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Isolated suprascapular nerve lesions

Article in Injury October 1983

DOI: 10.1016/0020-1383(83)90039-6 Source: PubMed

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Injury, 15, 1 17-l 26 Printed in Greet Britain
Isolated suprascapular nerve lesions
Hugh L. Weaver
Austin Hospital, Melbourne, Australia
Summary
This paper shows how the suprascapular nerve is liable to
isolated injury and where it is most vulnerable. Lesions of
the suprascapular nerve are related to disorders of the
shoulder. The management of isolated suprascapular nerve
lesions is discussed.
INTRODUCTION
ISOLATED lesions involving the suprascapular nerve are
not commonly reported, which is in contrast with
other large branches of the brachial plexus. However,
lesions of the suprascapular nerve are undoubtedly
more frequent than is suspected and they may be
responsible for many of the symptoms in the shoulder
region. This naner sets out to:
(9 classify the forms of lesions of the supra-
scapular nerve and to indicate their causes.
(ii) consider the contribution of the supra-
scapular nerve to the normal function of the
shoulder.
(iii) discuss the controversial relationships
between lesions of the suprascapular nerve
and other syndromes affecting the upper
limb, such as frozen shoulder and rotator
cuff lesions.
(iv) suggest appropriate methods of management
Anatomy
The suprascapular nerve is a large branch of the upper
trunk of brachial plexus at Erbs point. It most often
derives its fibres solely from the fifth cervical root, but
may receive some from either the fourth or sixth. It
sometimes arises more distally, from the anterior or
even the posterior division of the upper trunk (Kerr,
19 18). The usual origin lies in the posterior triangle of
the neck, on a slightly deeper plane than the posterior
belly of the omo-hyoid. The nerve accompanies this
muscle laterally to disappear beneath the anterior
border of the trapezius, descending to the upper border
of the scapula in company with the suprascapular
artery. At the scapula, the nerve passes close to the
scapular attachment of omo-hyoid medially, and to
the base of the coracoid process laterally. It enters the
supraspinous fossa via the suprascapular notch, the
notch being converted into an osseofibrous foramen by
the attachment of the bridging suprascapular (trans-
verse scapular) ligament, whereas the suprascapular
artery and vein pass superficial to the ligament before
joining the nerve within the supraspinous fossa. The
117
nerve sometimes shows a bulge just before passing
beneath the ligament (Last, 1978) and this may be
relevant to the occurrence of entrapment at this point
(see below).
Within the supraspinous fossa the nerve provides
small articular twigs to the gleno-humeral and
acromio-clavicular joints, a branch to the coraco-
acromial ligament, and two motor branches to the
supraspinatus. It then turns around the lateral free
margin of the scapulas spine, or spinoglenoid notch,
to run through the infraspinous fossa, supplying at
least two motor branches to the infraspinatus. (Fig. 1).
No sensory endings are given off to the skin and this
fact is relevant to the nature of the pain that is
characteristic of the nerve.
Means of injury
Direct injury of the nerve, which is at risk in several
places
(a) The posterior triangle of the neck
Here, the nerve is vulnerable to penetrating injuries
but such injuries are rare. Sunderland (1978) noted
that Foerster (1929) found only 16 such injuries out
of a total of 3907 peripheral nerve injuries observed
among the First World Wars veterans. Frazier and
Silbert (1920) similarly found only one case in a total
of 500 mixed peripheral injuries resulting from the
same conflict. More recently, the risks entailed by
radical operations in the neck for cancer have been
indicated by SwiA (1970), but he found only two cases
of suprascapular damage in 33 cranial and peripheral
nerve injuries sustained during operations on this
region.
(b) The supraclavicular region
Bateman (1967) reported that a blow on the supraclav-
icular fossa can injure the suprascapular nerve, but
that it is much more usual for such an injury to cause
diffise damage to the upper trunk or upper roots of the
plexus. He emphasized the difficulties arising from the
tendency for isolated lesions to remain unnoticed for
some time. Both Seddon (1975) and Sunderland (1978)
accepted that direct injury of this region occasionally
causes an isolated lesion but together with Kopell and
Thompson (1963), they both supported the concept of
traction on the shoulder girdle as the usual cause of
injury (see below).
