Presentation is loading. Please wait.

Presentation is loading. Please wait.

Atypical Electrodiagnostic Findings in Scapular Winging Secondary to Multiple Neuropathies: A Case Series Mitul Kapadia MD, MS 3, Oluseum Olufade MD 2,

Similar presentations


Presentation on theme: "Atypical Electrodiagnostic Findings in Scapular Winging Secondary to Multiple Neuropathies: A Case Series Mitul Kapadia MD, MS 3, Oluseum Olufade MD 2,"— Presentation transcript:

1 Atypical Electrodiagnostic Findings in Scapular Winging Secondary to Multiple Neuropathies: A Case Series Mitul Kapadia MD, MS 3, Oluseum Olufade MD 2, Gilbert Siu DO PhD 2, Theera Vachranukunkiet, MD 1, C.R. Sridhara MD 1,2,3 1 MossRehab, Elkins Park, PA, 2 Temple University Hospital, Philadelphia, PA 3 Jefferson University Hospital, Philadelphia, PA ABSTRACT Setting: Electrodiagnostic laboratory at tertiary care rehabilitation center Patients: Four patients, two males and two females, with mean age of 46 years (range years) with scapular winging. Background: Scapular winging is an easily diagnosed condition seen by visible inspection. Causes of scapular winging usually involve one nerve (long thoracic, spinal accessory or dorsal scapular nerve), resulting in either lateral or medial scapular winging. We present a series of four patients for electrodiagnostic evaluation with atypical scapular winging. Assessment & Results: One patient presented with right shoulder pain after a flu-like illness and electrodiagnostic studies revealed an axon-loss neuropathy involving the right upper and middle spinal accessory nerve branches and dorsal scapular nerve. The second patient presented with right arm weakness after a fall with a traumatic brain injury and was found to have isolated neurapraxic block with preservation of axons involving the upper and lower spinal accessory nerve branches and long thoracic nerve. The third patient presented with right arm weakness and pain after thyroidectomy and was found to have axon-loss neuropathy involving the upper and middle spinal accessory nerve branches and long thoracic nerve. The fourth patient presented with right shoulder weakness after a fall/injury and was found to have axon-loss neuropathy involving the all three branches of spinal accessory nerve, long thoracic nerve and a C5 radiculopathy. Discussion: Unilateral scapular winging with similar clinical presentation can result from various neuropathic etiologies. Electrodiagnostic findings in these four cases revealed multiple neuropathies involving two or three nerves that cause winging of the scapula. Etiology in two of the four patients was trauma, one patient with Parsonage Turner Syndrome and one patient due to surgery related to carcinoma. Conclusions: Although uncommon, this case series provides examples of multiple nerve involvement in scapular winging and the importance of electrodiagnostic studies for evaluating involvement of the specific nerves. Keywords: Scapula winging; Dorsal scapular neuropathy; Spinal accessory neuropathy; Long thoracic neuropathy CASE SERIES DESCRIPTION The first patient is a 68 year-old female with a history of a traumatic brain injury who presented with severe right shoulder pain shortly after having an acute flu-like respiratory infection. Physical examination revealed marked atrophy of the right shoulder girdle with medial winging of the scapula at rest with glenoid depression or clockwise rotation (Figure 1). The second patient is a 36 year-old male who presented with right arm weakness after a fall down a number of stairs that resulted in a traumatic brain injury. Physical examination revealed atrophy of his right shoulder girdle muscles. The right scapula was depressed and laterally rotated with medial winging exacerbated with forward flexion (Figure 2). Muscle strength was diminished in the right upper and lower trapezius and serratus anterior. The third patient is a 21year-old male who presented with right upper arm weakness and pain following a total thyroidectomy for multifocal papillary thyroid cancer. Subsequently, the patient underwent right extended comprehensive cervical lymphadenectomy. Physical examination revealed right scapular winging both with activation of the serratus anterior and the middle trapezius. Muscle strength was diminished in the right serratus anterior and trapezius. The fourth patient is a 60 year old female who presented with right shoulder weakness and pain after a fall in which she fell on her outstretched right hand while she had heavy books with her and also another local trauma to shoulder. Physical examination revealed significant depression of the right scapula, winging of the right scapula with the inferior angle more medial than the glenoid, and atrophy of all sections of the trapezius. She had decreased strength on manual muscle testing of all sections of the right trapezius (upper, middle, and lower) along with the serratus anterior. DISCUSSION CONCLUSION REFERENCES Even though scapular winging involving a single nerve is a rare debilitating condition, having multiple nerves involved is uncommon and atypical with need for complex rehabilitation planning. This case series highlights the importance of electrodiagnostic studies for evaluating multiple specific nerves involved in scapular winging that would generally have been overlooked. 