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Isolated long thoracic nerve paralysis - a rare complication of anterior spinal surgery: a case report

Abstract

Introduction

Isolated long thoracic nerve injury causes paralysis of the serratus anterior muscle. Patients with serratus anterior palsy may present with periscapular pain, weakness, limitation of shoulder elevation and scapular winging.

Case presentation

We present the case of a 23-year-old woman who sustained isolated long thoracic nerve palsy during anterior spinal surgery which caused external compressive force on the nerve.

Conclusion

During positioning of patients into the lateral decubitus position, the course of the long thoracic nerve must be attended to carefully and the nerve should be protected from any external pressure.

Introduction

Isolated long thoracic nerve paralysis causes weakness of the serratus anterior muscle and winging of the scapula [1, 2]. The normal function of the serratus anterior muscle is to maintain the scapula in apposition to the thorax when the arm is elevated forward at the shoulder [1]. Paralysis of the serratus anterior muscle causes the scapula to rotate posteriorly on its vertical axis, producing the characteristic appearance of winging of the scapula [1, 2]. So far, several traumatic and non-traumatic causes of damage to the long thoracic nerve have been reported [3, 4]. We present a patient with long thoracic nerve palsy caused by the direct compression of the nerve during anterior spinal surgery. To the best of our knowledge this is the first case report of this complication in the literature.

Case presentation

Our patient was a 23-year-old woman with a history of a car accident and an L1 flexion-distraction injury, which had been treated in another center by posterior spinal fusion and instrumentation with Cotrel-Dubousset (Figure 1). Nine months later she was referred to our department because of the failure of the instrumentation and resultant thoracolumbar kyphosis (Figure 2). She was neurologically intact. We first removed the failed instrument via a posterior approach; a week later anterior spinal release and fusion was performed. In this procedure the patient was positioned in the right lateral decubitus position (right side down) with the table flexed and a rolled towel under her axilla in order to remove the pressure from the brachial plexus and axillary vessels. Her spine was exposed by the left thoracoabdominal approach and the tenth rib resected. In the third stage,one week later, she underwent posterior spinal fusion and instrumentation. The radiographic result was satisfactory (Figure 3).

Figure 1
figure 1

Initial radiographs. 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
figure 2

Nine months after the primary surgery. Nine months after the primary operation the patient presented with implant failure and thoracolumbar kyphosis.

Figure 3
figure 3

Final radiographs. Posteroanterior and lateral views after the three stages of surgery.

She was discharged with a total contact body brace and, after 2 weeks, on the first postoperative visit, she complained of weakness of the right upper limb during overhead activities, mild fatigue and pain in the right periscapular region. On physical examination, the right upper limb was intact for both sensory and motor innervation, but the right scapula was winged and she was not able to flex her arm forward over 60°.

An electrodiagnostic study carried out two months later revealed an isolated long thoracic nerve lesion. The patient was treated conservatively using physical therapy and observation. As a result, the weakness of her serratus anterior muscle has lessened gradually, but on her last visit five years after the surgery some weakness was still detectable and, although she could manage her daily activities without fatigue, mild winging was still present during overhead activities (Figure 4). Finally, in the last electrodiagnostic study that was carried out 5 years after the surgery, partial and incomplete regeneration of the long thoracic nerve was reported. Although we had offered her neurolysis or nerve decompression [5]-[7] for her limited dysfunction she did not want to be operated on again.

Figure 4
figure 4

Latest photograph. Winging of the right scapula in pushing posture in the last follow-up visit 5 years after the surgery.

According to the details of the electrodiagnostic studies we carried out, the site of injury was around the axillary folds. The site exactly correlated with the location in which we had inserted the axillary roll.

Discussion

The serratus anterior is a broad muscle that has its origin in the first through to the ninth ribs. The muscle extends posteriorly and inserts on the medial border of the scapula. The long thoracic nerve, which is derived from the ventral rami of the fifth, sixth and seventh cervical nerve roots, travels over the first rib and descends on the lateral aspect of the chest wall where it divides and innervates the serratus anterior muscle [1, 2].

