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Peripheral Nerve Injuries in the Cervicothoracic Region

There are many etiologies of peripheral nerve injuries in the cervicothoracic region. The injuries commonly involve the phrenic nerve Phrenic nerve The motor nerve of the diaphragm. The phrenic nerve fibers originate in the cervical spinal column (mostly C4) and travel through the cervical plexus to the diaphragm. Diaphragm: Anatomy, the suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy, the dorsal scapular nerve Dorsal scapular nerve Axilla and Brachial Plexus: Anatomy, the long thoracic nerve Long thoracic nerve Axilla and Brachial Plexus: Anatomy, or the thoracodorsal nerve Thoracodorsal nerve Axilla and Brachial Plexus: Anatomy. The nerves arise from the cervical plexus and brachial plexus. Causes of injury vary and may include trauma, compression Compression Blunt Chest Trauma, nerve entrapment, stretch or traction from repetitive movement, infection, surgical injury, or metabolic causes. Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor depends upon the motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology innervation of the affected nerves. Diagnosis is mostly clinical but may also be confirmed with imaging or electrodiagnostic studies. Depending on the specific injury, management may be either surgical or conservative ( physical therapy Physical Therapy Becker Muscular Dystrophy and avoidance of precipitating movements).

Last updated: 3 Dec, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Anatomy

Nerve roots emerge from the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy at the C1 level and below.

Cervical plexus

C1 through C4 nerve roots close to the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy merge to form the cervical plexus.

Cutaneous branches of the cervical plexus innervate the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions, transmitting sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology information:

  • C2: The lesser occipital Occipital Part of the back and base of the cranium that encloses the foramen magnum. Skull: Anatomy nerve innervates the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions on the posterolateral aspect of the head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.
  • C2, C3: The greater auricular nerve innervates the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions of the ear and the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions over the parotid glands Parotid glands The largest of the three pairs of salivary glands. They lie on the sides of the face immediately below and in front of the ear. Gastrointestinal Secretions.
  • C2, C3: The transverse cervical nerve innervates the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions on the anterior and lateral aspects of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.
  • C3, C4: The supraclavicular nerve innervates the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions of the shoulder and clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture region.

Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology branches of the cervical plexus innervate muscles of the shoulders and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess:

  • C1, C3: The ansa cervicalis (superior and inferior roots) innervates the infrahyoid muscles (omohyoid, sternohyoid, and sternothyroid) of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.
  • C1, C5: The segmental and other muscular branches innervate the deep muscles (geniohyoid and thyrohyoid) of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess and portions of the scalenes Scalenes Muscles of the Neck: Anatomy, levator scapulae, trapezius, and sternocleidomastoid Sternocleidomastoid Muscles of the Neck: Anatomy muscles.
  • C3, C5: The phrenic nerve Phrenic nerve The motor nerve of the diaphragm. The phrenic nerve fibers originate in the cervical spinal column (mostly C4) and travel through the cervical plexus to the diaphragm. Diaphragm: Anatomy innervates the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy.
Cervical plexus

Cervical plexus:
C1 through C4 nerve roots close to the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy merge to form the cervical plexus.

Image: “Cervical plexus” by Henry Vandyke Carter. License: Public Domain

Brachial plexus

C5 through T1 nerve roots merge to form the brachial plexus, which travels from the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy into the cervicoaxillary canal and the armpit. The nerves are divided into regions called trunks, divisions, cords, branches, and nerves.

