BACKGROUND: Conventionally, neural transfer of the spinal accessory nerve to the suprascapular nerve for shoulder abduction in traumatic brachial plexus injury is performed via the anterior approach. However, important advantages of the posterior approach have made it an alternative option, such as the proximity of neural coaptation to the muscle to be reinnervated and negating the effects of a second injury to the suprascapular nerve.
METHODS: Retrospective data was collected from 30 patients with brachial plexus injury who underwent spinal accessory nerve to suprascapular nerve transfer over 4 years. There were 15 patients in the anterior-approach group (group A) and 15 in the posterior-approach group (group B). Functional outcome at the shoulder was measured as muscle power and active range of motion at 18 months, and data on patients\' satisfaction levels and surgeons\' perceptions was also collected.
RESULTS: No statistical difference was found in the muscle strength achieved in the 2 groups (P = 0.34), but significant recovery was found in the external rotation achieved by group B (P = 0.02). Statistical difference was insignificant in the 2 groups\' active range of motion during abduction and external rotation. The satisfaction index of patients was 86.7% in group B as compared to 68% in group A. Surgeons\' perspective showed a faster speed of suprascapular nerve exploration in the posterior approach, with better visibility of supraspinatus muscle contraction, and overall surgeons preferred the posterior approach.
CONCLUSIONS: External rotation at the shoulder is better via the posterior approach, but no difference in abduction was noted. Patients who underwent the posterior approach were more satisfied with the recovery, and surgeons preferred the posterior approach.

Objective: Percutaneous electrical nerve stimulation (PENS) appears to be effective for the treatment of musculoskeletal pain. The aim of this trial was to investigate the effects on disability and pain, as well as on the psychological aspects of adding PENS into an exercise program in patients with subacromial pain syndrome. Methods: A randomized, parallel-group clinical trial was conducted. Sixty patients with subacromial pain were allocated into exercise alone (n = 20), exercise plus PENS (n = 20), or exercise plus placebo PENS (n = 20) groups. Patients in all groups performed an exercise program twice daily for 3 weeks. Patients allocated to the PENS group also received four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves. Patients allocated to the exercise plus placebo PENS received a sham PENS application. The primary outcome was related disability (Disabilities of the Arm, Shoulder, and Hand, DASH). Secondary outcomes included mean pain, anxiety levels, depressive symptoms, and sleep quality. They were assessed at baseline, one week after, and one and three months after. An analysis was performed using intention-to-treat with mixed-models ANCOVAs. Results: The results revealed no between-group differences for most outcomes (related disability: F = 0.292, p = 0.748, n2p = 0.011; anxiety: F = 0.780, p = 0.463, n2p = 0.027; depressive symptoms: F = 0.559, p = 0.575, n2p = 0.02; or sleep quality: F = 0.294, p = 0.747, n2p = 0.01); both groups experienced similar changes throughout the course of this study. Patients receiving exercise plus PENS exhibited greater improvement in shoulder pain at one month than those in the exercise (Δ -1.2, 95%CI -2.3 to -0.1) or the placebo (Δ -1.3, 95%CI -2.5 to -0.1) groups. Conclusions: The inclusion of four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves into an exercise program did not result in better outcomes in our sample of patients with subacromial pain syndrome at one and three months after treatment.

UNASSIGNED: Painful shoulder is one of the most frequent consultation causes. Multiple treatments have been described to relieve pain, restore range of motion and improve functionality.
UNASSIGNED: This randomised clinical trial was conducted in 60 patients. The treatment group received combined pulsed radiofrequency (PRF) on suprascapular nerve (SN) and axillary-circumflex nerve (ACN). The control group received PRF on SN only. The primary outcome was pain intensity measured by the Numerical Rating Scale (NRS). The secondary outcomes were the Shoulder Pain and Disability Index (SPADI), the Constant-Murley range of motion scale and Disability of the Arm, Shoulder and Hand (DASH) scale. The patients were monitored at the baseline visit and at 1, 3, 6 and 9 months. A mixed ordinal regression model was estimated to evaluate the association between the study group and pain measured with NRS.
UNASSIGNED: A global decrease in pain at the end of the study was noted. The global baseline NRS was 8.4, and the global final NRS at 9 months of follow-up was 6.2. Combined PRF on SN and ACN was not associated with lower NRS pain scores compared to single SN PRF [odds ratio (OR) =1.04, 95% confidence interval (CI) 0.91-1.20, P = 0.507]. Secondary outcomes showed no significant differences: SPADI (OR = 1.04, 95% CI 0.92-1.18), Constant-Murley (OR = 1.01, 95% CI 0.90-1.14), DASH (OR = 1.04, 95% CI 0.92-1.17).
UNASSIGNED: Combined PRF applied to SN and ACN was not superior to PRF applied to SN alone.

