Trapezius Palsy Research Articles

Evaluation of the Dysfunctional Scapula.

Periscapular pain and dysfunction are relatively common complaints in the practice of upper extremity surgeons. However, evaluation of the dysfunctional scapula is intimidating for most. Physical examination of the periscapular muscles is very rich, and a systematic approach provides the opportunity to establish a diagnosis for most patients. Conditions underlying scapular dysfunction include trapezius palsy, serratus palsy, brachial plexus injuries, muscular dystrophy, snapping scapula, pectoralis minor syndrome, congenital undescended scapula, and functional scapular dyskinesis, among others. Patients should be examined with their torso uncovered and assessed from the front and back. Inspection, evaluation of motion, and strength testing may be followed by certain examination maneuvers specific for each condition. The scapular assistance test may help predict the outcome of treatment for certain conditions. Plain radiographs oftentimes need to be complemented with magnetic resonance of the chest to capture periscapular muscles as well as an electromyogram with nerve conduction studies. Computed tomography is particularly helpful for skeletal abnormalities. Ultrasound is used to assess certain peripheral nerve injuries and to guide diagnostic and therapeutic injections. A focused evaluation of the scapula followed by a more specific and directed approach for each condition suspected will allow upper extremity surgeons to approach the evaluation of the dysfunctional scapula with much more confidence.

Modified Eden-Lange Triple-Tendon Transfer for Chronic Trapezius Palsy

Background: Trapezius palsy can occur due to traumatic or idiopathic spinal accessory nerve injury. As a result of trapezius palsy, shoulder girdle imbalance can develop and present as lateral scapular winging and diminished shoulder range of motion and function. The modified Eden-Lange triple-tendon transfer procedure is a notable salvage operation which can treat chronic trapezius palsy after failure of conservative and nonsalvage interventions. Indications: A 42-year-old right-hand dominant woman who underwent a cervical lymph node biopsy 3 years before presents with chronic left shoulder weakness, severe shoulder pain, and scapular winging. On presentation, she has failed conservative treatments and operative interventions including attempted spinal accessory nerve exploration and repair with ansa cervicalis autograft. Technique Description: A modified Eden-Lange triple-tendon transfer, using the Elhassan modification, was performed to treat the patient’s chronic trapezius palsy. The levator scapulae, rhomboid minor, and rhomboid major were sequentially transferred to the lateral scapular spine, central scapular spine, and medial scapular spine, respectively. Results: At interval follow-up, the patient was recovering well from her operation and with progressively improving range of motion and strength. Discussion/Conclusion: The modified Eden-Lange triple-tendon transfer technique is a salvage procedure for treating chronic trapezius palsy by anatomically reconstructing the force vectors of the native trapezius muscle. Effective restoration of proper scapular and shoulder kinematics via the triple-tendon transfer technique can result in improved pain and shoulder girdle function. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Triple Tendon Transfer of the Levator Scapulae, Rhomboid Major, and Rhomboid Minor to Reconstruct the Paralyzed Trapezius

Trapezius paralysis is a relatively uncommon condition that orthopaedic surgeons may encounter. Despite the paucity, it presents as a debilitating condition with sequelae of poor function and deconditioning. Conservative management often fails, and patients are left with limited surgical options. In the current Eden-Lange procedure, tendon transfer of the levator scapulae, rhomboid major, and rhomboid minor is performed to reconstruct the paralyzed trapezius. Although good outcomes have been found with this technique, the pull of the levator scapulae and the pull of the rhomboids are in opposition to each other, which presents a biomechanical problem for patients because this fails to re-create the natural function of the trapezius. In this article, we present a technique that is a modification of the Eden-Lange triple tendon transfer using suture bone bridges in which the levator scapulae is transferred as with the original procedure; however, the rhomboids with bony bridges are transferred to a different point along the medial scapula. Our technique therefore may better re-create the natural pull of the fibers of the upper, middle, and lower trapezius.

