Meta-Analysis of Long Thoracic Nerve Decompression and Neurolysis Versus Muscle and Tendon Transfer Operative Treatments of Winging Scapula.

BACKGROUND: Injury to long thoracic and the spinal accessory nerves can cause winging scapula as a result of weakness and paralysis of the trapezius and serratus anterior muscles. Although these nerve and muscle operations have been reported to correct winging scapula due to various causes, there is no report on comparing the outcomes of these procedures in peer-reviewed Pubmed-indexed literature. In this article, we compared the improvements in the restoration of shoulder functions in winging scapula patients after long thoracic nerve decompression (LTND) in our present study with outcomes of muscle and tendon transfer operations published in the literature (Aetna cited articles).
METHODS: Twenty-five winging scapula patients met the inclusion criteria, who had LTND and neurolysis at our clinic since 2008. Electromyographic evaluation of the brachial plexus and long thoracic nerve distribution was performed preoperatively for all our patients in this study. Operating surgeon (R.K.N.) examined all patients and measured pre- and postoperative range of motion of the affected shoulder. The mean follow-up was 23 months (range, 13-46 months). Age of our patients in this study at the time of surgery was between 13 and 63 years. These patients had winging scapula between 5 days (tennis injury) and several years before surgery and some were unknown.
RESULTS: Shoulder flexion and abduction improved to an average of 163˚ (P < 0.000006) and 157˚ (P < 0.0000005) from 104˚ and 97˚ at least 1-year post-LTND in 25 winging scapula patients in our present study. This is statistically significant in comparison to the reported improvements resulting from muscle and tendon transfer procedures in the Pubmed-indexed (Aetna cited) literature.
CONCLUSION: This meta-analysis suggests that nerve surgeries such as LTND and neurolysis are effective techniques in correcting winging scapula in comparison with muscle transfer operations.

BACKGROUND

Injuries to long thoracic and the spinal accessory nerves are the most frequent cause of winging scapula[1,2] as a result of weakness and paralysis of the trapezius and serratus anterior muscles.[3] Dynamic winging scapula[4] resulting from long thoracic and the spinal accessory nerve palsy is restored in general by nerve decompression and neurolysis.[5-9] Static winging scapula[4] in muscular dystrophy, facioscapulohumeral dystrophy, is corrected mainly by scapulothoracic fusion/arthrodesis and tendon transfer procedures.[2,10-17]

In this article, we report statistically significant improvements in shoulder flexion and abduction in 25 winging scapula patients by long thoracic nerve decompression (LTND) and neurolysis. Further, reporting meta-analysis of our present data, and our published results in this subject versus the reported outcomes of muscle or tendon transfer procedures in the restoration of shoulder functions in winging scapula patients in the Pubmed (Aetna cited) literature.

METHODS AND PATIENTS

We retrospectively analyzed our patients’ records, who had LTN decompression and neurolysis[6,7] since 2008. This excludes our winging scapula patients in our previous publications.[6,7] Twenty-five winging scapula patients met the inclusion criteria in our present study, who had LTN decompression and neurolysis at our clinic since 2008 and had postoperative follow-up over 1 year. Electromyographic evaluation of the brachial plexus and long thoracic nerve distribution was performed[8,18] preoperatively for all our patients in this study. Operating surgeon (R.K.N.) examined all patients and measured pre- and postoperative range of motion of the affected shoulder. We adhered to the following inclusion and exclusion criteria of our patients from LTND surgery in our present study.

Inclusion Criteria

Articles from Aetna document that are indexed in Pubmed, reporting Active Range of Motion (AROM), shoulder flexion and abduction, in winging scapula patients, who had muscle and tendon transfer procedures.

Surgical outcomes of our patients’ data that was published already.

Case reports and review articles.

RESULTS

Scapular winging was present on physical examination in all patients. The mean follow-up was 23 months (range, 13–46 months). Age of our patients in this study at the time of surgery was between 13 and 63 years. These patients had winging scapula between 5 days (tennis injury) and several years before surgery and some were unknown. The cause of winging scapula, age at the time of surgery, the time between injury and surgery in our study patients are given in Table 1.

Table 1.

Demographic of LTND Patients in this Study

Electrophysiological studies (motor and sensory nerve conduction) showed a delayed distal latency and revealed evidence of active denervation in the serratus anterior muscle/long thoracic nerve in the affected side of our patients in this study, who had undergone LTND and neurolysis.

Shoulder flexion and abduction improved to an average of 163˚ (P < 0.000006) and 157˚ (P < 0.0000005) from 104˚ and 97˚ at least 1 year post-LTND in 25 winging scapula patients in our present study (Table 2; Fig. 1).

Table 2.

Improvement of AROM in 25 Winging Scapula Patients after LTND in the Present Study

Fig. 1.

Apparent improvement in shoulder abduction and flexion from 0˚ AROM to 170˚ after LTND and neurolysis in the winging scapula patient at our clinic in this report. A 13-year-old boy with right winging scapula resulting from exercise and over use of the arm. A and B, Pre- and postoperative (LTDN) pictures. Apparent improvement from 0˚ AROM to 170˚.

This is statistically significant in comparison with the reported improvements resulting from muscle and tendon transfer procedures in the Pubmed-indexed (Aetna cited) literature (Fig. 2).

Fig. 2.

Outcomes of LTND versus muscle and tendon transfer operations in winging scapula patients.

Further, we compared this improvement after LTND with outcomes of muscle transfer surgical procedures published in the Pubmed-indexed literature (Aetna cited articles) and summarized in Table 3.

Table 3.

This Table Summarizes the Improvements of LTND Versus Other Muscle Procedures Published in the Pubmed-Indexed Literature (Aetna Cited Articles) in Winging Scapula Patients

DISCUSSION

Some of our patients had unsuccessful nonoperative treatments, such as physical therapies and bracing. Other investigators have reported that at least a quarter of winging scapula patients did not respond to nonsurgical therapies.[19] Studies involved muscle procedures that have not reported the improvement of shoulder abduction and flexion angle from Table 3 (Pahys et al.,[13] Galano et al.,[2] Wiater and Flatow[16]) are also excluded in the meta-analysis report in Figure 2.

Investigators, who performed muscle and tendon transfer procedures, reported their patients’ outcomes and improvements in shoulder abduction and flexion are shown in figure 2 (Aetna list) to compare to our patients’ outcomes after LTND. However, they have not reported whether their data were statistically significant or not, except for Glenn Jr, and Romeo, 2005.[20] Teboul et al.[21] suggested neurolysis, nerve graft, or repair within 6–12 months in injuries resulting from surgery or penetrating trauma. Some of our winging scapula patients in this report had onset over 12 months, and yet they had significant improvement after LTN decompression and neurolysis.

CONCLUSION

This meta-analysis report suggests that nerve surgeries such as long thoracic or spinal accessory nerve decompression and neurolysis are effective techniques in correcting winging scapula in comparison with muscle and tendon transfer operations.

PATIENT CONSENT

The patient provided written consent for the use of his image.

ACKNOWLEDGMENTS

We thank the patients and families who participated in this study.

Institutional Review Board Statement: This was a retrospective study of patient charts, which exempted it from the need for IRB approval in the United States. Patients were treated ethically in compliance with the Helsinki declaration. Documented informed consent was obtained for all patients.