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Teixeira LFN, Sandrin F, da Silva RFKC, Petrella F, Bertolaccini L, Simoncini MC, Spaggiari L. The Incidence of Winged Scapula after Thoracic Cancer Surgery: A Prospective Cohort Study. Thorac Cardiovasc Surg 2024. [PMID: 38698601 DOI: 10.1055/s-0044-1786196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Lung cancer is the leading cause of cancer-related deaths, and surgery is still the first treatment of choice in early and locally advanced cases. One of the iatrogenic complications is the serratus anterior palsy, which could lead to a winged scapula (WS). Unfortunately, the incidence of this deficit in thoracic surgery is unclear. Our primary aim was to determine the incidence of WS in lung cancer patients in a single-center experience. METHODS We conducted a retrospective analysis of prospectively collected data with patients eligible for oncological thoracic surgery from March 2013 until January 2014. A physical evaluation of the WS was performed pre- and postoperatively, at the discharge and after 1 year of follow-up. RESULTS A total of 485 patients were evaluated; 135 (27.8%) showed WS. Longer operative time (p < 0.0001), type of surgery (p < 0.0001), lymphadenectomy (p < 0.0001), and neoadjuvant treatment prior surgery (p = 0.0005) were significantly related to the WS injury. Multivariable analysis showed that type of surgery was significantly associated with WS (p < 0.0001). After 1 year, 41.6% still had WS. CONCLUSION The incidence of WS was similar to the literature. As WS incidence is underdiagnosed, assessment and correct education about possible deficits or impairments should be improved. Moreover, when a minimally invasive approach is not planned, it is a good clinical practice to discuss surgical strategies with surgeons to reduce this deficit.
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Affiliation(s)
| | - Fabio Sandrin
- Department of Physiotherapy, European Institute of Oncology, Milano, Italy
| | | | - Francesco Petrella
- Thoracic Surgery Department, European Institute of Oncology, Milano, Italy
| | - Luca Bertolaccini
- Thoracic Surgery Department, European Institute of Oncology, Milano, Italy
| | | | - Lorenzo Spaggiari
- Department of Thoracic Surgery, Istituto Europeo di Oncologia, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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Plaza Meza MP, Marín Fermín T, Maffulli N. Diagnosis and epidemiology of winged scapula in breast cancer patients: A systematic review and meta-analysis. Br Med Bull 2021; 140:23-35. [PMID: 34471931 DOI: 10.1093/bmb/ldab021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper extremity's function and poor performance in daily activities. SOURCES OF DATA A systematic review and meta-analysis were performed following the PRISMA guidelines. Two independent reviewers searched PubMed, Embase and Virtual Health Library databases from January 1, 2000 to December 1, 2020. Clinical studies evaluating the diagnosis and epidemiology of WS among breast cancer surgery (BCS) patients were included. AREAS OF AGREEMENT The diagnosis of WS relies almost entirely on physical assessment. Studies have suggested a high variability in the report of the incidence of WS given the subjectivity of its diagnosis, and the different criteria used during clinical assessment. AREAS OF CONTROVERSY The diagnosis of WS in BCS patients remains a challenge given the lack of standardized diagnostic protocols. Physical examination cannot rely on one manoeuvre only, as it may overlook patients with subtle injuries or overweight and contributing to the underreporting of its incidence. GROWING POINTS BCS patients undergoing axillary lymph node dissection experience a significantly higher incidence of WS than those undergoing sentinel lymph node dissection. The global incidence of WS after BCS is 16.79%. Additionally, the anterior flexion test and the push-up test are the most commonly performed diagnostic manoeuvers. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies should aim for objective diagnostic tests, especially when the condition is not evident.
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Affiliation(s)
- Milger P Plaza Meza
- Department of General Surgery, Hospital Universitario Periférico de Coche, Av. Intercomunal de El Valle con Calle Zea, 1090 Caracas, Venezuela.,Clínica de Prevención del Cancer, Sociedad Anticancerosa de Venezuela, Av. Norte 3, Canónigos a Esperanza, N° 43, Parroquia Altagracia, 1010 Caracas, Venezuela
| | - Theodorakys Marín Fermín
- Department of Traumatology, Hospital Universitario Periférico de Coche, Av. Intercomunal de El Valle con Calle Zea, 1090 Caracas, Venezuela
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK
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Ortí-Asencio M, Salinas-Huertas S, Luzardo-González A, Terra-Falótico J, Planas-Balagué R. Scapular winging in surgical treatment of breast cancer, prospective study to optimize the follow-up protocol. Clin Transl Oncol 2021; 23:2090-2098. [PMID: 33829395 DOI: 10.1007/s12094-021-02612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION One of the most common complications of the surgical treatment of breast cancer is limited range-of-motion in the shoulder. Scapular winging is one of the most underdiagnosed shoulder mobility impairments. OBJECTIVE The main objective of this study was to determine the incidence of scapular winging in patients who underwent breast cancer surgery as the basis for expanding the protocol to patients who have had a sentinel lymph node biopsy. The secondary objective was to determine the risk factors that lead to the development of a winged scapula presented after breast cancer treatment in our sample. METHODS This was a prospective, observational, and multidisciplinary study. Between 2013 and 2018, 214 consecutive patients who had been diagnosed with breast cancer and treated for it surgically were followed by Rehabilitation Department for 3 years. The patients were evaluated in the 1st, 6th, 12th, 18th, 24th and 36th months following surgery. Scapular winging was evaluated at each visit by means of static and dynamic tests. RESULTS The cumulative incidence of scapular winging was 3.6% and seven cases of winged scapula were diagnosed. All the cases were diagnosed at the first visit, 1 month after the intervention. In the univariate analysis, the axillary lymph node dissection technique was a more significant risk factor for a winged scapula than sentinel lymph node biopsy. CONCLUSIONS The axillary lymph node dissection technique is a risk factor for developing a winged scapula. No evidence was found for any other significant risk factor.