 118 Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2

A CLAVICLE
B FIRST COSTAL CARTILAGE
C SUPRASCAPULAR ARTERY
0 SUBCLAVIAN ARTERY
E SUPRASCAPULAR NERVE
F CORACOID PROCESS
G SUPRASCAPULAR (TRANSVERSE
SCAPULAR) LIGAMENT
H ACROMION PROCESS (RESECTED)
J SUPRASPINATUS
K SCAPULAR SPINE (IN SECTION)
L INFRASPINATUS
M UPPER TRUNK
OF BRACHIAL PLEXUS
N SCALENUS ANTERIOR
0 SCALENUS MEDIUS

Fig. 1. Postero-superior view of left shoulder region (semi-diagrammatic) showing course taken by suprascapular nerve,
and its essential relations. Omo-hyoid (not shown) is attached to the upper border or scapula and suprascapular ligament,
adjacent to point G.

(c) Distal to the suprascapular foramen
Although little has been written about it, there is evi-
dence that direct injury of the distal part of the nerve
does occur. Seddon (1975) mentioned a case of isolated
palsy following a fracture through the blade of the
scapula, and I have seen a 23-year-old man who was
injured in a fight, in the course of which he was stabbed
with a long spike of broken glass. The most serious
wound was over the lateral end of the spine of the left
scapula. This was sutured in a Casualty department
without exploration, but the bleeding from it was
sufficient to merit his admission to hospital for several
days. At the time of discharge, his shoulder was
reported to feel stiff and weak, but nothing more was
done. Several weeks later he consulted his own doctor
because of persisting weakness of the shoulder and he
was sent for physiotherapy.
The therapist noted a full range of passive move-
ments of the shoulder but active abduction was limited
to 90, with only grade 3 power present. No active
lateral rotation was possible. One month later an
orthopaedic surgeon confirmed these findings and
added that the infraspinatus was definitely, and the
supraspinatus probably, wasted. The deltoids bulk
and power were full, with normal sensibility ofthe skin
of the upper part of the arm. Plain radiographs of the
shoulder revealed no abnormality. Conduction studies
and electromyography were undertaken in the left
supraspinatus, infraspinatus and deltoid; denervation
potentials were noted in infraspinatus. Stimulation of
the nerve trunk at Erbs point showed delayed conduc-
tion to infraspinatus. There was clear evidence of
denervation of this muscle, with probably partial
denervation of supraspinatus. The deltoid was thought
Weaver: Isolated nerve lesions
to be normal but in view of the persistently weak
abduction it was suggested that an intra-articular
derangement be excluded. Arthrography of the
shoulder was normal.
Subsequent management included ultrasound and
active exercises. Because the shoulder went on
improving slowly the nerve was not explored. One
year after the injury, he noted that combined abduc-
tion and lateral rotation (as in placing heavy objects
upon a high shelf) were still weak and there was still
some flattening of the infraspinatus. Nevertheless, the
muscle could be felt to contract and a full range and
power of movement, including lateral rotation, seemed
to have returned.
Fractures of the superior lateral angle of the scapula,
with en trapmen t
Entrapment neuropathies in general will be considered
in the next section, but they constitute the largest
group of isolated lesions of the suprascapular nerve
and mention must be made of a specific form of
entrapment at the suprascapular notch. This results
from fractures of the superior lateral angle of the
scapula. In 1974, Zdravkovic and Damholt reported
finding no evidence of weakness of the shoulder or arm
following fracture through the region of the supra-
scapular notch but their experience is in marked
contrast to that of other authors, notably Edeland
and Zachrisson (1975) and Solheim and Roaas (1978).
The former reported 18 patients who had previously
sustained comminuted fractures of the superior, lateral
angle of the scapula. They noted that in 1956 De
Coulx had classified fractures of the scapula into three
groups, of which group 3, those of the superior lateral
angle, frequently showed a fracture running into the
suprascapular notch. Edeland and Zachrisson found
that seven of their eighteen patients complained of
symptoms suggestive of weakness of the supraspinatus.
