Long Thoracic Nerve Palsy

Long thoracic nerve palsy is a medical condition involving the damage of the long thoracic nerve, due to an acute injury to the nerve itself, or other circumstances not related to traumatization.

Presentation

The long thoracic nerve is responsible for supplying the serratus anterior muscle, whose function is to maintain the scapula in a balanced position while upper extremity movements are performed [1]. A case of long thoracic nerve palsy (LTNP) corresponds to a weakened serratus anterior muscle [2] [3]. The most easily observed manifestation related to the long thoracic nerve palsy is winging of the scapula (a protrusion of the scapula from the back) [1] [4].

Patients are mainly adults which are between 20 and 60 years old. They present with marked scapular winging and inability to elevate the arm or push efficiently [3]. Loss of normal shoulder mobility is the primary complaint of the affected patients, that can also be followed by a feeling of instability. Athletes experience a restriction in their exercising potential, whereas non-athletic patients report a significant difficulty in performing everyday tasks, such as getting dressed or pushing. Pain in the shoulder region is also experienced when the back is resting upon a firm surface.

Long thoracic nerve palsy and subsequent paralysis of the serratus anterior muscle is a medical condition encountered frequently which, in general, leads to a considerable disability in everyday activities [5] [6]. Tendonitis may also arise in the affected shoulder joint, and so may brachial plexus radiculitis, adhesive capsulitis, and subacromial impingement [7]. Paresthesia of the shoulder girdle is another possible symptom [8].

Respiratoric

Pleural Effusion

Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome[mistysurimd.com]

Musculoskeletal

Winged Scapula

This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function.[ncbi.nlm.nih.gov]
Damage of the long thoracic nerve may result in abnormal protruding of the scapula or shoulder blade, commonly known as winged scapula.[mistysurimd.com]
This odd positioning has led to the name “winged scapula.” Shoulder pain and loss of movement occur as the imbalance in muscle functioning causes stress to the muscles of the shoulder.[chrisshort.net]
File usage on Commons The following page uses this file: File usage on other wikis The following other wikis use this file: Usage on de.wikipedia.org Scapula alata Usage on en.wikipedia.org Winged scapula This file contains additional information such[commons.wikimedia.org]

Frozen Shoulder

Frozen Shoulder/Adhesive Capsulitis GH joint capsule thickens resulting in lost axillary pouch, onset 30s 40s and 50s, unknown cause. Freezing: shoulder pain 2-9 months, ROM decreases.[quizlet.com]

psychiatrical

Distractibility

-Spurling, -Distraction, -ULTT and he denies any numbness or tingling. I am currently applying NMES to his serratus ant while he does a scapular stab program.[physicaltherapy.rehabedge.com]
The initial trauma caused L1-L2 flexion-distraction injury. The patient was first treated by posterior spinal fusion and instrumentation from T11 to L3. Figure 2 Nine months after the primary surgery .[link.springer.com]

Impulsivity

Once the nerve recovers and neural impulses to the serratus anterior resume, a continued strengthening program should be maintained to facilitate full function of the serratus anterior allowing normal resumptions of activities during daily living and[digitalcommons.hope.edu]

Neurologic

Peripheral Neuropathy

In: Dyck PJ, Thomas PK, Griffin JW, et al (eds) Peripheral Neuropathy, vol 2. 3rd edition. WB Saunders, Philadelphia, p 911 Google Scholar 10. Narakas AO (1988) Pain syndromes in brachial plexus injuries.[link.springer.com]
Focal peripheral neuropathies in instrumental musicians. Phys Med Rehabil Clin N Am. 2006;17(4):761–79. CrossRef PubMed Google Scholar 14. Bizzarri F, Davoli G, Bouklas D, Oncchio L, Frati G, Neri E.[link.springer.com]

Workup

Long thoracic nerve palsy is typically diagnosed clinically; even though electromyography can provide a clear confirmation of the diagnosis, it brings desired results only after 6 weeks from the initial symptomatology.

The following clinical findings constitute sufficient evidence for the existence of LTNP:

Inability to fully flex the upper limb forward
Scapular winging, visible from the lateral or posterior side
Asymmetry of the scapulae during arm elevation, viewed from the posterior side.
Positive scapular compression test: pressure is applied on the scapula from the posterior side, while the thorax is stabilized from the anterior side with the other hand. The patient is asked to flex the presumably affected arm forward. The test is compatible with long thoracic nerve palsy when this maneuver alleviates pain and enables better movements.
Manual muscle testing (MMT) and shoulder joint range of motion (ROM) should also be performed [8].

Radiographs are not expected to illustrate abnormalities in a case of LTNP, except for an occasional, slight discrepancy in the positioning of the scapulae. They are obtained in order to exclude the possibility of a scapular mass. Electromyography is carried out at least six weeks after the symptoms have developed and offers the final confirmation of LTNP.

