Leschinger Tim, Hackl Michael, Zeifang Felix, Scaal Martin, Müller Lars Peter, Wegmann Kilian
Center for Orthopedic and Trauma Surgery, University Medical Center, Kerpenerstr. 62, 50937, Cologne, Germany.
Cologne Center for Musculoskeletal Biomechanics, Medical Faculty, University of Cologne, Cologne, Germany.
Arch Orthop Trauma Surg. 2017 Jan;137(1):135-140. doi: 10.1007/s00402-016-2585-7. Epub 2016 Oct 28.
The purpose of the study was to evaluate the position of the subscapular nerves relative to surgical landmarks during exposure and to analyze the pattern of innervation of the subscapularis to avoid injury during anterior shoulder surgery.
20 embalmed human cadaveric shoulder specimens were used in the study. The muscular insertions of the subscapular nerves were marked and their closest branches to the musculotendinous junction and the coracoid process were measured in horizontal and vertical distances. In addition, the innervation pattern of each specimen was documented.
14/20 specimens showed an innervation of the subscapularis with an upper, middle and lower subscapular nerve branch. Even though the nerve branches were in average more than 2 cm medial to the musculotendinous junction, minimal distances of 1.1-1.3 cm were found. The mean vertical distance as measured from the medial base of the coracoid to the nerve innervation point into the muscle was 0.7 cm for the upper nerve branch, 2.2 cm for the middle nerve branch and 4.4 cm for the lower nerve branch.
The subscapularis has a variable nerve supply, which increases the risk of muscle denervation during open shoulder surgery. Dissection or release should be avoided at the anterior aspect of the subscapularis muscle more than 1 cm medial to the musculotendinous junction. In approaches with a horizontal incision of the subscapularis, splitting should be performed at a vertical distance of 3.2-3.6 cm to the coracoid base to avoid iatrogenic subscapular nerve injuries.
本研究旨在评估肩胛下神经在暴露过程中相对于手术标志的位置，并分析肩胛下肌的神经支配模式，以避免在前路肩部手术中造成损伤。
本研究使用了20个防腐处理的人体尸体肩部标本。标记肩胛下神经的肌肉附着点，并测量其与肌腱结合部和喙突最近分支的水平和垂直距离。此外，记录每个标本的神经支配模式。
20个标本中有14个显示肩胛下肌由上、中、下肩胛下神经分支支配。尽管神经分支平均位于肌腱结合部内侧2厘米以上，但发现最小距离为1.1 - 1.3厘米。从上喙突基部到神经进入肌肉的支配点测量的平均垂直距离，上神经分支为0.7厘米，中神经分支为2.2厘米，下神经分支为4.4厘米。
肩胛下肌的神经供应存在变异，这增加了开放肩部手术中肌肉失神经支配的风险。在肩胛下肌肌腱结合部内侧1厘米以上的前部应避免进行解剖或松解。在肩胛下肌水平切口入路时，应在距喙突基部垂直距离3.2 - 3.6厘米处进行劈开，以避免医源性肩胛下神经损伤。
