Axillary nerve decompression for quadrangular syndrome
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Axillary nerve exposure and decompression may be required for primary entrapment neuropathy known as the “quadrangular space syndrome”, for evaluation of an axillary nerve injury and optimisation of the environment for recovery from more proximal injury or for poor regeneration following C5 spinal nerve root decompression.The symptoms and functional loss will be defined by the underlying pathology.
Quadrangular space syndrome was reported in throwing athletes and those engaged in overhead activity. In this condition there is usually posterior shoulder pain with sensory disturbance in the upper lateral cutaneous nerve territory, weakness of the deltoid and often paralysis of the teres minor resulting in impaired shoulder external rotation in the elevated and abducted shoulder position. There is often occlusion of the posterior circumflex humeral artery on shoulder abduction and external rotation (the ABER position). Placing the patient’s arm in this position may induce symptom onset and is a clinical examination test supporting the diagnosis.
Decompression is performed using a posterior approach and the axillary nerve can be evaluated with nerve stimulation. Compression points can be released using this approach, however the full course of the axillary nerve from its take-off from the posterior cord cannot be visualised and in trauma presenting early an anterior approach is to be preferred to facilitate access for reconstruction of a ruptured nerve. In late presenting cases, the posterior approach is more useful because if there is no functional continuity of the axillary nerve, a nerve transfer from the triceps motor branches can be performed close to the axillary nerve motor points, allowing late salvage of a complete lesion of the axillary nerve.
The modified Somsak nerve transfer technique is described as a separate operative technique in OrthOracle Modified Somsak nerve transfer (medial head of triceps nerve transfer to anterior division of the axillary nerve through a posterior approach)
Author:Dominic Power FRCS Tr & Orth, Consultant Hand and Peripheral Nerve Surgeon.
Institution: West Midlands Peripheral Nerve Injury Service, Birmingham Hand Centre, UK.