Scapula alata: Diagnosis and treatment by nerve surgery and tendon transfers

Scapula alata, also known as winged scapula, can lead to severe upper limb impairment. The shoulders’ function is altered because the scapula, which supports the upper limb, is no longer stable. Typical scapula alata is described for serratus anterior palsy; however, any scapulothoracic muscle impairment may lead to scapular winging, particularly trapezius palsy, which is easy to miss, thus needed to be considered as a differential diagnosis. The diagnosis is difficult and based on various clinical tests and a thorough examination as well as electroneuromyography and MRI. The treatment ranges from conservative treatments for spontaneous recovery, nerve surgery including neurolysis, nerve transfers and nerve grafts for acute cases, to tendon transfers for more chronic cases and when nerve procedures are no longer feasible. Tendon transfers in serratus anterior palsy produce excellent results with a high rate of patient satisfaction and are described with the sternal or clavicular head of the pectoralis major; we describe our preferred technique in this article. Tendon transfers in trapezius palsy are performed with the levator scapulae, rhomboid minor and major muscles. Our preferred method is the Elhassan triple transfer. Scapula alata is a frequent and often misdiagnosed condition. Appropriate management can yield excellent results. Patients should be referred right away to specialized centers for surgery if recovery is not spontaneous.

Tendon transfer for trapezius palsy

The trapezius muscle produces upward scapular rotation that in turn allows complete lateral elevation (abduction) by maintaining the acromiohumeral distance and the deltoideus resting length. Loss of trapezius function leads to shoulder drooping, loss of scapular external rotation with secondary loss of abduction. When conservative treatment has failed and in cases where nerve surgery is not indicated, the most common procedure for treating this condition is the Eden-Lange (EL) procedure. This procedure entails transferring the levator scapulae (LS) to the lateral part of the scapular spine, and the rhomboid major (RM) and minor (Rm) to the infraspinatus fossa to restore the lost trapezius function. Recently, Elhassan et al. proposed a modification of the original EL procedure to recreate the line of pull of the different parts of the trapezius muscle. The modified transfer may yield successful outcomes in patients with trapezius paralysis who failed to improve after well-conducted conservative treatment. Longer follow-up is needed to confirm the stability of the good outcomes of this reconstruction.

The Modified Eden-Lange Tendon Transfer for Lateral Scapular Winging Secondary to Spinal Accessory Nerve Injury

Trapezius paralysis following injury to the spinal accessory nerve can be a debilitating complication resulting from lymph node biopsy, radical neck dissection, or penetrating trauma in the region of the posterior cervical triangle. Disruption of the delicate muscular balance in the shoulder girdle may result in lateral scapular winging, ipsilateral upper extremity radiculopathy, and limited shoulder function and range of motion. Spontaneous recovery with nonoperative management is possible in some patients, and restoration of function after reparative neural procedures has been observed in patients undergoing timely repair. However, extended delays from the time of injury to surgery are common and may necessitate various muscle transfers to reestablish the complex biomechanics and balance of the shoulder girdle. We describe a modification to the classic Eden-Lange procedure with lateral transfer of the levator scapulae and rhomboid minor to the scapula spine and rhomboid major transfer with a small wafer of bone to the scapula body for chronic lateral winging of the scapula following injury to the spinal accessory nerve as the result of a cervical lymph node biopsy.

Scapular Winging – A Schematic Review

Scapular winging is a rare, painful and debilitating condition that leads to limited functional activity of the upper extremity. The composite scapular movement of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. It can result from numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made by inspection of the scapula from back, with serratus anterior paralysis resulting in medial winging of the scapula while lateral winging is caused by trapezius and rhomboid paralysis. Most cases of serratus anterior and rhomboid paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. Patients become candidates for corrective surgery if they fail a 6–24 month course of conservative treatment. This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment.

Surgical treatment of trapezius palsy: A systematic review.