1.Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatment.. Curr Rev Musculoskelet Med Mar;1(1): Schreiber AL, Abramov R, Fried GW, Herbison GJ. Expanding the differential of shoulder pain: Parsonage-Turner syndrome. J Am Osteopath Assoc Aug;109(8): Akgun K, Aktas I, Terzi Y. Winged scapula caused by a dorsal scapular nerve lesion: a case report. Arch Phys Med Rehabil Oct;89(10): Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop Relat Res Nov;(368):5-16. Most cases of scapular winging described in the literature results in neuropathy of single nerve, most commonly the long thoracic nerve, and have a clearly discernable presentation. However, scapular winging due to multiple nerve and muscle involvement is rarely reported. In this study, we present a series of cases of unilateral scapular winging which presented with indistinct presentations. The initial cause of scapular winging in these cases was either trauma, remote trauma with possible Parsonage Turner Syndrome or surgery related to carcinoma. Physical examination findings varied in each patient, but proved inconclusive in elucidating the precise neuropathic etiology. Although a scapular winging is a clinical diagnosis, the electrodiagnostic evaluation helped to clarify the unusual multiple neuropathies involved in the atypical presentations of these cases. The neuropathies in each of these cases involved two or three nerves varying from spinal accessory nerve branches, dorsal scapular nerve, long thoracic nerve and C5 radiculopathy. These multiple neuropathies lead to weakness in multiple scapular muscles and disruption of scapular motion (Figure 3). It is this multiple nerve etiology of the scapular winging that led to indistinguishable presentations and illustrates precisely the value of electrodiagnostic evaluation in discerning etiology of scapular winging. Without electrodiagnostic verification of these scapular winging cases, successful rehabilitation and treatment for scapular winging would have been difficult due to the multiple nerves involved. Therefore, in these patients, rehabilitation was prescribed to target at least two muscle groups with scapular stabilization. EMG Table SpontaneousMUAPRecruitment IAH.F.Dur.PPPPattern R. Rhomboid Maj C5 NNone1+2+Mild Red R. Serr Ant C5, 6,7 NNoneNNMild Red R. Trapezius (M) C3, 4 NCRD'sN2+N Nerve / SitesRec. SiteLatAmpRel AmpArea msmV%mVms R Spinal Accessory - Trapezius 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Spinal Accessory - Trapezius 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Long Thoracic - Upper Ext 1. NeckThorax R Long Thoracic - Upper Ext 1. NeckThorax Nerve / SitesRec. SiteLatAmpRel AmpArea msmV%mVms L Spinal Accessory - Trapezius Neck (X1 - X2)Upper Trap Neck (X3 - X4)Mid Trap Neck (X5 - X6)Lower Trap R Spinal Accessory - Trapezius Neck (X1 - X2)Upper Trap Neck (X3 - X4)Mid Trap Neck (X5 - X6)Lower Trap Nerve / SitesRec. SiteRespLatAmpRel AmpArea msmV%mVms L Long Thoracic - Serratus Ant NeckSer Ant R Long Thoracic - Serratus Ant NeckSer AntNo Patient #1. Pertinent electrodiagnostic results showing axon-loss neuropathy involving the right upper and middle spinal accessory nerve branches and dorsal scapular nerve. EMG Table Sponta neous MUAPRecruitment IADur.PPPPattern R. Rhomboid Maj C5 NNNN R. Serr Ant C5, 6,7 NNNN R. Trapezius (M) C3, 4 NNNN EMG Table SpontaneousMUAPRecruitment IA Fib PSWDur.PPPPattern R. Serr Ant C5,6,7 Increase1+ NNMild Red R. Trapezius (U) C3,4 Increase2+3+NNDiscrete R. Trapezius (M) C3,4 Increase1+ NNDiscrete R. Trapezius (L) C3,4 Increase1+ NNMod Red R. Deltoid C5,6 NNone NNN Nerve / SitesRec. SiteLatAmpRel AmpArea msmV%mVms R Spinal Accessory - Trapezius (3 Ch) 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Spinal Accessory - Trapezius (3 Ch) 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Long Thoracic - Upper Ext 1. NeckSer Ant R Long Thoracic - Upper Ext 1. NeckSer Ant EMG Table SponMUAPRecruitment IAAMPDurPPPPattern R. Serr Ant C5,6,7NN1+2+Discrete R. Deltoid C5,6NNN1+N R. Trapezius (U) C3,4NNN1+Mod Red R. Trapezius (L) C3,4N1-/N 1+Mild Red R. SCMN1-/N 1+Mild Red Nerve / SitesRec. SiteLatAmpRel AmpArea msmV%mVms R Spinal Accessory - Trapezius (3 Ch) 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Spinal Accessory - Trapezius (3 Ch) 1. NeckUpper Trap NeckMid Trap NeckLower Trap L Long Thoracic - Upper Ext 1. NeckSer Ant R Long Thoracic - Upper Ext 1. NeckSer Ant Patient #2. Pertinent electrodiagnostic results showing right isolated neurapraxic block with preservation of axons involving the upper and lower spinal accessory nerve branches and long thoracic nerve. Patient #4. Pertinent electrodiagnostic results showing right axon-loss neuropathy involving the all three branches of spinal accessory nerve, long thoracic nerves and a C5 radiculopathy. Patient #3. Pertinent electrodiagnostic results showing right axon-loss neuropathy involving the upper and middle spinal accessory nerve branches and long thoracic nerve.. Figure 3. A schematic diagram of the scapula demonstrating different muscle involvements in scapular winging. Figure 1 Figure 2


Download ppt "Atypical Electrodiagnostic Findings in Scapular Winging Secondary to Multiple Neuropathies: A Case Series Mitul Kapadia MD, MS 3, Oluseum Olufade MD 2,"

Similar presentations


Ads by Google