The function of the serratus anterior muscle is to stabilize the scapula against the chest wall while elevating the arm. In initial abduction, the serratus anterior fixes the scapula so that the supraspinatus and deltoid muscles can act effectively on the humerus raising the extremity to the right angle. The serratus anterior and trapezius muscles simultaneously rotate the scapula so that the arm can be raised to the vertical position [1, 2, 4]. When this muscle is paralyzed, the scapula's medial border, and especially its lower angle, stands out prominently. The patient cannot raise the arm fully or push, and attempts to do so are followed by further projection or "winging of scapula" [1, 2, 4]. Due to its long and superficial course, the long thoracic nerve is vulnerable to damage at various levels. Several causes of its damage have been reported, including closed trauma, compression, stretching, traction, direct extrinsic force, penetrating injury, improper surgical technique, electrocution, chiropractic manipulation, various sport-related injuries including tennis, hockey, bowling, soccer, gymnastics, and weight lifting, deep massage, repetitive overhead movement, bracing for back deformity, iatrogenesis, viral infection and neuritis such as Parsonage-Turner syndrome [8]-[20]. Scapular winging can also result from repetitive or sudden external biomechanical forces that may either exert compression or place extraordinary traction in the course of the long thoracic nerve [16]-[18].

In our patient, during the anterior spinal surgery she was in the right lateral decubitus position with a rolled towel under her axilla. The operation took four hours and it appears that external compression on the nerve during surgery was the most probable cause of the nerve palsy.

Since this event we have changed patient positioning during lateral decubitus surgeries. Before this, we placed the chest or axillary roll under the dependent chest wall just beneath the axilla to take pressure off the dependent shoulder and to prevent compression of the neurovascular bundle by the humeral head. Now, we place the roll about 10 cm distal to the axillary folds, roughly over the seventh to ninth ribs. This new position not only does the same as before, but also protects the main trunk of the long thoracic nerve from injury (Figure 5).

Figure 5
figure 5

Incorrect and correct positioning. The image shows the previous (A) and current method (B) of our patient positioning during lateral decubitus surgery.

Iatrogenic injuries to the nerve have been reported during needle thoracocentesis, breast reconstruction, cardiac surgery, anesthetic block of the brachial plexus and chest tube placement [12]-[15]. In all of these iatrogenic injuries the nerve was directly traumatized, but in our patient the injury was secondary to an external compressing force.

Conclusion

During positioning of patients into the lateral decubitus position the course of the long thoracic nerve must be attended to carefully and the nerve should be protected from any external pressure.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

References

  1. Hollinshead WH: Anatomy for Surgeons. 3rd edition. Philadelphia: Harper and Row; 1998.

    Google Scholar 

  2. Bertelli JA, Ghizoni MF: Long thoracic nerve: anatomy and functional assessment. J Bone Joint Surg Am 2005, 87:993-998.

    Article  PubMed  Google Scholar 

  3. Gozna ER, Harris WR: Traumatic winging of the scapula. J Bone Joint Surg Am. 1979, 61: 1230-1233.

    CAS  PubMed  Google Scholar 

  4. Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res. 1999, 368: 17-27. 10.1097/00003086-199911000-00004.

    PubMed  Google Scholar 

  5. Nath RK, Lyons AB, Bietz G: Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord. 2007, 8: 10.1186/1471-2474-8-25.

    Google Scholar 

  6. Nath RK, Melcher SE: Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury. J Brachial Plex Peripher Nerve Inj. 2007, 2: 10.1186/1749-7221-2-4.

    Google Scholar 

  7. Disa JJ, Wang B, Dellon AL: Correction of scapular winging by supraclavicular neurolysis of the long thoracic nerve. J Reconstr Microsurg. 2001, 17: 79-84. 10.1055/s-2001-12694.

