Thanks, Ben. We're going to have some time to talk about some of these principles in the case presentation, but I think that Ben obviously hits upon some very important points and explains to us the failure rate. The literature is pretty impressive. The failure rate of slap repair, I think, number one, and we're going to talk about this in my talk, they're maybe not fixed properly. Number two, they're not fixed at all. And the other thing we're going to talk about at some point is the fact that we don't address the causative mechanisms post-op that got them there in the first place. So next I'm going to bring up my good friend, Mike O'Brien, who's going to talk about the suprascapular nerve issue and how to treat that. Thanks, Mike. Thank you, John. It's an honor to be included in this fantastic panel. So we're going to talk about, just really focus on suprascapular neuropathy specifically in those overhead athletes. These are my disclosures. So the suprascapular nerve originates from C5 and C6, and typically you will find two sites of compression. So either at the suprascapular notch or the spinal glenoid notch. So the suprascapular notch, it can be compressed by that transverse scapular ligament. And in that position, they'll usually get weakness of supraspinatus and infraspinatus. Spinal glenoid notch, which is really more common in overhead athletes, they really get isolated infraspinatus weakness only. So that can give you a hint on your physical exam. This was a dissection we did. So this is a superior approach in a cadaver. We're viewing from the top. The right side of the screen is anterior. The left side of the screen is posterior. So you can see the conoid ligament there. So there's your CC ligaments going from the coronoid up to the clavicle. And that little retractor is pulling the supraspinatus posterior. So I find images like this helpful if you're going to operate on these, because it just helps you remember the anatomy a little bit. So typically, the artery goes over the ligament, and the nerve goes under the ligament. So you can see the two white arrows are pointing at the nerve going under the ligament. And then the arrowhead at the bottom is pointing at the artery. Once the nerve passes under the ligament on the right image, then it starts to give out branches going to the supraspinatus muscle. So usually, and there's variations here, where there's about 80% of the time it follows this type of anatomic pattern. There's another about 10% where the nerve actually branches. And you can have a branch go over the ligament and under the ligament. But typically, at the suprascapular notch, this is the type of anatomic variation that you'll see. Then in the back, at the spinal glenoid notch, so now we're viewing from posterior. So that nerve wraps around the spinal glenoid notch, and then it branches out on top of the infraspinatus to innervate the infraspinatus. So I know that we have a left shoulder in the cadaveric dissection and a right shoulder in the drawing. But that's kind of the path that the nerve takes. So it's going to wrap around that spinal glenoid notch and then innervate the supraspinatus on top. So for isolated neuropathy, typically, they're going to have painless weakness. It kind of mimics a rotator cuff tear because their rotator cuff is weak, but they don't have a tear. They may have a short-lived period of kind of an acute, severe pain that usually resolves. Most often, by the time they end up in your clinic, they're going to have painless weakness. And again, if it's supraspinatus and infraspinatus, you're thinking more suprascapular notch. If it's isolated infraspinatus, which I think is more common in throwers, then you're thinking spinal glenoid notch. Also, if they do have a partial rotator cuff tear, their weakness is out of proportion to their exam. So if they have a partial cuff tear on their MRI, but they're profoundly weak, consider getting an EMG because their exam doesn't quite fit with the picture. Once it's advanced, you can start to see some atrophy on exam, but that's usually once it's pretty far gone. So if you have an active thrower, hopefully they aren't this bad by the time they end up in your clinic. If you get an MRI, you can show edema in both muscle bellies, and that's just kind of innervate denervation to the muscle from nerve compression. So you may see just increased signal in the supraspinatus and or infraspinatus. You may see some inflammation around the nerve, around the spinal glenoid notch. Most commonly, you'll see this with a posterior labral tear, just like Ben said, and a big cyst. And so you can see the cyst coming off. If you get your sagittal views, you'll see the cyst in the spinal glenoid notch. Sometimes the cyst can be quite large. And typically, like Ben said, these will come from a posterior superior labral tear. To get an EMG, you really need a neurologist that's interested in this. And we're lucky that we have a good one. And it's helpful to call them and say exactly what you're looking for and ask, can you see if this is coming from the suprascapular notch or the spinal glenoid notch? And if you have a good neurologist, they can usually determine that and help figure that out. That gives you a better idea of exactly where that nerve compression is coming from. There's some reports that ultrasound-guided aspiration can be successful. So using ultrasound, you can aspirate the cyst. Some people will inject a little steroid with it. And there's case reports that that can help resolve symptoms. So surgical indications is when they've failed all non-operative management. Usually, in the throwers, it's going to be with a posterior labral tear with a cyst, and everything else has failed. So if they have compression at the suprascapular notch, then you're going to plan to release the nerve at the suprascapular notch. If it's isolated infraspinatus weakness, then it's just going to be a decompression at the spinal glenoid notch only. In the setting of a labral tear, usually you'll fix the labrum as well. So you can decompress the cyst through the labrum if it's small, fix the labrum to close the door so the cyst doesn't recur. I