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Suprascapular Nerve Decompression (Spinoglenoid Notch)

Planning

B

Preoperative Plan

1

Radiographic templating

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Make sure tower working

  • 30° arthroscope
  • fluid pump system
  • standard arthroscopic instruments
  • arthroscopic shavers and burrs
  • radiofrequency ablation wand
  • arthroscopic scissors

2

Room setup and Equipment

  • standard OR table for lateral decubitus position

3

Patient Positioning

  • lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment

Technique

D

Scope Insertion

1

Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process and portal placement

2

Place posterior portal

  • mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion
  • make small skin incision
  • place blunt trocar with the arm in 15° of abduction and 30° of forward flexion
  • use lateral traction to avoid damage to the articular surface
  • place the 30° arthroscope.

3

Place anterior portal

  • halfway between acromioclavicular joint and the lateral aspect of the coracoid
  • pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis

4

Place lateral portal

  • place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge

5

Place medial portal

  • place 3-3.5 cm medial to the bisecting line at the midclavicle
E

Diagnostic Arthroscopy

1

Visualize the anatomy

  • articular cartridge of the humeral head and glenoid
  • labrum
  • biceps tendon
  • inferior recess
  • articular surface
  • insertion of the subscapularis, supraspinatus, infraspinatus and teres minor

2

Establish anterior portal

  • localize portal with an 18 gauge spinal needle placement
  • place a seven millimeter cannula using the outside-in technique
F

Notch Identification

1

Incise the labrum

  • with an intact labrum, the joint capsule above the superior-posterior labrum is incised
  • start posterior to the biceps root and extend posteriorly for 2 to 3 cm

2

After incision of the capsule, identify the spinoglenoid notch

  • the fibrous raphe between the supraspinatus and infraspinatus that is seen lateral to the spinoglenoid notch is a good landmark
  • palpate the notch with an arthroscopic instrument
  • this provides a bony landmark that can be correlated with the cyst position that is seen on the preoperative MRI
G

Ganglion Cyst Excision

1

Place a posterolateral accessory portal

  • through this portal bluntly dissect through the fibrovascular tissue that covers the neurovascular bundle
  • this can be done with a switching stick or with a similar tool
  • the suprascapular nerve is positioned medially in direct contact with the bone of the spinoglenoid notch
  • the vascular structures are positioned more laterally and closer to the glenoid

2

Excise the ganglion cyst

  • ganglion cysts are typically found posterior to the nerve
  • remove the cyst in its entirety including the lining

3

Inspect the nerve

  • inspect the nerve for any additional sites of decompression
H

Wound Closure

1

Irrigation and hemostasis

  • irrigate the portals

2

Deep closure

  • use 3-0 biosyn for closure

3

Superficial closure

  • use 4-0 biosyn for skin

4

Dressing and immediate immobilization

  • place sling

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • history
  • age
  • gender
  • smoker
  • trauma
  • physical exam
  • check range of motion
  • weakness of the extremity
  • inspect for atrophy
  • identify medical co-morbidities that might impact surgical treatment

2

Perform operative consent

  • describe complications of surgery including
  • infection
  • damage to the suprascapular nerve and vessels
  • incomplete decompression
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • schedule follow up
  • orders and interprets basic imaging studies
  • order postoperative radiographs of the shoulder to ensure appropriate implant placement

2

outpatient PT

  • sling for 2-3 days for comfort
  • pendulum exercises POD 1
  • increase active motion as tolerated
M

Outpatient Management

1

Obtains focused history and performs physical examination

  • provocative tests
  • differential diagnosis and physical exam tests

2

Orders basic imaging studies

  • radiographs
  • AP
  • true AP with active shoulder abduction
  • Axillary lateral
  • Scapular Y view

3

Prescribes non-operative treatment

  • physical therapy
  • anti-inflammatory medication

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provide basic post op management

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • diagnose and management of early complications
N

Advanced Evaluation and Management

1

Interpret basic imaging studies

  • radiographs
  • MRI
  • labral tears
  • arthritis
O

Complex Patient Care

1

Modifies and adjusts post operative rehabilitation plan as needed

  • post-operative stiffness

2

Order and interpret advanced imaging studies

  • MRI

3

Treats intra-operative and post operative complications

  • irrigation and debridement for infection
  • proper infection treatment
  • infectious disease consultation
 

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