  • Trunks: 
    • C5 and C6 roots merge to form the upper trunk.
    • The C7 root forms the middle trunk.
    • C8 and T1 roots merge to form the lower trunk.
  • Divisions: Each trunk divides into an anterior and posterior division, which creates 6 distinct divisions.
  • Cords are named with respect to the location of the axillary artery Axillary Artery The continuation of the subclavian artery; it distributes over the upper limb, axilla, chest and shoulder. Axilla and Brachial Plexus: Anatomy:
    • Anterior divisions of the upper and middle trunk form the lateral cord.
    • The anterior division of the lower trunk forms the medial cord.
    • Posterior divisions of all 3 trunks form the posterior cord.
  • Branches and nerves:
    • The long thoracic nerve Long thoracic nerve Axilla and Brachial Plexus: Anatomy arises from the roots of C5, C6, and C7.
    • The dorsal scapular nerve Dorsal scapular nerve Axilla and Brachial Plexus: Anatomy arises from the root of C5.
    • The suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy arises from the upper trunk.
    • The lateral cord divides and gives rise to the musculocutaneous nerve Musculocutaneous Nerve A major nerve of the upper extremity. The fibers of the musculocutaneous nerve originate in the lower cervical spinal cord (usually C5 to C7), travel via the lateral cord of the brachial plexus, and supply sensory and motor innervation to the upper arm, elbow, and forearm. Axilla and Brachial Plexus: Anatomy and contributes to the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve.
    • The posterior cord branches and gives rise to the axillary nerve Axillary nerve Axilla and Brachial Plexus: Anatomy, the subscapular nerve, the thoracodorsal nerve Thoracodorsal nerve Axilla and Brachial Plexus: Anatomy, and the radial nerve Radial Nerve A major nerve of the upper extremity. In humans the fibers of the radial nerve originate in the lower cervical and upper thoracic spinal cord (usually C5 to T1), travel via the posterior cord of the brachial plexus, and supply motor innervation to extensor muscles of the arm and cutaneous sensory fibers to extensor regions of the arm and hand. Axilla and Brachial Plexus: Anatomy.
    • The medial cord branches and contributes to the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve and then becomes the ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy. The medial cord also gives rise to the medial cutaneous nerves of the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy and forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy.
Brachial plexus

Schematic of the brachial plexus and the branches of the brachial plexus

Image by Lecturio.

Phrenic Nerve Injury

The phrenic nerve Phrenic nerve The motor nerve of the diaphragm. The phrenic nerve fibers originate in the cervical spinal column (mostly C4) and travel through the cervical plexus to the diaphragm. Diaphragm: Anatomy arises from anterior rami of C3, C4, and C5 nerve roots and provides motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology innervation to the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy:

Etiology of injury

  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) and thoracic surgery Thoracic Surgery Basic surgical intervention in the thoracic cavity has the primary goal of alleviating any malady that mechanically affects the function of the heart and lungs, which can be secondary to underlying pathologies or, most commonly, trauma. Interventions include tube thoracostomy, thoracentesis, and emergency thoracotomy. Thoracic Surgery
  • Blunt or penetrating trauma
  • Metabolic diseases (e.g., diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus)
  • Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease (e.g., Lyme disease Lyme disease Lyme disease is a tick-borne infection caused by the gram-negative spirochete Borrelia burgdorferi. Lyme disease is transmitted by the black-legged Ixodes tick (known as a deer tick), which is only found in specific geographic regions. Patient presentation can vary depending on the stage of the disease and may include a characteristic erythema migrans rash. Lyme Disease, herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox)
  • Tumor Tumor Inflammation invasion
  • Cervical spondylosis Cervical Spondylosis Neck Pain
  • Multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis
  • Myopathy Myopathy Dermatomyositis
  • Immunologic diseases (e.g., Guillain-Barré syndrome Guillain-Barré syndrome Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Guillain-Barré Syndrome)

Clinical features

Clinical features vary and depend upon the extent of the injury. Clinical features depend on whether nerves are injured bilaterally or unilaterally:

  • General:
    • Shortness of breath Shortness of breath Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Recurrent pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
    • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia
    • Morning headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
    • Excessive daytime somnolence
    • Orthopnea Orthopnea Pulmonary Edema
    • Fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
  • Unilateral diaphragmatic paralysis:
    • Asymptomatic at rest
    • Exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Often found as an incidental finding on chest radiograph
  • Bilateral diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy paralysis: severe shortness of breath Shortness of breath Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea

