atrophy Tenderness at post- sup shoulder Weakness with Jobe and ER Preserved motion 7
8 SSN Stretch Test Physician positioned behind patient STOP BEFORE IT BREAKS Lateral head rotation Away from pain Scapula & shoulder retraction (involved shoulder) Reproduces shoulder pain Diagnostic EMG Bilateral +++ Speed of the nerve (waiting time) Conduction (Intensity) Difficult to interpret! Neg EMG No SSN release 8
9 Diagnostic EMG In our opinion, SSN compression at the SS notch is a dynamic process. EMG/NCVs conducted in a comfortable, seated position may not reproduce the dynamic situation causing symptoms in most patients, and may affect the test accuracy. Diagnostic Injection G portal: ~2cm medial to Nevaiser s portal Needle angled slightly post to anterior 3-5cc of 1-2% Lido + Test: Sig pain relief 9
10 Indications Difficult to define! Non- operative Management Consider. Physical therapy Infiltration Prolonged course = Atrophy = worse outcomes 10
11 Operative Management 2 LOCATIONS Spino- glenoid Notch Suprascapular notch Operative Management Spinoglenoid Notch SSN Entrapment at the Spinoglenoid Notch: Caused by: Hypertrophied Ligament Repetitive overhead activities Damage of Neurovascularization Compression by Mass Release in RCT Can be adressed arthroscopically: From intraarticular From extraarticular 11
12 SSN Pathology at the Scapular Notch 12
13 Operative Management Open Surgery Difficult access (deep, narrow, bleeding) Through Trapezium Long surgery (surgeon & patient) Arthroscopic surgery Landmarks Fast & reliable Arthroscopic Release Scapular Notch How to do it? Technique for Endoscopic release of the Suprascapular nerve at the Suprascapular Notch Techniques in Shoulder and Elbow Surgery 7(1); 1-6, March 2006 Lafosse L, Tomasi A 13
14 Medial Exposure Deap breath! Pull scope back! Relocate landmarks 14
15 Indications When to do it? Series 3 groupes: GRP 1 (Isolated SSN Palsy) : 29 cases GRP 2 (Post Sup RCT): 32 cases GRP 3 (RCR Failure): 18 cases All EMG pre & post 6 months 3 GROUPES OF SSN 1. Normal Cuff (Isolated, GGcyst, ) 2. Cuff tear 3. After Cuff repair 15
16 Primary SSN Palsy Supra & Infraspinatus Palsy Muscle Atrophy NO cuff tear Normal MRI & CTscan => Positive EMG Primary SSN Palsy Idiopathique Weakness for External Rotation & Abduction Muscle Atrophy of SSP & ISP Normal MRI- / CTscan No cuff tear / mass => EMG: positive WHAT DID WE DO? Arthroscopic SSN Release January 2007 All improved and EMG => NRL This means, the technique works! 16
17 3 GROUPES OF SSN 1. Normal Cuff (Isolated, GGcyst, ) 2. Cuff tear 3. After Cuff repair SSN + ISP RC Tear 32 cases 165 Post Sup RCT (2T) Oct 2004 => Dec EMG (29,7%) 17 SSN Normal (34,7%) 7 Large 10 Massive 32 + (65,3%) 10 Large 22 Massive 17
18 SSN Pathology at the Scapular Notch Primary SSN Palsy Secondary SSN Palsy Ganglion cyst Cuff Tear Stripping (sport, work, injury) Cuff Release Glenoid Rim: supraglenoid tubercle scapular spine 2 cm 1 cm Safe Zone (Bigliani LU 1990) Neurovascular Structures at Risk 18
19 In context with RC-Tear SLING EFFECT Movement (Rengarchy) Retraction Before RC Repair! After RC Repair! Reduction (Warner JJP JBJS 1992) Neurovascular Structures at Risk 1/ Postero Rotator Cuff TEAR Effect??? Tendon tear => Supra Spinatus Muscle Retraction => Nerve Traction 19
20 Rotator Cuff Tear SHAPE of the TENDON LESION + MUSCLE CONTRACTION = DIRECTION of RETRACTION ANT L SHAPE POST RETRACTION 20
21 2/ Postero Rotator Cuff REPAIR Effects??? 21
22 Rotator cuff tear and SSN Study 2009 Hypothesis: Rotator cuff reduction and repair affects suprascapular nerve conduction. Questions: Is a surgical release of the SSN necessary? Does cuff repair and reduction lead to SSN neuropathy? If yes, which cuff tears predispose to this? (pre- op, peri- op and post- op data examined) Rotator cuff tear and SSN Study : 540 rotator cuff tear repairs performed 230/540 had both pre- op EMG and Arthro- CT/ MRI All these patients have been contacted for review in
23 Material and Methods CT preoperative EMG preoperative 2009 CT postoperative EMG postoperative 2 years follow up 4 groups of patients Cuff + EMG normal NO release Cuff + EMG normal PLUS release Group A Group B 32 Cuff + EMG + PLUS release Group D Group C Cuff + EMG + NO release 9 23
24 No significant result Number of patient should be encreased to get reliable conclusion. Today on my mind negative EMG is not reliable 3 GROUPES OF SSN 1. Normal Cuff (Isolated, GGcyst, ) 2. Cuff tear 3. After Cuff repair 24
25 Secondary SSN Palsy: After cuff repair!!! 10 Cases after perfect REPAIR of the cuff but: PAIN: Posterior shoulder WEAKNESS: Supra & Infraspinatus WHAT DID WE DO? Arthro CT scan Intact Cuff SSN-RELEASE CLINIC IMMEDIATE IMPROVEMENT EMG POSITIVE pathological EMG 7x NORMALIZATION 1x no change 2x lost to FU 25
26 Indications for SSN release 1. + Characteristic pain, weakness & muscle atrophy + SSN stretch test, + EMG/NCV, +/- RCT Characteristic shoulder pain and exam findings, + SSN test, normal/equivocal EMG/NCV, +/- RCT Pain and exam findings, - SSN test, normal/equivocal EMG/NCV, + diagnostic injection. Indications for SSN release 4. + Pain and disability, weakness, large to massive superior and posterior- superior RCT. 5. RCT, significant muscle atrophy limited RCT tear intra operative SSN entrapment 6. + Pain, disability, dysfunction, atrophy, +/- SSN test, after healed rotator cuff repair. 26
27 To RELEASE Or NOT to RELEASE? Conclusion New arthroscopic surgery Difficult and tricky But if you don t beat the Nerve he is not going to beat you! Very efficient and fast when experience 3 possible situations Diagnosis is not EMG Think of it and see it! 27
28 Thank you! 28
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