Colonoscopy

Multiple Ulcerations

After years of taking a variety of NSAIDs like ibuprofen and naproxen multiple ulcers have formed in my stomach. Turmeric has been known to have anti-inflammation effects. I also take fish oil for its joint and heart health benefits.[chrisshort.net]

Pleura

Pleural Effusion

Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome[mistysurimd.com]

Treatment

Timely treatment, often surgical, is vital to the recovery of scapular winging secondary to long thoracic nerve palsy.[ncbi.nlm.nih.gov]
No cases have been reported after the more recent treatment for breast cancer, lumpectomy with axillary dissection. This more recent surgical procedure is customarily followed by aggressive radiation therapy to the remaining breast tissue.[ncbi.nlm.nih.gov]
Although the incidence of isolated long thoracic nerve palsy following acute spinal trauma is rare, one such case is presented with discussion of injury and treatment.[ncbi.nlm.nih.gov]
We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment.[ncbi.nlm.nih.gov]
PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.[ncbi.nlm.nih.gov]

Prognosis

The occurrence of a prolonged interval between onset of symptoms and institution of therapy was found to adversely affect prognosis.[ncbi.nlm.nih.gov]
The prognosis for long thoracic neuropathy is quite variable with some authors reporting spontaneous recovery while other cases fail to respond to any treatment, including surgery. Initial management is typically conservative.[chiroup.com]
The indications for operation seem meager in a condition in which there is such a relatively good prognosis on a conservative regimen.[oandplibrary.org]
It is conceivable that the fact that the parties relied on Keller's incorrectly diagnosed injuries rather than her correctly diagnosed injuries would not rise to the level of a material fact, were the treatment, prognosis, and symptoms of the injuries[caselaw.findlaw.com]

Etiology

It was found that those patients whose lesions were due to acute trauma had only partial or no recovery of serratus function, while those with infectious, toxic, allergic or idiopathic etiologies had partial or complete recovery.[ncbi.nlm.nih.gov]
Trojaborg First published August 1, 1984, DOI: Abstract We studied nerve conduction in 24 patients with serratus anterior palsy of different etiology.[neurology.org]
You could also look for the following: Role of scapular stabilizers in etiology and treatment of impingement syndrome. Schmitt L, Snyder-Mackler L. J Orthop Sports Phys Ther. 1999 Jan;29(1):31-8.[physicaltherapy.rehabedge.com]
Unprovable etiologic contentions were frequent.[medlit.info]
Further imaging with computed tomography or magnetic resonance imaging might then be relevant, depending on the radiographic findings and suspected etiology of the condition. Imaging, however, is usually normal.[neupsykey.com]

Epidemiology

Midha R (1997) Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 40;1182–1189 PubMed CrossRef Google Scholar 6.[link.springer.com]
[…] shoulder and upper arm level, left arm, initial encounter A- initial encounter D- subsequent encounter S- sequela Scapular Winging ICD-9 907.4 (Late effect of injury to peripheral nerve of shoulder girdle and upper limb) Scapular Winging Etiology / Epidemiology[eorif.com]

Sex distribution

Age distribution

Pathophysiology

These data strongly support an inflammatory pathophysiology.[ncbi.nlm.nih.gov]
PubMed Google Scholar Lundborg G, Dahlin LB: The pathophysiology of nerve compression. Hand Clin. 1992, 8 (2): 215-227. PubMed Google Scholar Copyright Nath et al; licensee BioMed Central Ltd. 2007[bmcmusculoskeletdisord.biomedcentral.com]
[…] deltoid Sensory: C5 and C6 dermatomes No protective coverings (epineurium and perineurium) on the nerves after they exit the foramina Increased risk of stretch injury at neck and shoulder regions Contusion or compression of upper trunk at Erb point Pathophysiology[aafp.org]

Prevention

Additional studies are needed to confirm the conclusion that the device's benefits derive from proprioceptive feedback that prevents muscle overuse or overstretch and from its transfer of contralateral shoulder protraction force to the affected scapula[ncbi.nlm.nih.gov]
Eliminating muscle spasms leads to a better life experience overall and prevents nasty flare ups before they even start. It took ten years to realize this and hopefully others can learn from this.[chrisshort.net]
If memory serves, this is the article that incorporated a brace to support the scapula and prevent winging in active shoulder exercises. _____________________________ Charles Sheets PT OCS Dip MDT Re: Long thoracic nerve palsy - February 15, 2006 9:52[physicaltherapy.rehabedge.com]
Physiotherapy will be needed following surgery to help re-train your muscles to prevent any future shoulder problems occurring.[physio.co.uk]
Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎[books.google.es]

References

Article

Hollinshead WH. Anatomy for Surgeons. 3. Harper and Row; 1998.
Bertelli JA, Ghizoni MF. J Bone Joint Surg Am. 2005. pp. 993–998.
Gozna ER, Harris WR. Traumatic winging of the scapula. J Bone Joint Surg Am. 1979;61:1230–1233.
Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res. 1999;368:17–27.
Gregg JR, Labosky D, Harty M, et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979;61:825–832.
Pugliese GN, Green RF, Antonacci A. Radiation-induced long thoracic nerve palsy. Cancer. 1987;60:1247–1248.
Kuhn JE, Plancher KD, Hawkins RJ. Scapular Winging. J Am Acad Orthop Surg. 1995;3:319–325.
Shiro Nawa. Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer. J Brachial Plex Peripher Nerve Inj. 2015;10(1):e57–e61.

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Last updated: 2018-06-21 21:46