    Article  CAS  PubMed  Google Scholar 

  8. Patel DR, Nelson TL: Winging of the scapula in a young athlete. Adolesc Med. 1996, 7: 433-438.

    PubMed  Google Scholar 

  9. Packer GJ, McLatchie GR, Bowden W: Scapula winging in a sports injury clinic. Br J Sports Med. 1993, 27: 90-91. 10.1136/bjsm.27.2.90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Ebata A, Kokubun N, Miyamoto T, Hirata K: The bilateral long thoracic nerve palsy presenting with "scapula alata", as a result of weight training. A case report. Rinsho Shinkeigaku. 2005, 45: 308-311.

    PubMed  Google Scholar 

  11. Oakes MJ, Sherwood DL: An isolated long thoracic nerve injury in a Navy Airman. Mil Med. 2004, 169: 713-715.

    Article  PubMed  Google Scholar 

  12. Bizzarri F, Davoli G, Bouklas D, Oncchio L, Frati G, Neri E: Iatrogenic injury to the long thoracic nerve: an underestimated cause of morbidity after cardiac surgery. Tex Heart Inst J. 2001, 28: 315-317.

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Durand LS: Winging of the scapula in patients for breast reconstruction. Plast Reconstr Surg. 1984, 74: 153-154. 10.1097/00006534-198407000-00039.

    Article  CAS  PubMed  Google Scholar 

  14. Faruqi S, Raychaudhuri C, Thirumaran M, Blaxill P: Winging of the scapula: An unusual complication of needle thoracocentesis. Eur J Intern Med. 2008, 19: 381-382. 10.1016/j.ejim.2007.10.012.

    Article  CAS  PubMed  Google Scholar 

  15. Hassan WU, Keaney NP: Winging of the scapula: an unusual complication of chest tube placement. J Accid Emerg Med. 1995, 12: 156-157.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Debeer P, Van Den Eede E, Moens P: Scapular winging: an unusual complication of bracing in idiopathic scoliosis. Clin Orthop Relat Res. 2007, 461: 258-261.

    CAS  PubMed  Google Scholar 

  17. Elders LA, Van der Meche FG, Burdorf A: Serratus anterior paralysis as an occupational injury in scaffolders: two case reports. Am J Ind Med. 2001, 40: 710-713. 10.1002/ajim.10021.

    Article  CAS  PubMed  Google Scholar 

  18. Gupta V, Posner B: Trauma to the long thoracic nerve and associated scapula winging in a low-velocity rear-end automobile collision: case report. J Trauma. 2004, 57: 402-403. 10.1097/01.TA.0000053468.19289.54.

    Article  PubMed  Google Scholar 

  19. Still JM, Law EJ, Duncan JW, Hughes HF: Long thoracic nerve injury due to an electric burn. J Burn Care Rehabil. 1996, 17: 562-564. 10.1097/00004630-199611000-00015.

    Article  CAS  PubMed  Google Scholar 

  20. Zander D, Perlick L, Diedrich O: Scapula alata as a complication of infection with human parvovirus B19 (erythema infectiosum). Z Orthop Ihre Grenzgeb. 2001, 139: 174-176.

    CAS  PubMed  Google Scholar 

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Acknowledgements

We would like to express our gratitude to Katayoun Z Toossi for her help in reviewing, editing and correcting this paper.

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Correspondence to Farzad Omidi-Kashani.

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Authors' contributions

EA participated in the sequence alignment and drafted the manuscript. HB participated in the design of the study. FOK conceived of the study and participated in its design and coordination. All authors read and approved the final manuscript.

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Ameri, E., Behtash, H. & Omidi-Kashani, F. Isolated long thoracic nerve paralysis - a rare complication of anterior spinal surgery: a case report. J Med Case Reports 3, 7366 (2009). https://doi.org/10.4076/1752-1947-3-7366

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