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Affiliation(s)
- M Ortí-Asencio
- Department of Rehabilitation, Hospital Universitari Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - S Salinas-Huertas
- Department of Rehabilitation, Hospital Universitari Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - A Luzardo-González
- Department of Rehabilitation, Hospital Universitari Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - J Terra-Falótico
- Department of Rehabilitation, Hospital Universitari Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - R Planas-Balagué
- Department of Rehabilitation, Hospital Universitari Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
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Ormsby NM, Hawkes DH, Ng CY. Variation of surgical anatomy of the thoracic portion of the long thoracic nerve. Clin Anat 2021; 35:442-446. [PMID: 34595774 DOI: 10.1002/ca.23796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 09/22/2021] [Accepted: 09/26/2021] [Indexed: 11/09/2022]
Abstract
Decompression of the long thoracic nerve (LTN) is a potentially beneficial procedure for selected patients with LTN palsy. The aim of this work is to describe the surgical anatomy of the thoracic part of the LTN and highlight its variations. A retrospective review of patients undergoing exploration of the LTN was performed. Preoperatively, all patients had serratus anterior dysfunction and underwent electromyographic (EMG) assessment. All patients had an initial trial of nonoperative management. The surgical procedures were undertaken by the senior author. The anatomy of the LTN and the associated vasculature was recorded in patient records, and with digital photography. Forty-five patients underwent LTN exploration. Two patients with iatrogenic injury were excluded, leaving 43 patients for analysis. Mean age was 36 years. Sixty-seven percent of cases involved the dominant side. Trauma was the commonest cause, followed by neuralgic amyotrophy. Four patients had typical features of serratus anterior dysfunction but with normal EMG studies. Two distinct patterns of LTN anatomy were noted. In 79% of cases, a single major nerve trunk coursing along serratus anterior was observed and classified as a type I LTN. In 21% of cases, two equal major branches of the nerve were identified, which was classified as a type II LTN. Approximately one in five patients may have two major branches of the LTN. This is of clinical relevance to those who undertake any thoracic procedures, as well as those who are considering exploration of the LTN.
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Affiliation(s)
- Neal M Ormsby
- Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK
| | - David H Hawkes
- Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK
| | - Chye Yew Ng
- Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK
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Isono T, Mori S, Kusumoto H, Shiono H. Winged scapula following axillary thoracotomy with long thoracic nerve preservation. BMJ Case Rep 2020; 13:13/2/e232970. [PMID: 32079587 DOI: 10.1136/bcr-2019-232970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Winged scapula is a rare condition caused by injuries to the long thoracic nerve (LTN) and accessory nerves. A 69-year-old man underwent surgery for right lung cancer. Video-assisted thoracic surgery was converted to axillary thoracotomy at the fourth intercostal space. The latissimus dorsi was protected, and the serratus anterior was divided on the side anterior to the LTN. Two months after discharge, he presented with difficulty in elevating his right arm and protrusion of the scapula from his back. Active forward flexion of the right shoulder was limited to 110° and abduction to 130°. He was diagnosed with winged scapula. After 6 months of occupational therapy, the symptoms improved. The LTN may have been overstretched or damaged by the electric scalpel. We recommend an increased awareness of the LTN, and to divide the serratus anterior at a site as far as possible from the LTN to avoid postoperative winged scapula.