Examination confirmed the presence of wasting and
weakness of the spinati, and electromyography per-
formed on four ofthe seven patients showed additional
evidence of suprascapular nerve injury. Review of the
original films revealed that conventional antero-
posterior and lateral radiographs of the shoulder
had shown the suprascapular notch in only three of
the eighteen patients and in two of these a fracture
through the notch could just be seen. By using a
slightly different projection with the X-ray tube angled
15-30 caudally, clear views of the notch were
obtained in all seven patients with symptoms. In one,
a healing fracture of the suprascapular notch was
shown. As a result of their enquiry, the authors felt
able to suggest that the angled projection that they had
described be used in the radiological assessment of all
patients with group 3 fractures. Fig. 2 shows a film
exposed in this fashion on a cadaver in which a group
3 fracture had been caused by striking the shoulder.
Solheim and Roaas (1978) reported a 32-year-old man
who sustained a suprascapular neuropathy consequent
upon a comminuted fracture through the supra-
scapular notch. His pain and tenderness in the region
of the notch were temporarily relieved by local anaes-
thesia of the nerve within the notch. More lasting relief
was obtained by dividing the suprascapular ligament
Fig. 2. Radiograph from a cadaver study, showing the effect
of tilting the X-ray tube 30 caudally, in order to allow better
appreciation of the suprascapular notch than is seen in the
usual A/P projection. Note the presence of a group 3 frac-
ture, which enters the suprascapular notch.
and removing a rim of callus that was encroaching
upon the notch.
Entrapment neuropathy arising as a result of traction
on the nerve
By far the greatest number of isolated lesions of the
suprascapular nerve involve entrapment which occurs
because the nerve is constricted at the suprascapular
notch. The symptoms that ensue have been well
described by several authors (Kopell and Thompson,
1963; Ford, 1973; Murray, 1974; Clein, 1975; Seddon,
1975; Sunderland, 1978; Brogi, 1979). A poorly
localized, dull ache, is felt deep to the skin over the
posterior and lateral area of the shoulder. In some
individuals it tends to radiate from here either into
the side of the neck or to the elbow. It may be
accompanied by a similar pain within the extensor
muscles in the forearm. (This latter symptom has been
attributed to traction upon the radial nerve axis.)
At first, the pain is brought on by movement of the
shoulder girdle, but as time passes it occurs at rest and
it may become so severe as to disturb sleep and the
patient is unable to lie upon the affected side. This
may be because this position pushes the scapula
forwards. Weakness of the shoulder may also be
complained of, particularly in the movements of
abduction and lateral rotation. Sometimes the symp-
toms are precipitated by an injury of the shoulder such
as dislocation, fracture of the humeral tuberosity or
acromio-clavicular separation, but sometimes the
injury is distal, for example Colles fracture or fracture
of the scaphoid bone. Usually a more insidious onset
is noted, in which the outstanding feature is a history
of repeated wide excursions of the scapula to the chest
wall, (perhaps with repeated wide excursions of the
glenohumeral joint) as in the cases reviewed by Kopell
and Thompson (1963)) because the glenohumeral joint
120
was already stiff. It is postulated that movement of the
scapula on the chest wall, particularly forwards, kinks
the suprascapular nerve just proximal to the notch.
This in turn often causes the appearance of a localized
neuroma and produces the symptoms and signs of an
inflammatory neuropathy.
This concept is supported by a number of authors,
most notably Kopell and Thompson (1963) who
suggested that much of the pain in patients with a true
frozen shoulder(with impairment ofboth glenohumeral
and scapula-thoracic movement) is the result of irri-
tation of the suprascapular nerve at the notch. Their
hypothesis is,that pre-existing glenohumeral stiffness,
whether resulting from injury or from rheumatoid or
other inflammatory conditions leads to compensatory
wider scapula-thoracic excursions, which cause trac-
tion upon the nerve at the notch and, particularly in
those individuals with a narrow notch, an irritative
neuropathy ensues.