OBJECTIVE: The open Trillat Procedure described to treat recurrent shoulder instability, has a renewed interest with the advent of arthroscopy. The suprascapular nerve (SSN) is theoretically at risk during the drilling of the scapula near the spinoglenoid notch. The purpose of this study was to assess the relationship between the screw securing the coracoid transfer and the SSN during open Trillat Procedure and define a safe zone for the SSN.
METHODS: In this anatomical study, an open Trillat Procedure was performed on ten shoulders specimens. The coracoid was fixed by a screw after partial osteotomy and antero-posterior drilling of the scapular neck. The SSN was dissected with identification of the screw. We measured the distances SSN-screw (distance 1) and SSN-glenoid rim (distance 2). In axial plane, we measured the angles between the glenoid plane and the screw (α angle) and between the glenoid plane and the SSN (β angle).
RESULTS: The mean distance SSN-screw was 8.8 mm +/-5.4 (0-15). Mean α angle was 11°+/-2.4 (8-15). Mean β angle was 22°+/-6.7 (12-30). No macroscopic lesion of the SSN was recorded but in 20% (2 cases), the screw was in contact with the nerve. In both cases, the β angle was measured at 12°.
CONCLUSIONS: During the open Trillat Procedure, the SSN can be injured due to its anatomical location. Placement of the screw should be within 10° of the glenoid plane to minimize the risk of SSN injury and could require the use of a specific guide or arthroscopic-assisted surgery.

BACKGROUND: Continuous peripheral nerve blocks are commonly used for pain management. However, the incidence of catheter dislodgement or migration is unclear, and may be underestimated and underreported. Our objective was to assess suprascapular catheter tip positioning before and after routine simulated shoulder physiotherapy manipulation in an anatomical cadaver model.
METHODS: Eight ultrasound-guided continuous suprascapular nerve block catheters were placed in cryopreserved fresh cadavers. Computed tomography (CT) confirmed the location of the catheter tip after injection of 1 ml of contrast medium. We performed a series of standardized shoulder movements during a simulated shoulder physiotherapy session in cadavers. Following this, we administered 1 ml of methylene blue through the catheters, and then performed anatomical dissections to accurately identify the location of the catheter tips and compare them to their placement prior to the \'physiotherapy\'.
RESULTS: CT imaging confirmed the location of the catheter tips at the suprascapular notch in all cases. However, following physiotherapy, 2 catheters (25%) were found to have migrated - specifically, 1 was located in the supraspinatus muscle, and the other was located in the trapezius muscle.
CONCLUSIONS: Our findings suggest that catheter dislodgement may occur in approximately 25% of cases following simulated physiotherapy manipulation. However, further research is needed to determine the read incidence of catheter dislodgement in clinical practice.

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach. Level of Evidence: Level II (Therapeutic).

BACKGROUND: The suprascapular nerve block (SSNB) is a commonly used procedure for the management of pain in various shoulder pathologies. Both image-guided and landmark-based techniques have been utilized successfully for SSNB, though more consensus is needed regarding the optimal method of administration. This study aims to evaluate the theoretical effectiveness of a SSNB at 2 distinct anatomic landmarks and propose a simple, reliable way of administration for future clinical use.
METHODS: Fourteen upper extremity cadaveric specimens were randomly assigned to either receive an injection 1 cm medial to the posterior acromioclavicular (AC) joint vertex or 3 cm medial to the posterior AC joint vertex. Each shoulder was injected with a 10 ml methylene blue solution at the assigned location, and gross dissection was performed to evaluate the anatomic diffusion of the dye. The presence of dye was specifically assessed at the suprascapular notch, supraspinatus fossa, and spinoglenoid notch to determine the theoretic analgesic effectiveness of a SSNB at these 2 injection sites.
RESULTS: Methylene blue diffused to the suprascapular notch in 57.1% of the 1-cm group and 100% of the 3-cm group, the supraspinatus fossa in 71.4% of the 1-cm group and 100% of the 3-cm group, and the spinoglenoid notch in 100% of the 1-cm group and 42.9% of the 3-cm group.
CONCLUSIONS: Given its superior coverage at the more proximal sensory branches of the suprascapular nerve, a SSNB injection performed 3 cm medial to the posterior AC joint vertex provides more clinically adequate analgesia than an injection site 1 cm medial to the AC junction. Performing a SSNB injection at this location allows for an effective method of anesthetizing the suprascapular nerve.