Trapezius palsy results from injury to the spinal accessory nerve. The condition presents with loss of shoulder abduction, pain, and winging of the scapula. Surgical treatment may improve functional outcomes and quality of life. The purpose of this study was to report and evaluate the clinical outcomes following surgical management of trapezius palsy. Systematic review. The electronic databases EMBASE, MEDLINE, and PubMed were searched for studies and relevant data were abstracted. Only studies reporting on outcomes after the surgical treatments of trapezius palsy were included. A total of 10 studies including 192 patients were included in this review. All surgical interventions resulted in improved function and pain reduction. Patients reported high satisfaction (90-92%) following nerve reconstruction or the Eden-Lange procedure, in comparison to neurolysis. The most common procedure reported was the Eden-Lange muscle transfer (32% reported cases) demonstrating the highest patient satisfaction rates with low complication rate of 7.7%. Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy. All reported surgical procedures demonstrate reduction in pain the best results from the Eden-Lange muscle transfer. Further high-quality comparative studies are required to make definitive conclusions regarding the comparative efficacy of each surgical procedure.

A cadaveric study: the morphometric differences in the levator scapulae muscle

Although the levator scapulae are surrounded in the deep cervical fascia, it can be separated into a number of muscle slips at the proximal attachment. Originally the muscle was described as having 3 muscle slips at its origin. More recent texts have now adopted 4 slips of origin. Each slip coming from a different cervical vertebra. Levator scapulae is important with myofascial pain syndrome which is one of the leading causes of neck and shoulder pain. Surgically it can also be used to overcome trapezius paralysis. Anatomical variations of the levator scapulae are important and therefore clinically relevant. In this dissection study, we have investigated the morphometric differences in 46 levator scapulae muscles from 23 cadavers. Measurements of the proximal- and distal attachments and the total length of the muscles were taken. Between 3 and 6 muscle slips were reported at the proximal attachment. Differences were also observed between sides. The first report of a levator scapula muscle with 6 muscle slips at the proximal attachment, is described in this study.Keywords: Origin (proximal attachment); insertion (distal attachment); muscle slips

A case report of triple tendon transfer, an Eden-Lange variant procedure, to reconstruct trapezius paralysis

A case report of triple tendon transfer, an Eden-Lange variant procedure, to reconstruct trapezius paralysis

The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective

Iatrogenic or traumatic injury to the spinal accessory nerve is a rare but debilitating injury. An effective treatment, known as the Eden-Lange modification triple-tendon transfer procedure, involves the transfer of the rhomboid major (RM), rhomboid minor (Rm), and levator scapulae (LS). Careful detachment of their insertions is necessary to avoid injury of the dorsal scapular nerve (DSN). This study evaluated the surgical anatomy and safety of the DSN relative to this procedure. The study used 12 cadavers (22 shoulders). The RM, Rm, and LS were detached from their insertions, and the DSN was dissected. Measurements were taken to evaluate the anatomy of each relative to the triple-tendon transfer procedure. Additional measurements were taken to identify "danger zones" for DSN injury, regarding detachment of RM, Rm, and LS from their respective insertions. Measurements of the 22 shoulders included in the study showed wide variation in anatomy. The minimum distance between the scapula and the DSN at the vertebral scapular border was 0.7 cm, suggesting that care and precision are needed to perform this technique. The region where the DSN crosses the superior border of the Rm was shown to be the greatest "danger zone" of this technique, with a mean distance to the scapula of 1.61 ± 0.53 cm CONCLUSIONS: This study provides insight into the surgical anatomy of the DSN relative to a rare but successful procedure used to treat trapezius paralysis. The results of this study can inform the surgeon regarding potential anatomic considerations when performing the triple-tendon transfer.