When there has been no definite injury, a consider-
able variety of activities requiring repeated wide
excursions of the scapula has been reported: weight-
lifting, basketball, carrying large stones or other heavy
objects, hammering, baseball, throwing heavy articles,
relay running, and even, in one of Kopell and
Thompsons (1963) cases, dishwashing. This occurred
in a paraplegic patient who washed dishes in a sink
while seated in a wheelchair which necessitated her
scapula being well forward on her chest for long
periods. Kopell and Thompson postulated that this
posture stretches the nerve and presses it against the
edge of the foramen, as indicated in Fig. 3.
Whatever the explanation, there is almost always
wasting of the spinati with a deltoid of normal bulk;
often deep tenderness over the suprascapular notch;
occasionally tenderness in the origin of the extensor
muscles in the forearm, a full range of movements of
the neck; some loss of passive abduction at the
shoulder and loss of power of active abduction, but
more particularly of lateral rotation.
Relevant investigations include plain antero-pos-
terior and lateral radiographs of the shoulder; these
usually reveal no abnormality but evidence of pre-
existing lesions such as calcific tenosynovitis, acromio-
clavicular disruption, dislocation of the shoulder or
fracture of the greater tuberosity of humerus may
be apparent. Radiographs of the neck may show
degenerative diesease as a possible cause of the pain.
Cervical myelography, though not infrequently per-
formed in those cases in which suprascapular entrap-
ment neuropathy has been a late diagnosis, has no part
to play. A useful diagnostic aid is the use of selective
suprascapular nerve block, either with hydrocortisone
alone or in combination with a local anaesthetic agent;
this is injected into the region of the suprascapular
notch in the manner indicated by Colachis and Strohm
(197 1) and others. Even temporary abolition of pain
suggests that the suprascapular block may also be an
effective form of mangement. Interestingly Murray
(1974) stated that he had not found suprascapular block
useful in the diagnosis of the condition, simply be-
cause of the anatomy of the nerve. Many authors have
indicated the value of conduction studies and
electromyography as an aid to diagnosis (Colachis and
Strohm, 1971; Donovan and Kratt, 1974, Murray,
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2
RuNK
SUPRASCAP
NERVE
Fig. 3. Unilateral view to show relationship of scapular
motion to course of suprascapular nerve. A, position of
scapula when arm is across the body (reproduced with
acknowledgement).
1974; Clein, 1975; Brogi, 1979). Delayed contraction
of the spinati following stimulation at Erbs point,
positive sharp wave and fibrillation potentials, and
failure of recruitment of motor units all point to the
presence of a nerve lesion. Brogi and others describe
their method of investigating the electrical activity in
the infraspinatus by constructing a quad&lateral area
on the overlying skin surface, using easily recognised
bony reference points; by so doing, selective insertion
of a needle electrode into the subcutaneous part of the
muscle may be achieved, thus avoiding interference
from activity in other muscles nearby (Fig. 4).
Finally, arthrography of the shoulder joint, which
may be supplemented by cinefluoroscopy, is useful for
distinguishing a rotator cuff lesion from isolated
suprascapular nerve injury (Donovan and Krafi,
1974).
The Relationship between Suprascapular Nerve
Injury and Dysfunction of the Shoulder
Functional anatomy of the suprascapular nerve in
relation to active glenohumeral movetient
It is widely accepted that, as proposed by Inman,
Saunders and Abbott (1944) a couple operates at
the glenohumeral joint and that normal abduction
requires contributions from the deltoid (axillary nerve)
and supraspinatus (suprascapular nerve). Various
authors (Duchenne, 1959; Seddon, 1975; Sunderland,
1978) have observed patients with isolated axillary
nerve lesions and have noted that active abduction
between 90 and 155(according to different observers)
may be achieved by the supraspinatus alone. By
contrast, most are agreed that the loss of the supras-
pinatuss function in an otherwise normal shoulder is
far less serious, and that after a period of retraining
extending over several months many patients exhibit
no loss of active abduction, even in the presence of
permanent paralysis. These views have not evolved
without challenge; Tine1 (19 17) maintained that
the supraspinatus alone was incapable of acting
as an effective substitute for the deltoid whereas
Weaver: Isolated nerve lesions
Fig. 4. Diagram illustrating a method of constructing a quadrilateral area on the skin
surface overlying infraspinatus; whereby selective determination may be made of
electrical activity within the muscle (after Brogi).
