Nerve transfers in the shoulder are devised to restore shoulder function through reinnervation of target muscles. The shoulder is a complex joint that supports movements of the humerus in all degrees of motions and planes. Due to the complexity of the shoulder, the primary muscles that are targeted for reinnervation for the best functional outcome are the deltoid, serratus anterior, and supra/infraspinatus muscles. Several nerve transfers exist to reinnervate these muscles and can be used in combination with each other depending on the case scenario to provide the best functional outcome for shoulder reconstruction.

Nerve transfer combinations include the (1) double shoulder nerve transfer for the suprascapular and axillary nerve and the (2) double level nerve transfer for the long thoracic nerve. The double shoulder nerve transfer includes the combination of spinal accessory to suprascapular nerve and triceps branch to axillary nerve. This nerve transfer combination is commonly utilized together for patients without shoulder function and with available donor nerves. The double level nerve transfer utilizes two donor nerves (pectoral fascicle and thoracodorsal nerve) to reinnervate the long thoracic nerve at the proximal and distal level of the serratus anterior for complete reinnervation of serratus muscle slips

Procedures – Restoration of Shoulder Function

Spinal Accessory to Suprascapular (End-to-end) Nerve Transfer
Spinal Accessory to Suprascapular (End-to-side) Nerve Transfer
Pectoral Fascicle to Long Thoracic Nerve Transfer
Thoracodorsal to Long Thoracic Nerve Transfer

Title:Thoracodorsal to Long Thoracic Nerve Transfer.
Published: 3/28/2011, Updated: 3/28/2011.

Author(s): Susan E. Mackinnon MD, Andrew Yee BS.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

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Extended Version

Surgical Tutorial – Thoracodorsal to Long Thoracic Nerve Transfer. Patients with long thoracic nerve injuries exhibit scapular winging and sever shoulder dificents that include the inability to forward flex the shoulder past 90° of range of motion. Thoracodorsal to long thoracic nerve transfer utilizes a distal posterior branch of the thoracodorsal nerve to reinnervate the distal half of the long thoracic nerve. This operation occurs in the lateral aspect of the thorax. The distal half of the long thoracic nerve innervates the distal half of the serratus anterior, which inserts to the inferior angle of the scapula and provides scapular upward rotation during shoulder movements. A second procedure is used to reinnervate the proximal half of the serratus anterior. Together, the proximal and distal nerve transfers are known as the double-level nerve transfer for long thoracic nerve function.

Double Level (Pectoral Fascicle and Thoracodorsal) Nerve Transfer for Long Thoracic Nerve Function
Medial Triceps Branch to Axillary Nerve Transfer

Title: Medial Triceps Branch to Axillary Nerve Transfer.
Published: 5/9/2011, Updated: 5/9/2011.

Author(s): Susan E. Mackinnon MD, Andrew Yee BS.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

Figure 1 – Incision Description for Exposure. A longitudinal incision is marked on the posterior aspect of the upper arm between the long and lateral heads of the triceps brachii muscles to the posterior border of the deltoid muscle. The incision continues superiorly and “hockey-sticked” under the free edge of the deltoid muscle. The patient is prone.

Figure 2 – Incision Description for Exposure. A longitudinal incision is marked on the posterior aspect of the upper arm between the long and lateral heads of the triceps brachii muscles to the posterior border of the deltoid muscle. The incision continues superiorly and “hockey-sticked” under the free edge of the deltoid muscle. The patient is prone.

Figure 3 – Axillary Nerve Anatomy. (A) The axillary nerve includes two deltoid branches, one teres minor branch, and one superior lateral cutaneous branch. (B) When mobilizing this nerve for transfer, the axillary nerve is transected proximally to include the two deltoid branches and the teres minor branch. This will also reduce the surface area of the axillary nerve as they come together for the nerve transfer. The superior lateral cutaneous branch is always found on the inferior and superficial aspect of the radial nerve as it courses to innervate the superior lateral aspect of the arm.

Figure 4 – Radial Nerve Anatomy and the Triceps Nerve Branches. (A) The medial triceps branch (donor green) is identified superficial and medial to the radial nerve. With this posterior perspective, the medial triceps branch is seen as superficial. The long triceps branch is identified medial and the lateral triceps branch is identified lateral to the radial nerve. (B) The intrafascicular radial nerve anatomy is finger extensors, wrist extensors, and the sensory component from medial to lateral in the radial nerve respectively.

