“Isolated long thoracic nerve palsy”: more than meets the eye

Publication date: Available online 27 June 2017
Source:Journal of Plastic, Reconstructive & Aesthetic Surgery
Author(s): Andrés A. Maldonado, Scott L. Zuckerman, B.Matthew Howe, Michelle L. Mauermann, Robert J. Spinner
IntroductionTwo main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and potentially, the treatment.Material and methodsA retrospective review was performed of all patients with a diagnosis of non-traumatic isolated LTN palsy and an EDX and brachial plexus or shoulder MRI studies performed at our institution. The original EDX studies and MR exams were re-interpreted by a neuromuscular neurologist and musculoskeletal radiologist respectively, both blinded to our hypothesis.ResultsSeven patients met the inclusion criteria as having a non-traumatic isolated LTN palsy. Upon reinterpretation, all 7 patients were found to have findings not consistent with an isolated LTN. Three of them (43%) presented with weakness on physical examination in muscles not innervated by the LTN. Four of them (57%) had additional EDX abnormalities beyond the distribution of the LTN. Five of them (71%) had MRI evidence of enlargement of nerves or denervation atrophy of muscles outside of the innervation of the LNT, without evidence of compression of the LTN at the middle scalene muscle.ConclusionIn our series, all of the 7 cases originally diagnosed as having an isolated LTN, on reinterpretation were found to have a more diffuse muscle/nerve involvement pattern, without MR findings to suggest nerve compression. These data strongly support an inflammatory pathophysiology.



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