Hi, I'm Kevin Plancher and it is our honor to present the Suprascapular Nerve Release You Never Know When You Might Need It. Welcome to the Anna Knee and Shoulder Arthroscopy course. It's really exciting and I have to thank the chairs Kevin Bonner, Nick Scaglione, Ian Lowe, and Joseph Toro for putting this together. I'm here to tell you that the arthroscopic suprascapular nerve release is essential that you understand its entrapment because posterior shoulder pain is more often than not wrongly attributed to cervical disc disease and even rotator cuff disease. I will tell you that patients are often delayed in their treatment and no wonder why here you see in a picture a gentleman that looks fully muscular. He has rip-roaring infraspinatus or spinal gland nerve entrapment and when you delay treatment it will impede functional recovery. There are two areas of compression for the suprascapular nerve. The transvascular ligament you can see and when affected it gives atrophy to the supraspinatus and the infraspinatus and the spinal gland ligament which gives isolated infraspinatus atrophy. Remember that the nerve enters through the supraspinatus fossa and it travels as you can see where nerve underneath for navy army on top of the transvascular ligament. It gives off motor branches to the supraspinatus and actually sensory branches to the AC joint. It gives you atrophy to the supraspinatus and the infraspinatus as you see here. The problem is that motion is often preserved and so in a baseball pitcher that complains in spring training of discomfort and more often than not as entrapment and yet one thinks that it would get better but as we get older you have this severe atrophy seen there. If you look very carefully at the transvascular ligament here and you can see the setup all we need to do is be able to get in release the transvascular ligament and get out but it does require different portals and you can see them listed here. It's important to know that you start as almost a subacromial decompression as you'll see and move your way in towards the neck anterior finding the fine line of the supraspinatus tendon and then muscle and lo and behold you will find the transvascular ligament. Here you can see what we've done. This shoulder on the right has the needles first in the AC joint on the left and what we're doing is we're following the supraspinatus and we head in all the way and with the two needles one at the visor's portal deep down as you can see there and we're tracing it we make a small incision and put a trocar which you can see to the right and that's equivalent to the AC joint and then more medial and towards the neck. Here you can see the nerve and we're now palpating the transvascular ligament keeping the nerve out of harm's way and there are many different instruments some created by companies that make it easy to hold the nerve out of the way and cut it or you just take a trocar and you can take an appropriate knife to cut that transvascular ligament. This area is more comfortable for most of us because we do do coracoplasties or subacromial decompressions. There's a wonderful video online that will show this at the Arthrosphery Association North America Library that you can see it step by step. If we swing our eyes we can identify the anterolateral edge of the acromion with this spinal needle. We also can see as we go more medially the AC joint we can go and the spinal accessory nerve as we place this in and we bluntly now dissect and what will come into view immediately to look down at the confluence and lo and behold the transvascular ligament is seated there with the artery and its main branch on top and if we gently push with the trocar away in our purified ligament underneath the artery out of harm's way with clear visualization of the transvascular ligament and the nerve below we can take some type of cutting instrument in this case a duckbill and cut in a piecemeal fashion the transvascular ligament each time observing the nerve out of heart instrument like an acetone when it's calcified or a stronger cutting device you can easily show the nerve which is now seen in view as I retract back the artery. And so you can see that this is easily done and I encourage you to watch the full video. How about the spinal glenoid ligament? It travels obliquely down past the supraspinatus muscle in close proximity as you can see to the glenohumeral joint. It gives off branches three to four of the infraspinatus and you can get isolated infraspinatus atrophy. You see it in overuse syndromes, in chronic irritation, overhead workers, workers compensation who do light bulbs or electricians but shoulder motion is preserved again unfortunately and so we don't get the diagnosis right. We've marked out the spine of the scapula. The N stands for an advisor's portal and we've now marked out from the posterolateral corner of the acromion four centimeters as well as eight centimeters approximately are two portals to perform a spinal glenoid ligament release. At eight centimeters we will have a viewing portal and at approximately four centimeters we will have a working portal. We take the 11 blade below the level of the spine of the scapula. We've made sure our anesthesiologist has held our systolic pressure approximately at 100 millimeters or less. We place the trocar dull. We feel for the spine of the scapula and we go slightly below it giving resistance to the front of the chest as we pierce in. At this point no different than a subacromial decompression we will clear the space as we feel the posterior aspect of the scapula underneath the infraspinatus fossa. We'll take our arthroscope and place it in to visualize the bone before we turn on the water. There's the bone up top and we're going to turn on our inflow and what we see immediately is the bone as we head laterally towards the spinal glenoid notch. The perineural fat surrounds the suprascapular nerve in the spinal glenoid notch. We're going to take our spinal needle at this point making sure that the water pressure is low and now at four centimeters from the posterolateral edge triangulate looking inside at our spinal glenoid ligament. Here you can see the needle coming in as I pull back on the scope. I remove it and take my 11 blade and now make my second portal which is once again inferior to the spine of the scapula and I take my dull trocar once again with resistance anteriorly to the chest from my assistant. I see the bone and I triangulate once again to meet the two areas. So you saw the setup and now the goal for releasing the spinal glenoid ligament is we stay in more so I like to say now more lateral near the glenohumeral joint because you can see the nerve goes medially. So let's continue on to see what we do to release it. With the two portals in place you can see this posterior aspect in the spine of the scapula and the probe falling in