Systematic review of winged scapula

Objective To study the morbidity, pathogenesis, diagnosis and treatment of scapula. Methods The key words about winged have been used to search articles which include scapula patients in English and Chinese literature databases from 1958 to 2017. The articles have been filtrated by title, abstract and full text. There are 36 articles used for this study. All the patients are objects of this study, but the same patients' data in different articles have not been used repeatedly. The patients' data have been collected as much as possible, including age, sex, causes, treatment, follow-up and so on. All the patients' data have been used for systematic analysis. Results All of 356 patients with scapula were selected from 36 literatures for systematic analysis. There were 213 cases of anterior saw muscle paralysis, among which 16 cases were physical exercise, 11 cases were excellent and 5 cases were poor, with an excellent rate of 68.8%. There were 70 cases of neurolysis and transplantation, 50 cases were excellent and 20 cases were poor, with an excellent rate of 71.4%. There were 3 cases of scapulectomy, 1 case excellent and 2 cases poor. There were 124 cases of pectoralis major tendon metastasis, 88 cases were excellent, 36 cases were poor, and the excellent rate was 71%. There were 46 cases of trapezius paralysis, among which 14 cases were physical exercise, 12 cases were excellent, 2 cases were poor, and the excellent rate was 86%. 1 case of scapulopexy and 1 case of superior, with an excellent rate of 100%; There were 31 cases of Eden-Lange 31 cases, 27 cases of excellent and 4 cases of poor. One case of rhomboid myoplegia was treated, including 1 case of rehabilitation training (ultrasound guidance), 1 case of excellent, with an excellent rate of 100%. There were 96 cases of muscular dystrophy, including 96 cases of scapulectomy, 76 cases of excellent and 20 cases of poor, with an excellent rate of 79.1%. Conclusion Winged scapula is rare and its incidence is unknown, different causes determine different treatments: Anterior saw muscle palsy is more suitable for thoracolumbar tendon transfer, and modified Eden-Lange is more suitable for trapezius palsy.

Morphometric properties of the levator scapulae, rhomboid major, and rhomboid minor in human fetuses

The main objective of this study is to showcase the growth dynamics of levator scapulae, rhomboid major, and rhomboid minor algebraically, to help plan surgeries on newborns and young infants. Twenty-five formalin-fixed fetuses (11 male-14 female) with a mean gestational age of 21.80 ± 2.61 (range 18-27) weeks present in the inventory of Mersin University Faculty of Medicine Anatomy Department were dissected. Surface area of levator scapulae, rhomboid major, and rhomboid minor was calculated using digital image analysis software; width and length parameters were measured using digital calipers. Neither sex nor side significant differences were observed in relation with the numerical data of levator scapulae, rhomboid major, and rhomboid minor (p > 0.05). Algebraic parameters such as surface area, width and length were detected to exhibit a linear growth from 18th to 27th week. Linear functions for levator scapulae, rhomboid major and rhomboid minor surface areas were obtained as y = - 136.871 + 10.598 × age (weeks), y = - 480.567 + 33.147 × age (weeks) and y = - 128.090 + 8.843 × age (weeks), respectively. The results and data of this study can potentially be beneficial in planning of surgeries for many infancy diseases such as trapezius paralysis, obstetrical brachial plexus palsy, Sprengel's disease, or winged scapula. Linear functions calculated in this study are expected to provide a better understanding of the growth dynamics of levator scapulae, rhomboid major, and rhomboid minor in fetal term and more precise estimation of muscle sizes.

Spinal accessory nerve repair using a direct nerve transfer from the upper trunk: results with 2 years follow-up.

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Outcome of triple-tendon transfer, an Eden-Lange variant, to reconstruct trapezius paralysis

This study describes the technique and evaluates the outcome of the triple-tendon (T3) transfer, an Eden-Lange variant, to the scapula to stabilize the scapulothoracic articulation in the treatment of symptomatic trapezius paralysis. T3 transfers were performed in 22 patients with a history of persistent trapezius paralysis secondary to spinal accessory nerve injury. The indications for surgery included shoulder pain and weakness and limited range of motion of the shoulder. The T3 transfer included transfer of the levator scapulae to the lateral aspect of the spine of the scapula, the rhomboid minor to the spine of the scapula just medial to the levator scapulae insertion, and the rhomboid major to the medial spine of the scapula, including all muscles bony insertions. At an average follow-up of 35 months, winging was corrected in all patients, with improvement of shoulder asymmetry. All patients had significant improvement of pain (P < .01) and range of motion, including active shoulder abduction that improved from an average of 71° preoperatively to 118° postoperatively (P < .02) and shoulder flexion from an average of 102° to 150° (P < .01). There were also significant improvements in aggregate Constant Shoulder Score (P < .01), subjective shoulder value (P < .01), and Disabilities of the Arm, Shoulder and Hand score (P < .01). All patients were very satisfied with the outcome of surgery. This study shows that the T3 transfer is effective in stabilizing the scapulothoracic articulation and restoring the function of the trapezius, and thus, in improving pain and shoulder function in patients with symptomatic trapezius paralysis.