put this in here because this does not apply to overhead athletes. But there is a relative indication to also decompress the nerve in the setting of a massive cuff tear, but that doesn't really apply to this patient population. So releasing the nerve at the suprascapular notch, the scope's going to come in through the lateral portal. You're going to instrument anteriorly, and then you're going to use two nevizor portals. So standard nevizor portal, you can place a switching stick to protect the nerve. And then you need a more medial nevizor portal to actually decompress the ligament. So when you're draping these out, you want to drape very medially, all the way up the neck, because you want to give yourself plenty of space so you can make a second more medial nevizor portal. Once we get there, you're really looking for a room with four walls. So the ceiling is the clavicle, the floor is the coracoid. The medial wall is the supraspinatus muscle belly. The lateral wall is the coracoclavicular ligaments. Once you find the coracoid, keep working medial and posterior. It's always more medial than you think. And keep going medial, and you'll find the suprascapular notch. So here, this is a right shoulder. The scope's in the lateral portal. The cautery's coming in from anterior. Now it's coming in from posterior. So there's the acromion. And as you look down and to the right, you're going to find the CA ligament right there. Follow the CA ligament down to the coracoid. The spinal needle's coming in through a nevizor portal. So there, we're at the top of the coracoid. Keep working medial. Now we have a switching stick coming in. There's the coracoclavicular ligaments there. So now you're going to work medial and posterior behind the CC ligaments. You're going to go between the CC ligaments and the supraspinatus muscle belly. Keep working medial. You can use the switching stick to clear the soft tissues. The switching stick can also pull the supraspinatus posterior. And as you get over, you see you're going to fall off medially. So there's the artery. Using the switching stick then, there's the nerve. So you can use the switching stick. There's the nerve. Use the switching stick to retract the muscle medial. And I usually get them in there and you kind of work like chopsticks almost to kind of use two switching sticks. There's the nerve and it's passing under the ligament right there. So the ligament's on the bottom left hand of the screen. The switching stick pushes the nerve down. And then I use an arthroscopic scissors. So this is coming in through a medial nevizor portal to cut the ligament. So you can do this safely. Some people use a biter. Some people use a shaver. I like to use the scissors because it's very small. If there's a bone spur associated with that, you can shave that away with the shaver and now the nerve is released. So once you practice this a few times, it's really not hard. You just have to take your time and it's always more medial than you think. For the spinal glenoid notch, I usually do this in the lateral position because this is usually for me associated with a labral tear. And you need two posterior portals. So again, you're going to drape really medial. The shaver here is coming in your standard posterior portal. And then the switching stick is coming in even more medial. So just drape really wide. So this is a baseball pitcher posterior labral tear, just like Ben said. So this one was a posterior superior tear. Small cysts you can usually decompress through the tear. So there's the cyst contents coming out. So the scope is anterior superior. We're working posterior in the labrum. We'll get our shaver in there. You can roughen up the bone in preparation for your repair. If it's a small cyst, you can evacuate this all through the labrum right there. And then you'll fix your slap tear or posterior labral tear. This is an older video. So I have knotted anchors here. Now I prefer knotless. So those knots don't impinge on the infraspinatus and external rotation. Now we're up in the subacromial space. So we're viewing from lateral. There's the scapular spine. If they have a really big cyst, you may choose to decompress the cyst separately. So that switching stick is coming in through the posterior medial portal. There's the nerve right there. So the nerve is wrapping around the spinal glenoid notch, innervating the infraspinatus. And just above it on the left side of the screen is the cyst right there. So then you can use your switching stick to pop it. And you can pop into the cyst, move it around to try and open up that cyst cavity. So right here, we're going to pop the cyst. And you usually will see a bunch of cyst fluid come out. And then you can put a shaver in there to suck it out. Don't run the shaver because you don't want to damage the nerve. But you can completely decompress this just with the switching stick. Use the arthroscopy fluid to kind of wash it out. So I put the shaver in. I'm not running it just to help suck the fluid out of the cyst. So for a big spinal glenoid notch cyst, you can decompress it from posterior. If it's small, you can often decompress it just through the labral tear. So there's multiple case reports on the success of the procedure. There's a couple small series. So this one in 2019 looked at nine patients that had confirmed suprascapular neuropathy due to a paralabral cyst. These three were at the suprascapular notch. Six were at the spinal glenoid notch. Post-operative EMGs at six months showed that they all had complete recovery. Laurent Lafosse was one of the early ones to publish on this. This was in 2007, and found 90% excellent results. One was satisfactory, and their constant scores all improved. So in summary, I think suspect suprascapular neuropathy when they have isolated infraspinatus weakness. They've failed everything. They often will not have pain. But they'll have weakness on their rotator cuff. That is, an MRI shows there's no tear. overhead athletes, in my experience, this is usually associated with pain.

suprascapular nerve

slap repair failure

causative mechanisms

suprascapular neuropathy

ultrasound-guided aspiration