Physical examination

Diagnosis

  • Imaging:
    • Upright inspiratory chest radiograph:
      • Unilateral: elevated hemidiaphragm
      • Bilateral: smooth elevation of hemidiaphragm with small lung volumes, deep and narrow costophrenic and costovertebral sulci
    • Fluoroscopy Fluoroscopy Production of an image when x-rays strike a fluorescent screen. X-rays:
    • Diaphragmatic ultrasonography (diaphragmatic movement and thickness)
  • Pulmonary function tests and arterial blood gases
  • Diaphragmatic electromyography Electromyography Recording of the changes in electric potential of muscle by means of surface or needle electrodes. Becker Muscular Dystrophy
  • Measurement of transdiaphragmatic pressure

Management

  • Unilateral diaphragmatic paralysis:
    • Most are asymptomatic and do not require treatment.
    • Surgical plication
    • Transient ventilatory support
  • Bilateral diaphragmatic paralysis:

Suprascapular Nerve Injury

The suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy arises from the upper trunk of the brachial plexus (C5, C6) and gives:

  • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology innervation to the supraspinatus and infraspinatus muscles
  • Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology innervation to the glenohumeral and acromioclavicular joints

Injury most commonly occurs at the suprascapular notch, the spinoglenoid notch, or the superior transverse scapular ligament.

Suprascapular and axillary nerves of right side

The path of the suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy:
The suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy is most commonly injured at the suprascapular notch, the spinoglenoid notch, or the superior transverse scapular ligament.

Image: “Suprascapular and axillary nerves of right side, seen from behind” by Henry Vandyke Carter. License: Public Domain

Etiology of injury

  • Nerve entrapment in the suprascapular or spinoglenoid notch (also known as suprascapular nerve Suprascapular nerve Axilla and Brachial Plexus: Anatomy entrapment syndrome)
  • Trauma
  • Stretch or traction from repetitive movement (often in athletes)
  • Compression Compression Blunt Chest Trauma by a mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast:
    • Ganglion cyst Ganglion cyst Nodular tumor-like lesions or mucoid flesh, arising from tendon sheaths, ligaments, or joint capsule, especially of the hands, wrists, or feet. They are not true cysts as they lack epithelial wall. They are distinguished from synovial cysts by the lack of communication with a joint cavity or the synovial membrane. Examination of the Upper Limbs
    • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types cyst
    • Tumor Tumor Inflammation

Clinical features

  • Shoulder pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (impingement at the suprascapular notch)
  • Painless weakness (impingement at the spinoglenoid notch)
  • Dysfunction of shoulder abduction Abduction Examination of the Upper Limbs (supraspinatus weakness)
  • Dysfunction of shoulder external rotation External Rotation Examination of the Upper Limbs (infraspinatus weakness)
  • Muscle atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation

Diagnosis

  • Clinical (based on clinical features of disease):
    • Classic finding: aching pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the superior and posterior shoulder
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may radiate to the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy or neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.
    • Typically, symptoms worsen slowly.
  • Electrodiagnostic studies are the gold standard for diagnosis: evaluation of nerve latency, amplitude, fibrillation, and sharp waves
  • Imaging: 
    • Radiograph can show bony disease.
    • CT is useful for nerve impingement or abnormality.
    • MRI can identify soft tissue Soft Tissue Soft Tissue Abscess disease.

Management

  • Conservative management:
    • May help individuals with isolated neuropathy Neuropathy Leprosy
    • Improvement or resolution may take 12 months.
    • Antiinflammatory medications
    • Physical therapy Physical Therapy Becker Muscular Dystrophy (to preserve the range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs and strengthen shoulder/rotator cuff muscles)
    • The individual should avoid precipitating movements.
    • Ultrasound-guided injections
  • Surgical release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology (i.e., transverse scapular ligament)
  • Arthroscopic nerve decompression
  • Surgical excision (e.g., cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change, tumors)

Dorsal Scapular Nerve Injury

The dorsal scapular nerve Dorsal scapular nerve Axilla and Brachial Plexus: Anatomy arises from the anterior ramus of the C5 nerve root:

  • Innervates rhomboid major and minor muscles (retract, elevate, and stabilize the scapula)
  • Innervates the levator scapulae (elevates the scapula, inferiorly rotates the glenoid cavity)

Etiology and clinical features

Dorsal scapular nerve Dorsal scapular nerve Axilla and Brachial Plexus: Anatomy syndrome is caused by nerve compression Compression Blunt Chest Trauma:

  • Cause of injury: nerve entrapment due to hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation of the middle scalene muscle
  • Clinical features vary, but the classic appearance is a “winged scapula”:
    • Winged scapula: The scapula is further from the midline than the noninjured side.
    • Limited range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (inability to pull the shoulder back)
    • Shoulder pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy
    • Midscapular dysesthesia Dysesthesia Complex Regional Pain Syndrome (CRPS)
Scapula winging

Scapula winging:
A winged scapula can result from dorsal scapular nerve injury Nerve Injury Surgical Complications.