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Affiliation(s)
- Tomomi Isono
- General Thoracic Surgery, Kindai University Nara Hospital, Ikoma, Nara, Japan
| | - Shigeshi Mori
- Orthopaedics and Rheumatology, Kindai University Nara Hospital, Ikoma, Nara, Japan
| | - Hidenori Kusumoto
- General Thoracic Surgery, Kindai University Nara Hospital, Ikoma, Nara, Japan
| | - Hiroyuki Shiono
- General Thoracic Surgery, Kindai University Nara Hospital, Ikoma, Nara, Japan
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Tokgöz S, Karaca Umay E, Yilmaz KB, Akkoca M, Akinci M, Azili C, Saydam M, Ucar Y, Balas Ş. Role of Intraoperative Nerve Monitoring in Postoperative Muscle and Nerve Function of Patients Undergoing Modified Radical Mastectomy. J INVEST SURG 2019; 34:703-710. [PMID: 31711327 DOI: 10.1080/08941939.2019.1684603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study aimed to postoperatively evaluate the effects of intraoperative neural monitoring (IONM) on muscles and nerves in patients who underwent modified radical mastectomy (MRM). In the 11 patients included in the study, nerves were determined and protected by nerve monitoring during the axillary dissection (IONM group). In another 11 patients, nerve monitoring was not performed; however, protection of the same nerves was attempted through careful nerve dissection (cautious nerve dissection [CND] group). The control group consisted of 22 healthy subjects. Muscle and nerve functions were blindly evaluated by an experienced physical therapy and rehabilitation specialist using electromyography (EMG) and ultrasonography (US) methods. The EMG values of the pectoralis major muscle were similar in the IONM and control groups (1.97 mV/1.98 mV, p = 0.97) but significantly lower in the CND group (1.57 mV, p < 0.05). Significant differences were found in the US values of the pectoralis major and minor muscles between the IONM and CND groups. No significant difference was found between the IONM and control groups in terms of EMG values of the serratus anterior muscle. This is the first prospective randomized study to objectively evaluate preservation of the nerve through nerve monitoring and its functional results. Monitoring of nerves during MRM is of great importance in terms of demonstrating the positive effects on muscle and nerve functions.
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Affiliation(s)
- Serhat Tokgöz
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Ebru Karaca Umay
- Department of Physical Therapy and Rehabilitation, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Kerim Bora Yilmaz
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Muzaffer Akkoca
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Melih Akinci
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Cem Azili
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Mehmet Saydam
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Yasin Ucar
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Şener Balas
- Department of General Surgery, University of Health Science, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
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Puffer RC, Stone J, Spinner RJ. Avoidance of scapular winging while approaching tumors of the middle scalene region. Acta Neurochir (Wien) 2019; 161:1937-1942. [PMID: 31300885 DOI: 10.1007/s00701-019-04009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Large tumors arising from the middle scalene region can displace the middle scalene muscle and distort regional anatomy, placing nerves at risk. Understanding the surgical anatomy of these nerves is key to approaching pathology of the middle scalene muscle and avoiding damage to the dorsal scapular, long thoracic, and spinal accessory nerves, each of which can cause scapular winging and associated morbidity if injured. METHODS IRB approval was obtained for this study, allowing cases with relevant pathology to be reviewed and presented to highlight the relevant surgical technique. Anatomical depictions were created to correlate intraoperative images with known anatomical relationships. RESULTS Key to this approach is consideration of the regional anatomy in a standard supraclavicular approach, the superficial plane, containing the anterior scalene muscle and brachial plexus, and the oblique plane containing the middle scalene muscle, long thoracic, spinal accessory, and dorsal scapular nerves. Identification and mobilization of each of these structures prior to lesion removal can not only provide likely boundaries of the tumor, but also allow for protection of the nerves to avoid injury that may lead to scapular winging with associated morbidity and functional impairment of the upper extremity. CONCLUSIONS Lesions of the middle scalene region often split two important anatomical planes, the superficial and deep, creating an advantageous surgical corridor through an anterolateral approach. Through early identification of known anatomy, these two planes can be developed, and a safe approach to the lesion of the middle scalene region can be exploited.
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Affiliation(s)
- Ross C Puffer
- Department of Neurosurgery, Mayo Clinic, 200 1st St, SW, Rochester, MN, 55905, USA.
| | - Jonathan Stone
- Department of Neurosurgery, Mayo Clinic, 200 1st St, SW, Rochester, MN, 55905, USA
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, 200 1st St, SW, Rochester, MN, 55905, USA
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Abstract
The allegations made against custodians regarding ill treatments have been increased in Sri Lanka. However, their attention is grabbed by the immediate complications of torture, but not by late or delayed complications. A 35-year-old male was arrested for alleged housebreaking and kept under police custody. He alleged that he was hanged with his hands on several occasions. Six weeks after the incident, he presented to a tertiary care hospital with the weakness of his right shoulder. Examination revealed hyperpigmented scars over the left wrist and back of the left forearm with the right-sided medial winging of the scapula. He alleged that it had affected his day-to-day life. The presence of hyperpigmented scars over the left wrist and the long-term complications such as winged scapula of the right shoulder corroborated with the alleged history of torture by suspension from the wrists.
