Shoulder reanimation in brachial plexus injury

Stabilization of the shoulder joint with restoration of its function constitutes one of the major objectives in the treatment of patients with upper brachial plexus injuries. Suprascapular and axillary nerves form the primary targets in achieving this goal. Currently, transfer of the distal SAN into SSN performed through an anterior approach is a standard procedure in management of patients with upper brachial plexus injuries.

Technique details

Patient is placed in the lateral position with head of the operating table being raised by 40 degrees. A 12 to 14 cm long incision is made parallel to the spine of scapula. The trapezius muscle is elevated from the scapular spine with the help of a pair of sharp scissors, and a plane is dissected between the trapezius and supraspinatus muscles. Trapezius muscle is gently elevated  to expose the neurovascular bundle on its undersurface, which is covered by a thin layer of epimysium. The SAN is isolated from the thin vessels and looped in a vascular tape. The nerve is dissected at a distal location. Working laterally on the superior border of scapula, a strong downward traction is applied on the upper border of the supraspinatus muscle which reveales the glistening white suprascapular ligament overlying the notch. The suprascapular artery and vein are ligated superficial to the ligament. The ligament is sectioned. Suprascapular nerve is identified in the adipose tissue proximal to the notch. The SAN is then dissected as distally as possible to allow a tension-free coaptation with the SSN. The SAN is sutured to the distal segment of the SSN with 10-0 nylon suture under an operating microscope. The trapezius muscle is sutured back to the spine of scapula with 3-0 polyglactin suture and skin incision is closed.