Treatment for Medial and Lateral Scapular Winging: Tendon Transfers

Although rare, scapular winging can be a painful and disabling condition. Scapular winging has been categorized as medial or lateral winging, with medial being the more common type. Medial winging is the result of serratus anterior paralysis from injury to the long thoracic nerve. The most common etiology is neuropraxia after blunt or stretch injury. Lateral winging, from trapezius paralysis with injury to the spinal accessory nerve, is most likely iatrogenic from procedures involving the posterior cervical triangle. Recovery of nerve function can take up to 2 years. For those cases that do not have return of nerve function, operative treatment is an option. Tendon transfers were introduced in the early 1900s and have been met with satisfactory results in small case series. The purpose of this article is to describe the indications, operative technique, postoperative rehabilitation, and results of tendon transfer for medial and lateral scapular winging.

An unusual case of scapula winging

Acute or subacute unilateral winging of the scapula is a relatively uncommon cause of referral to a paediatric neurologist. Lesions such as neuralgic amyotrophy, long thoracic nerve injury, injury to the spinal accessory nerve causing loss of trapezius function, or weakness of all the scapula stabilisers caused by a primary muscle disorder are likely to be at the top of the list of differential diagnoses. Differentiation between these causes is usually relatively straightforward clinically. Damage to the long thoracic nerve can be differentiated from damage to the spinal accessory nerve as serratus anterior paralysis results in medial winging of the scapula with prominence of the vertebral border while trapezius paralysis causes lateral winging with downward rotation.

Modified Eden-Lange Procedure for Trapezius Paralysis with Ipsilateral Rotator Cuff-Tear Arthropathy

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Unusual insidious spinal accessory nerve palsy: a case report

IntroductionIsolated spinal accessory nerve dysfunction has a major detrimental impact on the functional performance of the shoulder girdle, and is a well-documented complication of surgical procedures in the posterior triangle of the neck. To the best of our knowledge, the natural course and the most effective way of handling spontaneous spinal accessory nerve palsy has been described in only a few instances in the literature.Case presentationWe report the case of a 36-year-old Caucasian, Greek man with spontaneous unilateral trapezius palsy with an insidious course. To the best of our knowledge, few such cases have been documented in the literature. The unusual clinical presentation and functional performance mismatch with the imaging findings were also observed. Our patient showed a deterioration that was different from the usual course of this pathology, with an early onset of irreversible trapezius muscle dysfunction two months after the first clinical signs started to manifest. A surgical reconstruction was proposed as the most efficient treatment, but our patient declined this. Although he failed to recover fully after conservative treatment for eight months, he regained moderate function and is currently virtually pain-free.ConclusionClinicians have to be aware that due to anatomical variation and the potential for compensation by the levator scapulae, the clinical consequences of any injury to the spinal accessory nerve may vary.

Accessory nerve lesion after cervicofacial lift: Clinical and electrodiagnostic evaluations of two cases

Two cases of accessory nerve lesion are reported that occurred within 2.5 weeks and 4.5 weeks, respectively, after surgery for cervicofacial lift. The patients were referred for electrodiagnostic examination because of persistent and unexplained unilateral shoulder pain and disability, 6 and 5 months, respectively, after face lift. In both cases clinical examination revealed severe right-shoulder weakness related to trapezius palsy, without trapezius muscle atrophy in the first case and with trapezius atrophy in the second. Electrodiagnosis revealed bilateral accessory nerve lesions in the first case and a unilateral lesion in the second case. Recovery for both cases was progressive but delayed, and both were evaluated 11 and 10 months, respectively, after the first evaluation. Clinical and especially electrodiagnostic findings suggested that the accessory nerve lesion was related to conduction block in the first case and severe axonal loss in the second case.