Watson-Jones (1955) believed that the arm could not
be effectively abducted by the deltoid acting alone
because the supraspinatus was an essential synergist.
However, Watson-Jones based his opinion on instances
of rupture of the supraspinatus tendon rather than
suprascapular nerve injury. Colachis and Strohm have
suggested (1971) that, with regard to its role as a
synergist, the anatomical continuity of a muscle from
its origin to its insertion may be of greater relevance
than its electrophysiological integrity. All authors are
agreed that whether traumatic or experimental, com-
bined lesions of the axillary and suprascapular nerves
result in complete loss of voluntary abduction. With
regard to the function of the infraspinatus, it is noted
that its loss of action through suprascapular palsy is
best demonstrated by weakness of resisted lateral
rotation (Duchenne, 1959; Cyriax, 1962).
Most observers agree with Sunderland that full
recovery of active lateral rotation eventually takes
place even in the presence of a permanent supra-
scapular nerve injury; this is owing to the compensatory
effect of other muscles (mainly teres minor). However,
Narakas (1979) believes that recovery remains incom-
plete, and accepts this as a reason for undertaking
exploration and attempting repair of many cases of
damaged suprascapular nerve.
It is feasible to block the suprascapular nerve near
the suprascapular notch with local anaesthetic agents,
121
and the use of this technique in the management of
painful shoulders will be described subsequently. The
procedure has been described by Rabson and Auday
(1960) and it relies on the fact that branches of the
nerve innervate the postero-superior part of the joint
capsule. It has also been employed experimentally as
a means of identifying the effect of supraspinatus
paralysis when there is already an axillary nerve lesion
(Highet, 1942). In 1963, van Linge and Mulder
blocked the nerve in ten healthy volunteers and
showed that the range of abduction was preserved but
that power was diminished; no estimate was made of
the loss of power of lateral rotation. Strohm and
Colachis (1965) followed the recovery of the supra-
scapular nerve in a 15-year-old boy who sustained an
isolated nerve injury after a surfing accident; they were
able to confirm that by clinical criteria, normal
activity had returned by the end of six months even
though abnormal EMG recordings were obtainable
from the infraspinatus for a considerably longer
period. As a method of control, they also investigated
the loss of power of abduction and lateral rotation in
a normal subject whose suprascapular nerve had been
blocked with a local anaesthetic and they augmented
this work when they induced suprascapular nerve
blocks in five subjects and a combined suprascapular
and axillary nerve block in a sixth individual.
(Colachis and Strohm, 1971). In all cases of supra-
122
scapular nerve block they were able to demonstrate a
50 per cent loss of power of abduction and a 60 per
cent loss of power of lateral rotation, noting particu-
larly that the power of abduction was less affected from
60 to 150 than from 0 to 60. In the subject in whom tention that the entrapment neuropathy is, in most
combined blocks were performed, active abduction
and lateral rotation were both completely abolished,
as was forward flexion.
Relationship of suprascapular entrapment to the frozen
shoulder
In their original article Kopell and Thompson (1959),
appeared to distinguish two groups of patients; a
majority in whom inability to abduct the shoulder
actively preceded the onset of the deep pain, now con-
sidered so typical of an entrapment neuropathy, that
is, patients who were described as suffering from a
frozen shoulder, and another group in whom the
entrapment symptoms were either a sequel to an
injury or had a spontaneous onset. For both groups it
was postulated that extensive movement of the scapula
on the chest wall, particularly forwards, stretches the
nerve and kinks it where it enters the foramen. In those
individuals with any degree of stenosis at this point,
an irritative lesion would be established. However, the
point was made that entrapment can occur with or
without restriction or scapulohumeral motion. They
subsequently found that operations to release a
trapped nerve in the presence of a frozen shoulder
usually resulted in a considerable reduction of pain,
but not necessarily in marked improvement of move-
ment at the shoulder. This observation tended to rein-
force the concept that the symptoms of entrapment
and the restriction of motion had different causes.