to the spinal glenoid notch. We are viewing from eight centimeters from the posterolateral edge medially and working four centimeters to identify right here the spinal glenoid ligament. We know that the nerve hugs medially as we will identify it in a few moments right in this perineural fat and that the ligament is sitting right on top and this space will be now cleared with a shaver. As we pull tight we can see the anatomy. With our shaver in place or a probe and using the shaver as a probe it's almost immediately you can see the nerve as it comes from the spinal glenoid notch. It will be surrounded by fat. It moves medially as you can see here and as we age some people have a less stout ligament. This cadaver is of an older individual. In young individuals no different than a ligamentum mucosa or an infrafatella plica you will see the ligament firmly attached to the roof of the spinal glenoid notch. We're going to now debride with the suction off some of the material lateral to the nerve. Inflow is kept to allow us to have this infraspinatus area open so we can visualize. You can see the standard arthroscopic portals which we know and I marked out the spinal glenoid portals. I've highlighted this because most of us feel rightfully so putting myself uncomfortable because we haven't been there before and hone in on it. In this left shoulder to the left of the screen laterally I have the probe trapped on part of the spinal glenoid ligament which is trapping the nerve or tethering it so it can't move freely. We're going to release it. I want to point out the nerve is medially to the right in this left shoulder clearly seen here with the fibers as well as the vessel and so you can safely remove the ligament to the left which is what we will do now with some type of shaver or any other device that is scissor or arthroscopic instrument with the suction on either non-existent or low. This is a safe area. As you push the scope in you can create that space no different than we all do with a subacromial decompression. It's important as you shave to take a break. You can see the fibers on the superior aspect where the ligament used to sit that we've resected back as I said almost like a ligament of a ligament of mucosa they are gone and now we see the fat in place and now we'll take a probe to finish our ligament release. You can see on the medial side or the right of the screen the nerve clearly defined the perineural fat that we saw at the beginning of the case has now been left. There is mobility of the nerve which was not present before as it wraps around medially descending from the superior aspect. To the left are remnants or fibers that are seen off the superior aspect where the spinal glenoid ligament was prior. This is the spine of the scapula. As we move laterally we would enter the joint this would be the glenohumeral joint where the gold probe is now going. We have completed the release of the spinal glenoid ligament successfully. Here you can see the atrophy that occurs in this young athlete but you have to ask the patient to remove their shirt and inspect the posterior shoulder and the woman have some shoulder gowns appropriately fitted for those patients because without looking you'll never know and you have to learn about subtle atrophy. You can see infraspinatus atrophy isolated in a orthopedic surgeon to the right and in fact to an overhead collegiate athlete so it's more common than you think. It's been seeing us but I don't know that we've been seeing it. Atrophy is not always obvious and so you say well how can I diagnose this especially sometimes if an EMG perhaps is not positive for the suprascapular nerve entrapment and I'm telling you this person has rip-roaring infraspinatus occlusion from the supraspinatus. Well why don't you try an injection? If it's the transvascular ligament and you have wasting and you're thinking it's both let's take with acute cases and no wasting posterior approach three centimeters medial to divisor's portal aim towards the neck of the corner of the acromion here and you can inject lidocaine obviously aspirate and see how can you see well the cross-arm adduction test I told you has a branch from the suprascapular nerve and if the x-ray in the zanka view is normal and you do a cross-arm adduction test and it hurts and now do a lidocaine test and now the repeat injection gives you a physical exam which is negative on a cross-arm adduction test you have your diagnosis. You can do the same thing posteriorly. Utilize this injection when there's no muscle wasting go four centimeters medial to the post lateral corner of the acromion just below the spine of the scapula inject aspirate obviously first 10 cc's and do a cross-arm adduction test before and after and because one of the branches to the suprascapular nerve goes to the ac joint and now you have relief you can fool even some other patients because they think you're going posterior and now the anterior pain goes away. You of course can use the MRI look for t-weighted increased signal intensity the spinal glenoid cyst is very common as you can see here in the multiple views and EMG will show spontaneous activity with positive fibrillations and polyphasic potentials to look for. It is not an easy EMG but when positive it's very satisfactory and now you know how to help the patient. What does the literature say? Well you can see in 2018 in elite overhead athletes with a question of labor lesions that the suprascapular nerve release had a significant improvement with UCLA and constant scores were returned to work with 97 percent with suprascapular release and without it was only 84 percent so those who believe that you need to take care of the labor lesion I tell you it is the suprascapular nerve that is more important. In 2019 another study that showed it Pete Millett showed it five years significant improvement in external rotation strength which you can't always guarantee with high satisfaction rates at five years out. Here a study a systematic review 2018-21 studies mean age older 42 years of age before surgery had this deep posterior shoulder pain which you think is rotator cuff undergoes EMG positive outcomes return to sport 92 percent. How about this systematic review in 2018 with 42 percent seen in spinal glenognosis arthroscopic release 92 percent a significant improvement. Very good. Volleyball players think of it. So Dr. Post said a long time ago to defer surgery in the hope that posterior shoulder pain will subside and that full function will be preserved is not well founded. I encourage you to learn about it practice and do it and hopefully it will help your patients. I wish you all great health in these difficulty times to you and your families. I thank Anna for allowing me to present this and have a great day.

arthroscopic surgery

suprascapular nerve

shoulder pain

nerve entrapment

Kevin Plancher