Image: “Right sided Winging of Scapula” by Dwaipayanc. License: CC BY-SA 3.0

Management

Conservative management is preferred. Surgery is reserved for individuals with severe injury refractory to nonoperative means:

Long Thoracic Nerve Injury

The long thoracic nerve Long thoracic nerve Axilla and Brachial Plexus: Anatomy is a pure motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology nerve, which travels inferiorly along the serratus anterior muscle Serratus anterior muscle Chest Wall: Anatomy:

Etiology

  • Neuralgic amyotrophy Neuralgic amyotrophy Mononeuropathy and Plexopathy
  • Surgery (e.g., breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer surgery)
  • Trauma or compression Compression Blunt Chest Trauma (e.g., underarm injury from athletics)
  • Stretch or traction from repetitive activities (e.g., carrying a heavy weight for a prolonged period of time)

Clinical features

Clinical features are generally minimal. Classic findings and symptoms may be present in more severe cases:

Management

  • Conservative management (preferred):
  • Surgery:
    • Muscle transfer
    • Fascial graft Graft A piece of living tissue that is surgically transplanted Organ Transplantation
    • Nerve transfer (using thoracodorsal or medial pectoral nerve)

Thoracodorsal Nerve Injury

Thoracodorsal nerve Thoracodorsal nerve Axilla and Brachial Plexus: Anatomy:

Etiology

Thoracodorsal nerve injury Nerve Injury Surgical Complications can occur from surgical injury during axillary dissection for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer.

Clinical features

Diagnosis

Management

Latissimus dorsi muscle

Latissimus dorsi muscle (part of the superficial or extrinsic posterior axioappendicular muscles)

Image by BioDigital, edited by Lecturio

References

  1. Reece C.L., Varacallo M., Susmarski A. (2020). Suprascapular Nerve Injury. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK559151/
  2. Rutkove S.B. (2019). Overview of upper extremity peripheral nerve syndromes. In Shefner J.M. et al. (Ed.), UpToDate. Retrieved August 27, 2021, from https://www.uptodate.com/contents/overview-of-upper-extremity-peripheral-nerve-syndromes
  3. Celli B.R. (2021). Causes and diagnosis of unilateral diaphragmatic paralysis and eventration in adults. In King T.E. et al. (Ed.), UpToDate. Retrieved August 27, 2021, from https://www.uptodate.com/contents/causes-and-diagnosis-of-unilateral-diaphragmatic-paralysis-and-eventration-in-adults
  4. Celli B.R. (2021). Causes and diagnosis of bilateral diaphragmatic paralysis. In King T.E. et al. (Ed.), UpToDate. Retrieved August 27, 2021, from https://www.uptodate.com/contents/causes-and-diagnosis-of-bilateral-diaphragmatic-paralysis
  5. Celli B.R. (2021). Treatment of diaphragmatic paralysis. In Shefner J.M. et al. (Ed.), UpToDate. Retrieved August 27, 2021, from https://www.uptodate.com/contents/treatment-of-diaphragmatic-paralysis
  6. Mandoorah S., Mead T. (2020). Phrenic Nerve Injury. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482227/
  7. Watson L.J. (2021). Brachial plexus. Geeky Medics. https://geekymedics.com/brachial-plexus/
  8. Chu B., Bordoni B. (2020). Anatomy, Thorax, Thoracodorsal Nerves. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK539761/
  9. Bishop K.N., Varacallo M. (2021). Anatomy, Shoulder and Upper Limb, Dorsal Scapular Nerve. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK459343/

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