Figure 5 – Medial Triceps Branch to Axillary Nerve Transfer. (A) The axillary nerve (recipient) originates from the quadrangular space to innervate the deltoid and teres minor and the superior lateral cutaneous aspect of the arm. The medial triceps nerve branch (donor) and adjacent long and lateral triceps nerve branches, and the radial nerve originate deep (prone perspective) to the teres major. The donor medial triceps branch is identified superficial to the radial nerve. To mobilize the donor nerve and attain sufficient surface area for transfer, the medial triceps branch is transected distally to its branching point. (B) The donor medial triceps branch is transposed superiorly to innervate the recipient axillary nerve. The recipient axillary nerve includes the deltoid and teres minor branches, but excludes the sensory superior lateral cutaneous nerve which is neurolyzed away.

Figure 6 –Sensory Component of Radial to Superior Lateral Cutaneous Branch End-to-side Nerve Transfer. Figure 6 – (A) To provide rudimentary sensation to the superior lateral aspect of the arm, the recipient superior lateral cutaneous branch of the axillary nerve is transferred end-to-side (ETS) to the sensory component of the radial nerve through an epineural window. (B) The superior lateral cutaneous branch (red) is ETS transferred to the sensory component (green) of the radial nerve. (C) The sensory component is found on the lateral aspect of the radial nerve and lateral to the finger and wrist extensor components.

Figure 7 – Medial Triceps Branch to Axillary Nerve Transfer and the Sensory Component of Radial to Superior Lateral Cutaneous End-to-side Nerve Transfer. The medial triceps branch is transferred to the axillary nerve by an end-to-end coaptation. The superior lateral cutaneous branch of the axillary nerve is end-to-side transferred to the sensory component of the radial nerve.

Pectoral Fascicle to Spinal Accessory Nerve Transfer

Title: Pectoral Fascicle to Spinal Accessory Nerve Transfer

Published: 12/16/2011, Updated: 12/16/2011.

Author(s): Lawrence Zieske BA, Andrew Yee BS, Susan E. Mackinnon MD.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

Figure 1 – Orientation for pectoral fascicle of middle trunk to spinal accessory nerve transfer. The supraclavicular incision is marked from the lateral border of the sternocleidomastoid to the trapezius muscle. The lateral border of the sternocleidomastoid is marked.

Figure 2 – Dividing the anterior free border of the trapezius for identification of the spinal accessory nerve. The free edge of the trapezius muscle is identified deep to the platysma muscle. Through the platysma muscle, the supraclavicular nerves are identified and protected. This free edge is divided to reflect a short portion of the trapezius to expose the spinal accessory nerve which is immediately adjacent to the trapezius muscle.

Figure 3 – Identifying the spinal accessory nerve. The spinal accessory nerve is intimate to the undersurface of the trapezius muscle. The released edge of the trapezius muscle is reflected posteriorly to facilitate easier identification of the accessory nerve.

Figure 4 – Identifying the middle trunk of the brachial plexus. In this exposure, the brachial plexus is located deep to the divided omohyoid muscle. The brachial plexus is located lateral to the anterior scalene muscle. The suprascapular nerve is identified as it branches from the upper trunk. Deep to the upper trunk, the middle trunk is identified. During this exposure, the long thoracic nerve is identified lateral to the middle scalene and protected.

Figure 5 – Identifying the donor pectoral fascicles of the middle trunk. (A) The pectoral fascicular group is identified on the anterior surface of the middle trunk and innervates the pectoralis major through the lateral pectoral nerve. Two pectoral fascicles are commonly found. Note the upper trunk is retracted medially. (B) The micro forceps delineate the pectoral fascicle on the anterior surface of the middle trunk.

Figure 6 – Selecting the donor fascicle from the pectoral fascicular group. Two fascicles to the pectoralis major are identified on the anterior surface of the middle trunk. These fascicles are confirmed with stimulation, and the fascicle that elicits a stronger response is selected for the donor nerve for transfer. A length of two centimeters will be dissected for the nerve transfer.

Figure 7 – Neurolyzing the donor pectoral fascicle to transfer to the recipient spinal accessory nerve. A length of at least two centimeters of the donor fascicle is dissected distally. Posterior/medial to the pectoral fascicles is the fascicle to the triceps brachii, which can be confirmed by electrical stimulation.

Figure 8 – Pectoral fascicle of middle trunk to the spinal accessory nerve transfer. The nerves in this transfer are neurolyzed to sufficient length so as to avoid any tension by dividing the donor pectoral fascicle distally and the recipient spinal accessory nerve proximally.