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Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 161-165

The infraclavicular approach for neurectomy of the spastic shoulder

1 Birmingham Hand Centre, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
2 Department of Plastic and Reconstructive Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
3 Upper Limb Spasticity Service, Department of Hand Surgery, Royal Orthopaedic Hospital, Birmingham, UK

Correspondence Address:
Mr. Dominic M Power
Birmingham Hand Centre, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, West Midlands Brachial Plexus and Peripheral Nerve Injury Service, 6th Floor, Nuffield House, Mindelsohn Way, Edgbaston, Birmingham B15 2WB
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmsr.jmsr_104_18

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Objectives: Total or partial motor neurectomy may be used in the management of recalcitrant spasticity. A shoulder posture with adduction and internal rotation, impair function, and left untreated may result in established contractures. The aims of this anatomical study and clinical case series were to define a safe surgical approach to the infraclavicular plexus for selected motor neurectomy that avoids the axillary skin and can be readily completed in the presence of early axillary contractures. Methods: Using a cadaveric model, we adopted the pectoralis major muscle-splitting approach to the brachial plexus to afford access to the infraclavicular motor branches to the shoulder. The pectoral nerve origins can be identified and traced to their respective cords. Following pectoralis minor tenotomy, the interval between the lateral cord and the axillary artery is developed to expose the posterior cord. The subscapular and thoracodorsal nerves are identified using nerve stimulation. Results: The procedure has been used in the four non-functional limbs with shoulder adduction and internal rotation deformity with early axillary contractures resistant to physiotherapy and splinting. A mean of 6.25 nerves were sectioned in each case. All patients or their caregivers reported improvements in shoulder posture and pain with examination, demonstrating a mean increase passive in brachiothoracic angle of 45° (range: 30°–60°) facilitating washing and dressing. The improvements have been maintained at 12-month follow-up. Conclusion: Management of the painful adducted and internally rotated spastic shoulder is challenging. A mini-incision pectoralis major splitting incision provides access to the key motor nerves to the shoulder for neurectomy. Comparative studies evaluating neurectomy and tenotomy at the shoulder are required to demonstrate efficacy.

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