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Affiliation(s)
- H K Ranil Sanjeewa
- Department of Forensic Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
| | - Muditha Vidanapathirana
- Department of Forensic Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
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Rizzi SKLDA, Haddad CAS, Giron PS, Pinheiro TL, Nazário ACP, Facina G. Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection. Support Care Cancer 2016; 24:2707-15. [PMID: 26800686 DOI: 10.1007/s00520-016-3086-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to determine the incidence of winged scapula after breast cancer surgery, its impact on shoulder morbidity and difference in incidence according to surgery type. METHODS Patients with breast cancer and surgical indication for axillary dissection were included. A total of 112 patients were surveyed with one physical evaluation before the surgery and others 15, 30, 90, and 180 days after. Winged scapula was assessed with test proposed by Hoppenfeld. Shoulder range of motion (ROM) was assessed with goniometer for flexion, extension, adduction, abduction, internal rotation, and external rotation. A verbal scale from 0 to 10 was used to assess pain. RESULTS Winged scapula incidence was 8.0 % 15 days after surgery. Two patients recovered from winged scapula 90 days after surgery and four more 180 days after surgery, while three patients still had winged scapula at this time. The incidence after 15 days from surgery was 20.9 and 22.6 % among patients submitted to sentinel node biopsy or axillary lymphadenectomy (AL), respectively (p < 0.01). There was no statistical difference of incidence according to breast surgery type. Operated side shoulder flexion, adduction, and abduction ROM changes were statistically different in patients with or without winged scapula. The mean reduction was higher in patients with winged scapula. Both groups showed the same pattern over time in pain. CONCLUSION Winged scapula incidence was 8.0 % and was higher in AL, and prevalence decreased during 6 months after surgery. Patients who developed winged scapula had more shoulder flexion, adduction, and abduction limitation.
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Affiliation(s)
| | - Cinira Assad Simão Haddad
- Department of Gynecology, Federal University of São Paulo, Rua Marselhesa, 249. Vila Mariana, Sao Paulo, SP, 04020-060, Brazil
| | - Patricia Santolia Giron
- Department of Gynecology, Federal University of São Paulo, Rua Marselhesa, 249. Vila Mariana, Sao Paulo, SP, 04020-060, Brazil
| | - Thaís Lúcia Pinheiro
- Department of Gynecology, Federal University of São Paulo, Rua Marselhesa, 249. Vila Mariana, Sao Paulo, SP, 04020-060, Brazil
| | - Afonso Celso Pinto Nazário
- Department of Gynecology, Federal University of São Paulo, Rua Marselhesa, 249. Vila Mariana, Sao Paulo, SP, 04020-060, Brazil
| | - Gil Facina
- Department of Gynecology, Federal University of São Paulo, Rua Marselhesa, 249. Vila Mariana, Sao Paulo, SP, 04020-060, Brazil
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Belmonte R, Monleon S, Bofill N, Alvarado ML, Espadaler J, Royo I. Long thoracic nerve injury in breast cancer patients treated with axillary lymph node dissection. Support Care Cancer 2014; 23:169-75. [PMID: 25035064 DOI: 10.1007/s00520-014-2338-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/23/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The objectives of this study were to electromyographically (EMG) describe and analyze factors associated with long thoracic nerve injuries in breast cancer patients after axillary lymph node dissection. METHODS This was a prospective longitudinal observational study. Two hundred sixty-four women with primary invasive breast cancer were included between 2008 and 2011. All of them were treated by axillary lymph node dissection. Patients were evaluated at 1, 6, and 12 months following surgery. The presence of winged scapula was systematically tested at each follow-up and an EMG performed whenever it was observed. Affected and unaffected groups were compared for demographic, tumour, and treatment variables. Student t test, Mann-Whitney U test, chi-squared or Fisher test were computed as appropriate. RESULTS Among the 36 (13.6%) winged scapula observed, the EMG confirmed long thoracic nerve injury in 30 (11.3%) of them, 27 were partial axonotmesis and three were severe axonotmesis. At 12 months, the EMG showed that injury persisted in six (2.27%) patients. Patients with long thoracic nerve injury had a lower body mass index than unaffected patients (26.2 vs. 28.2, p = 0.045). Age, tumour stage, type of breast surgery, nodes excised, surgical complications, previous chemotherapy and previous hormonotherapy were not factors associated with winged scapula. CONCLUSIONS A lower body mass index was the only factor associated to long thoracic nerve injury. In most of the patients, the EMG showed partial axonotmesis. At 12 months, 2.27% of studied patients remained with an unsolved long thoracic nerve injury.
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Affiliation(s)
- Roser Belmonte
- Servei de Medicina Física i Rehabilitació, Hospital Mar-Esperança, C/ Sant Josep de la Muntanya, 12, 08024, Barcelona, Spain,
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