In their later discussion Kopell and Thompson
(1963) appear to have circumscribed their definition of
a frozen shoulder. In particular, they were no longer
prepared to accept restriction of scapulohumeral
movement as sufficient and insisted that scapulo-
thoracic movements must also be markedly diminished.
In so doing they stressed the frequency with which
these conditions caused subsequent entrapment of the
suprascapular nerve. Typically, they considered that
any cause of embarrassment of glenohumeral abduc-
tion (such as tenosynovitis of the rotator cufl) follow-
ing injury of the head of the humerus or inflammatory
disease led to a compensatory increase in scapulo-
thoracic excursion and that where there is stenosis at
the suprascapular foramen, stretching and kinking of
the nerve will ensue. The resulting inflammatory
neuropathy causes pain during scapula-thoracic move-
ments, followed by pain at rest, with a subsequent
reluctance to carry out the painful movement. This
in turn initiates secondary fibrotic changes in the
sternoclavicular and acromioclavicular joints, further
freezing the shoulder. This view is not universally
shared and in his five cases Clein (1975) made no
mention of finding an associated frozen shoulder.
Indeed at least two of the cases discussed appear to
have been attributed to repeated wide abduction of the
shoulder while playing baseball and running relay
races. Clein believed that three ways of injury account
for the pathophysiology of this condition: transmitted
forces (as in Colles fracture), direct injuries and trac-
Iniuv the British Journal of Accident Surgery Vol. 1 ~/NO. 2
tion. Of these, he believes traction to be the most
frequent.
Similarly, Brogi and others (1972) discuss this
matter in some detail and state emphatically their con-
instances, an entirely different phenomenon from
frozen shoulder and they note that in their two
reported cases (a basketball player and weightlifter,
and a baker who lifted heavy weights) there was little
loss of movement; the main symptom was postero-
lateral pain in the shoulder. They also pointed to the
fact that in other cases of capsulitis reported, there was
no evidence of delayed conduction in the nerve when
stimulated at Erbs point, nor of abnormal EMG
changes in the muscles innervated by the C5 and C6
roots.
Certainly, in those instances in which a nerve lesion
has been seen to co-exist with disorder of the rotator
cuff or other abnormalities of the shoulder, it seems
logical to accept Kopell and Thompsons requirement
that two separate causes be recognized and to treat
them simultaneously.
Differentiation of suprascapular nerve lesions from
tears of the rotator cuff
Bateman (1967) had indicated the need to eliminate an
intra-articular derangement when weak or faulty
abduction co-exists with a vigorously contracting del-
toid. This subject has been enlarged upon by Donovan
and Kraft (1974), who reported five patients with this
combination. All had been subjected previously to
injury of some kind and they complained of inability
to abduct the arm actively. Pain about the shoulder
was an inconstant feature but it was particularly notice
able in the one patient who was subsequently shown
to be suffering from neuritis affecting the supra-
scapular nerve. When she was seen shortly after injury
no wasting of the spinati was found, but wasting was
a marked feature in all the other patients, who were
seen weeks or months after the onset of symptoms.
Active contraction of the deltoid was usually present
but with little or no active glenohumeral abduction,
although one patient was able to maintain the position
against resistance after the arm had been placed pass-
ively in the fully abducted position. Electromyography
and arthrography were employed to distinguish torn
rotator cuffs from suprascapular nerve lesions. In four
of the patients normal electromyography was associ-
ated with a tom rotator cuff, as shown by arthrography
or cinefluoroscopy. The remaining patient, who com-
plained of pain in both shoulders, was found to have
grossly abnormal EMG patterns, indicative of involve-
ment of both suprascapular nerves. Based on these
findings, the authors recommended electromyography
and arthrography as means of distinguishing these
conditions.
Management of patients with suspected supra-
scapular nerve lesions
Diagnosis is established by the combination of a
careful history, physical examination and a few inves-
tigations. In the history, emphasis is placed on the
complaint of poorly localized, dull pain over the
Weaver: Isolated nerve lesions
posterolateral aspect of the shoulder. An initial history
of pain provoked by excessive movement of the
shoulder may proceed to pain at rest and disturbance
of sleep. The pain may radiate to the neck or lateral
part of the forearm. There may also be weakness of
such actions as brushing the hair or reaching overhead.