UNASSIGNED: To investigate the anatomical feasibility of the infraspinatus branch of the suprascapular nerve (IB-SSN) reconstruction by lower subscapular nerve (LSN) transfer.
UNASSIGNED: The morphological study was performed on 18 adult human cadavers. The length of the distal stump of the IB-SSN, the length of the LSN available for reconstruction and diameter of both stumps were measured. The feasibility study of the LSN to IB-SSN transfer was performed.
UNASSIGNED: The mean length of the IB-SSN to the end of its first branch was 40.9 mm (±4.6). Its mean diameter was 2.3 mm (±0.3). The mean length of the LSN stump, which was mobilized from its original course and transferred to reach the distal stump of the IB-SSN was 66.5 mm (±11.8). Its mean diameter was 2.1 mm (±0.3). The mean ratio between LSN and IB-SSN diameters was 0.9 (±0.1). The nerve transfer was feasible in 17 out of 18 cases (94.4%).
UNASSIGNED: This study demonstrates that direct LSN to IB-SSN transfer is anatomically feasible in most cases in the adult population. It may be used in cases of complex scapular fractures resulting in severe suprascapular nerve injury.

A shoulder block without lung affection is desirable. In this study, we compared a low versus a high volume of a modified supraclavicular brachial plexus block. We hypothesised that a low volume of local anaesthetic would provide non-inferior block success rate with better preserved lung function.
Healthy volunteers were randomised to receive ultrasound guided 5 or 20 ml ropivacaine 0.5% at the departure of the suprascapular nerve from the brachial plexus. Primary outcome was successful shoulder block-defined as cutaneous sensory affection of the axillary nerve and motor affection of the suprascapular nerve (>50% reduction in external rotation force measured with dynamometry). We used a non-inferiority margin of 20%. Secondary outcome was change in lung function measured with spirometry.
Thirteen of 16 (81.3%; 95% confidence interval [CI] 57.0% to 93.4%) in the 5 ml group and 15 of 16 (93.8%; 95% CI 71.7% to 98.9%) in the 20 ml group had successful shoulder block (p = .6). The ratio of the event rates of the 20 ml (standard) and 5 ml (intervention) groups was (15/16)/(13/16) = 0.937/0.813 = 1.15 (95% CI 0.88 to 1.51). All mean reductions in lung function parameters were non-significantly lower in the 5 ml group compared with the 20 ml group.
For our primary outcome, the 95% CI of the difference of event ratio included the non-inferiority margin. We are therefore unable to conclude that 5 ml LA is non-inferior to 20 ml LA with respect to block success rate.

UNASSIGNED: The optimal position for creating portals for arthroscopic suprascapular nerve decompression has not been sufficiently verified. Therefore, this study aimed to investigate the anatomical characteristics of the scapula for optimal portal creation using 3-dimensional computed tomography images. The posterolateral corner of the acromion was designated as the starting point for measurements because there is no secondary ossification center present.
UNASSIGNED: This study included 223 patients (females, 129; males, 94) who underwent computed tomography of the shoulder joint. Three-dimensional images of the scapula were created, and the distance from the posterolateral corner of the acromion to the suprascapular and spinoglenoid notches was measured. Additionally, the correlation coefficient with height and the differences between the female and male groups were investigated.
UNASSIGNED: The distances from the posterolateral corner of the acromion to the suprascapular and spinoglenoid notches were 42.9 ± 4.6 and 31.5 ± 3.6 mm, respectively, and their correlation coefficients with height were 0.12 and 0.067, respectively. There was no significant difference in the distance from the posterolateral corner of the acromion to the suprascapular (42.5 ± 4.1 vs. 43.9 ± 5.1 mm, P = .098) and to the spinoglenoid (31.4 ± 3.3 mm vs. 32.0 ± 3.9 mm, P = .12) notches between the female and male groups.
UNASSIGNED: Regardless of height and sex, the distances from the posterolateral corner of the acromion to the suprascapular and spinoglenoid notches were approximately 43 and 32 mm, respectively. Therefore, creating portals at these locations may be effective for arthroscopic suprascapular nerve decompression.