The Diagnosis and Treatment of Bilateral Suprascapular Nerve Compressions

Sir: We present a case report of bilateral suprascapular nerve entrapment in a 22-year-old woman. The purpose is to underscore a case in which a thorough physical examination and numerous diagnostic tests failed but in which a simple nerve block procedure proved to be diagnostic. The patient's condition, arising at age 14, was examined closely by multiple physicians, with complaints of diffuse right shoulder pain radiating to the elbow with a bluish discoloration of the right hand. The suggested diagnoses were reflex sympathetic dystrophy, thoracic outlet syndrome, autoimmune disorders, bursitis/tendinitis, and brachial plexopathy. Diagnostic testing proved to be normal. She was prescribed medications and physical therapy, which briefly alleviated symptoms. She received three serial cortisone injections, which provided temporary relief (Figs. 1 and 2).Fig. 1.: Postoperative photograph.Fig. 2.: Postoperative photograph.On presentation to our office at age 18, physical examination revealed tenderness to deep scapular palpation, and restriction of right arm abduction to 70 degrees and external rotation to 45 degrees. We identified a trigger point, and used saline blocks as a placebo to rule out psychosomatic disorder. We administered lidocaine and bupivacaine, which provided relief, confirming the diagnosis of suprascapular nerve entrapment. A right suprascapular nerve decompression was subsequently performed. The transverse ligament over the suprascapular notch was identified and carefully surgically dissected and transected off. With microsurgical techniques, epineurectomy was performed on the nerve and its branches. Immediately, the patient had resolution of her pain with increased range of motion for 4 months. The patient then presented with similar pain in the contralateral left shoulder for which the diagnosis of suprascapular nerve entrapment was confirmed by means of nerve block. A similar decompression was performed, which allowed the patient to partake in activities that involved full range of shoulder motions without restrictions. Thirty months later, the patient presented with recurrent pain in the right shoulder. A similar nerve block was performed to confirm the diagnosis, followed by a second right suprascapular notch decompression where the scar tissue was removed. Eighteen months later, the patient is doing well, without pain/restrictions. The suprascapular nerve is predominantly a motor nerve that originates from the upper trunk of the brachial plexus formed by the roots of C5 and C6. It passes through the suprascapular notch, under the transverse scapular ligament. Anomalies in size, shape of the notch, and the ligament have been associated with nerve injury at this level.1–6 The predisposing factors include extreme shoulder motions and repetitive trauma. Most patients present with a burning, diffuse pain over the lateral/posterior shoulder, exacerbated by activity. The differential diagnoses include thoracic outlet syndrome, subacromial impingement syndrome, rotator cuff abnormality, C5-6 radiculopathy, rotator cuff tendinitis, and burner/stinger syndrome. In our patient, after a thorough history and physical examination, diagnosis was reached by means of a simple nerve block at the suprascapular notch. This diagnostic technique is underused and offers a quick and effective method of diagnosis. On all three occasions, we used this technique to confirm the diagnosis and subsequently provide successful, long-term surgical decompression for our patient. Andrew I. Elkwood, M.D. Michael I. Rose, M.D. Matthew R. Kaufmann, M.D. Russell L. Ashinoff, M.D. Tushar R. Patel, M.D. Mona A. Parikh Kumar C. Sunkeula Adam T. Silverman, M.D. The Plastic Surgery Center Shrewsbury, N.J.