Numbness in any area is evidence against a supra-
scapular nerve lesion because its sensory branches are
to the shoulder and acromioclavicular joints.
There may have been previous injuries such as dis-
locations of the shoulder or acromioclavicular joint,
fractures of the scapula or wrist, or there may have
been inflammatory or degenerative processes involv-
ing the shoulder. Special note should be made of the
patients handedness, occupation and of any prefer-
ence for those activities which are likely to require
wide excursions of the scapula.
Typical signs include wasting of the spinati or del-
toid; tenderness over the suprascapular notch (just
above the lateral end of the scapular spine), around the
rotator cuff and at the origin of the forearms extensor
muscles. Resisted extension of the middle finger on
the same side sometimes causes pain in the shoulder,
indicating traction on the radial axis.
Movements of the neck may cause radiating pain.
Evidence of glenohumeral block by previous teno-
synovitis of the rotator cuff is important, as is evidence
of a tear of the supraspinatus or other component of
the rotator cuff, particularly in a patient with consider-
able abduction who is unable to maintain active
abduction below the 90 position. The power of active
abduction and resisted lateral rotation of the shoulder
is reduced and carrying the affected arm across the
front of the chest reproduces the pain complained of.
Plain radiographs of the cervical spine and shoulder
region will often be normal, but in some cases there
will be evidence of an old injury, or calcification of the
rotator cuff may be seen. In those patients suspected
of fractures of the scapula, the angled antero-posterior
projection previously described should be used. Cervi-
cal myelography has no place in the diagnosis of a
supra-scapular nerve lesion.
Electromyography is a very useful investigation in
doubtml cases, and may require to be repeated in
order to assess progress. Estimating the delay in
conduction after stimulating at Erbs point is supple-
mented by recording potentials in the infraspinatus,
supraspinatus and deltoid muscles. Arthrography of
the shoulder may be required in order to distinguish
lesions of the suprascapular nerve from tears of the
rotator cuff.
Finally, most authors agree that blocking the supra-
scapular nerve at the foramen can be an aid in estab-
lishing the diagnosis. Murray (1974) alone seems to
have reservations about this. Kopell and Thompson
(1963) recommend the use of hydrocortisone injection
alone to reduce local inflammation at the foramen,
without abolishing pain arising from the rotator cuff.
Early abolition of pain both during movement and at
rest indicates entrapment of neuropathy if hydrocort-
isone alone is used. The technique has been described
by Colachis and Strohm (197 1) and others.
TREATMENT
The treatment of suprascapular nerve lesions is
123
ACROMION
CORACOIO
I PROCESS
INFRASPINATUS
V
0 SUPRASCAPULAR ARTERY
-TRANSVERSE SCAPULAR
LIGAMENT
v SUPRASCAPULAR NERVE
........ BONE RESECTION LINE
----- FRACTURE
Fig. 5. A dorsal view of left scapula shows a cornminuted
fracture and the scapular notch with wide resection of bone
(reproduced, with acknowledgement).
influenced by its position as well as its cause. Isolated
injuries proximal to the foramen, whether due to trac-
tion or to direct wounding, are too rare to allow a
confident recommendation; injuries in the supraclav-
icular region are likely to accompany more extensive
damage to the upper trunk of the brachial plexus, so
the decision whether or not to explore is likely to be
determined by ones attitude to the management of the
more extensive injury. However, it can be noted that
Bateman (1967) argues in favour of intervention if no
recovery of the suprascapular nerves function has
become apparent by six weeks, and Narakas (198 1)
believes that satisfactory external rotation of the
shoulder will not be regained in the presence of a
continuing disruption. More distal injuries, such as the
stab wound reported, seem to recover spontaneously
if very slowly. Sunderland (1978) has stated that other
muscle groups compensate for the abducting action of
the supraspinatus and the external rotating action of
the infraspinatus.
Entrapment at the foramen secondary to fractures
through the superior lateral angle of the scapula
appear to respond well to surgical decompression by
dividing the suprascapular ligament and removing a
rim of callus surrounding the notch (Fig. 5). Kopell
and Thompson (1963) were reluctant to interfere with
the bony margin in cases of neuropathy not associated
with a fracture; however, Solheim and Roaas (1978)
regard this manoeuvre as an essential component of
their procedure.
