Vol. 15 Issue 20
Thoracic Nerve Injury
An ADVANCE Q&A with Neurosurgeon Rahul Nath, MD
When reconstructive microsurgeon Rahul Nath, MD, developed a winging scapula injury, in which the nerve holding down the shoulder blade becomes damaged, he became discouraged with the invasive and often disfiguring surgical options he faced.
So Dr. Nath, who has been peer-nominated as one of America's Top Doctors for four years running, began to perfect a new technique in which the middle scalene muscle surrounding the long thoracic nerve is resected, relieving the compression on the delicate nerve as it passes through the muscle.
He also feels that the orthopedic and rehabilitation communities often harbor misunderstandings about peripheral nerve injury in general, and feels more education in this area is a critical need.
ADVANCE spoke recently with Dr. Nath from his office in Houston to learn more about winging scapula injury and what PTs should know about its detection and management.
ADVANCE: What are the tell-tale signs of a winging scapula injury?
Dr. Nath: This is a condition that can take a while to be recognized. One of the simplest tests is to have the patient extend the arms straight out at shoulder level, and examine the symmetry of the back. If there is a winging injury, the weight of the patient's arms should result in an asymmetrical presentation. You'll also usually have upper trunk involvement, deltoid and bicep weakness; external rotation will often be weak as well.
ADVANCE: What's going on anatomically with this injury?
Dr. Nath: Generally, winging of the scapula will result from some type of insult to the long thoracic nerve, such as a pinching within the middle scalene muscle. Among all the muscular nerves you have, this is a very unusual one. It has an important function in stabilizing the entire shoulder joint, yet the nerve itself is very slender, fragile and see-through. So there is a mismatch there, and even a minor injury can result in winging and shoulder instability.
ADVANCE: How does it usually occur?
Dr. Nath: This is a traumatic complication, not usually an inflammatory one. The typical history will involve some type of athletics–the patient has been weightlifting, throwing a ball, golfing, or even just yanking a piece of furniture across the room. Many times ptients are not even aware that they hurt something. We also see more minor causes of stress to the nerve, as when a person wakes up with a crick in the neck, and direct external pressure to the area such as deep massage can also be a factor.
ADVANCE: What are the traditional courses of management?
Dr. Nath: The main thing to keep in mind is that strengthening has a limited role with this injury. We do not want additional stress placed on that muscle. If you push and try to strengthen the area, you'll just end up stretching the serratus anterior muscle more and aggravating the symptoms. So in the early stages post-injury, it's very conservative management; many times, there really isn't anything to do. Supportive stretches to prevent tightness in the latissimus and pectoralis, perhaps some e-stim, though it's very difficult to get the electrodes around the scapula.
ADVANCE: When is surgery considered?
Dr. Nath: Some professionals will say "wait two years, and it will get better." In my experience, that's not the case. So I'm more aggressive with considering surgery before that. After three months, if there is no resolution, secondary consequences will begin to surface, such as inflammation, pain and further instability, and clicking or popping of the shoulder joint. Most likely it will not resolve on its own after this point, and this is the time when most patients will come to see me.
ADVANCE: What are the surgical options?
Dr. Nath: Orthopedists will often perform a pectoralis muscle transfer, which has a failure rate of around 60 percent. Also, a scapular-thoracic fusion is possible, but that is a huge operation and even that carries a 50 percent to 60 percent failure rate. For the last six or seven years, I've been performing a new technique in which epineurial scarring is repaired and the middle scalene muscle is resected to alleviate pressure on the nerve as it passes through the muscle.
ADVANCE: How successful is this technique?
Dr. Nath: We've just completed a study that will be sent to the Journal of Bone & Joint Surgery in which 50 patients showed more than a 96 percent improvement in shoulder instability following this operation. Eighty percent of those who had pain as a preventing symptom before the surgery reported relief from symptoms within two years. My guess is that as the medical community becomes more aware of the cause of this injury, this technique will become the preferred way of addressing it.
ADVANCE: What do you recommend for post-op rehab?
Dr. Nath: We try to begin active range of motion of the shoulder and neck immediately to prevent scarring. After three to four months, light strengthening may be introduced, and if all goes well, at six months we'll progress to some heavier weights before discharging the patient from rehab.
ADVANCE: What are some signs that rehab isn't going as well as expected?
Dr. Nath: I'd recommend grading the winging on a daily basis, and the angle of the winging is always a better way to measure it than length in centimeters. Also check shoulder strength, and if these are not improving almost daily, the thing to do is probably to back off and give them a holiday for a few weeks. Stressing and straining the serratus is a common problem, so you have to be careful. Because of the unique relationship between the muscle and the nerve, this is one of the few areas in which you want to be more conservative than proactive.
Learn more about Dr. Nath's surgical procedures and winging scapula injury at www.drnathwingingscapula.com
Jonathan Bassett is on staff at ADVANCE, and can be reached at firstname.lastname@example.org
'Let's Push It'
Swimmer Overcomes Winging Scapula Injury to Compete in Athens
Neurosurgeon Rahul Nath, MD, stresses a low-key rehab approach following delicate operations such as the anterior scalene decompression he perfected for winging scapula injury.
But in the case of champion swimmer Eugene Botes of Thornton, PA, Dr. Nath knew he had to relax his rules a little.
"Eugene's injury occurred while weightlifting in December of last year, and he had Olympic swimming trials in April, so there was no time to lose," recalled Dr. Nath, who was contacted by Botes' father while the family researched this common yet relatively unknown injury online. "We both realized that his dream of going to the Olympics was the whole reason he elected to have this surgery performed. So we said, 'let's push it.'"
Push it Botes did. Within six weeks he was back to heavy training in the water. The combination of a successful surgery and Botes' high-octane training drive paid offafter not being able to raise his right arm above his head in December, he finished third place in the 100-meter butterfly finals during the Olympic Trials in his native South Africa on April 19. Good enough for a trip to Athens.
"I was excited to call Dr. Nath and tell him that Eugene placed third in the trials," said Rosemary Botes, Eugene's mother. "Considering he had been out of the pool for six weeks, this was an amazing accomplishment for him. His winging is almost completely gone."
Representing his native land, Boteswho currently holds the national record for the 100-meter butterfly therefinished 30th out of 59 in the heat rankings with a brisk 54.15 time, missing qualification for the finals by just 14 positions.