Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri.
Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
J Reconstr Microsurg. 2023 Oct;39(8):616-626. doi: 10.1055/s-0042-1757752. Epub 2023 Feb 6.
Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery.
This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores.
A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively ( = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively ( < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively ( < 0.001). Total follow-up was 17.3 ± 4.3 months.
A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.
腋神经损伤是影响肩部功能的最常见神经损伤。神经修复、移植和/或端对端神经转移用于重建完全性神经断裂的腋神经损伤。虽然许多不完全性腋神经损伤可以自行恢复，但神经断裂是不可预测的，且恢复不完全。同样，在四角间隙处叠加压迫性神经病可能会进一步抑制恢复。目前管理不完全性腋神经损伤的框架通常不包括手术。
这是一项回顾性分析，研究对象为 2015 年至 2019 年间接受四角间隙减压术和/或选择性内侧三头肌至腋侧端侧神经转移术的 7 例不完全腋神经麻痹患者，共 23 例连续患者。主要观察指标包括使用肌电图（MRC）量表评估的肩外展 M3 或更高的患者比例，以及视觉模拟量表（VAS）评估的肩部疼痛。次要观察指标包括术前和术后手臂、肩部和手部残疾问卷（DASH）评分。
共有 23 例患者符合纳入标准，在损伤后平均 10.7 个月接受神经手术。与术前 4 例（17%）相比，19 例（83%）患者术后获得 MRC 肩外展 3 级或更高，差异有统计学意义（=0.001）。术后肩部疼痛 VAS 评分从术前的 4.2±2.5 显著降低至 1.9±2.4（<0.001）。DASH 评分也从术前的 48.8±19.0 显著降低至术后的 30.7±20.4（<0.001）。总随访时间为 17.3±4.3 个月。
提出了一种用于诊断和治疗不完全性腋神经损伤的手术框架。四角间隙减压术和/或选择性内侧三头肌至腋侧端侧神经转移术可改善不完全性腋神经麻痹患者的肩外展力量、疼痛和 DASH 评分。