The commonest cause of isolated suprascapular
lesion is entrapment at the suprascapular foramen not
associated with previous fracture. Opinion is divided
as to the best method of management. Successml
methods have included observation alone, (Colachis
and Strohm, 1971); resting the affected shoulder for a
month in a thoracobrachial plaster jacket, followed by
a further two months exercises (Brogi et al., 1979);
physiotherapy alone, with local ultrasound and active
exercises, and injecting hydrocortisone alone or in
combination with local anaesthetic. However, the
reports by Kopell and Thompson (1963), Ford (1973)
124 Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2

SJPRASCAPULAR ARTERY

\ /
DIRECTION TAKEN BY UNDERLYING
SUPRASCAPULAR NERVE \ /

_ SUPRASCAPULAR LIGAMENT
.--I

FLAT DISSECTOR /
BEING PASSED THROUGH
SUPRASCAPULAR FORAMEN
h oUTLINE OF SUPRASCAPULAR NOTCH

I
\
Fig. 6. Posterior approach for decompression of suprascapular foramen, with division
of trapezius and retraction of supraspinatus (after Clein).

and particularly those by Murray (1974) and Clein
(1975), indicate the value of decompressing the nerve
by dividing the transverse ligament. In Cleins series of
five patients, four were operated on via a posterior
approach (Fig. 6), with the patient either semi-prone
or, preferably, on the side. A transverse incision is
made parallel to and one inch above the spine of the
scapula, well laterally, and the trapezius is divided in
the line of its fibres. The underlying supraspinatus is
identified and, since it is usually atrophic, the upper
border of the scapula can usually be exposed without
difficulty. After passing a flat dissector beneath the
suprascapular ligament to protect the nerve, the trans-
verse scapular ligament is divided by cutting down
onto the dissector. The nerve is seen to bulge up into
the defect. The wound is closed in layers without
drainage. The arm is rested in a sling between exercise
periods, which may be commenced almost immedi-
ately. Clein (1975) claimed excellent results from this
procedure, after which all the patients were relieved of
pain, and three of the four regained power of lateral
rotation. Two of the four recovered the bulk of the
infraspinatus.
Murray (1974) preferred an anterior approach using
a sabre-cut incision over the medial aspect of the cor-
acoid process. The delto-pectoral interval is developed
(Fig. 7) and, if necessary, the adjacent margins of del-
toid and pectoralis major are stripped from the clavicle
to expose the coracoid process. A plane is opened
medial to the coracoid, which may require that the
pectoralis minors attachment be partially divided.
One must remain in close to the clavicle in order to
avoid the brachial plexus. Once the plane along the
medial margin of the coracoid has been defined, the
medial border of the conoid and trapezoid ligaments
can be palpated, medial to which again lies the omo-
hyoid muscle. Beneath this muscle lies a fat pad,
within which is the suprascapular nerve. By following
the nerve along its superior edge, the suprascapular
notch is gained. A flat dissector can now be inserted
and the ligament divided onto it. Like Kopell and
Thompson (1963). Murray (1974) believes that re-
moval of a bony rim from the notch may be followed
by heterotopic formation of bone.
The authors approach also allows the rotator cuff
to be explored, should that seem necessary (Murray,
1974). The wound is closed in layers.
CONCLUSIONS
Isolated lesions of the suprascapular nerve are un-
common, but perhaps less so than has been suspected.
They constitute a fascinating group in which the
patient experiences pain and dysfunction in the
shoulder for a number of different reasons. The cause
must be identified as well as any concomitant lesion
such as a torn rotator cuff. When the nerve is
compressed at the suprascapular notch, surgical
decompression is successful.
Weaver: Isolated nerve lesions
SUPRASCAPULAR
. AND LIGAMENT
/
PECTORALIS MAJOR
(RETRACTED)
Fig. 7. Anterior approach for decompression of suprascapular foramen, using the delto-
pectoral interval and exposing the region medial to the coracoid process (after Murray).
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