Quadrangular Space Syndrome: a systematic review of surgical and medical therapeutic advances

Background

The axillary nerve and posterior circumflex humeral artery are compressed in Quadrangular Space Syndrome (QSS), which can be treated with conservative approaches or surgical decompression in recalcitrant instances. There are no clear guidelines for determining which surgical method is optimal for treating QSS and other disorders that mirror QSS.

Objective

The goal of this study is to grade and review past, current, and planned medicinal and surgical care modalities for QSS.

Materials and Methods

The review protocol is registered with PROSPERO (ID: CRD42022332766). To identify recent advances in the methods/techniques of medical and surgical management of QSS, PubMed and Medline databases were searched until March 2022 for publications, including case studies, case reports, and review articles, using medical subject headings terms like quadrilateral space syndrome, surgical management, and medical management. Throughout the study, all the authors scrupulously followed a well-developed registered review process and the risk of bias in systematic reviews guidance tool. Data on proposed medical and surgical management methods/techniques were compiled, and each was analyzed based on the underlying neuro-vascular systems.

Results

There were 88 items found in the first search. Following applying the inclusion and exclusion criteria, 16 papers were chosen for synthesis in the review study after a thorough assessment. Three studies (conservative and advanced) focused on medical care of QSS, while 12 articles (prior, current, and newer) focused on surgical management of QSS. Only four of the 15 studies reviewed proposed different surgical approaches/techniques for surgical decompression in QSS.

Conclusions

There were two regularly used surgical procedures discovered, one anterior/delto-pectoral and the other posterior/ scapular. The anterior route is more technically straightforward and can be employed for surgical QSS decompression.

Revisiting the Surgical Approaches to Decompression in Quadrilateral Space Syndrome: A Cadaveric Study

Background

Quadrangular space syndrome involves compression of the axillary nerve and posterior circumflex humeral artery. In a few cases, its management requires surgical decompression. The current study reviews the surgical approaches used in the decompression of neurovascular structures and presents our reflections and recommendations.

Methodology

In this study, four human cadavers were used for dissection of the axillae and the scapular region by the senior residents of the Department of Anatomy and Department of Orthopedics. The residents dissected the quadrangular space in the eight upper limbs using anterior and posterior surgical approaches.

Results

To identify the quadrangular space and secure its contents, the posterior approach was recognized as the easier and quicker method by both Anatomy and Orthopedic residents; however, it may result in increased postoperative morbidity. Although the anterior (deltopectoral) approach involves more skill, it reduces postoperative morbidity.

Conclusions

The anterior (deltopectoral) approach with suggested modifications can be an effective method in the surgical decompression of quadrangular space syndrome. The authors suggest more cadaveric studies to provide anatomists and surgeons with the opportunity to practice and evaluate older and newer surgical approaches.

Feasibility of arthroscopic decompression of the axillary nerve in the quadrilateral space: Cadaver study

INTRODUCTION

Axillary nerve compression is a rare, but disabling condition. The three main causes are quadrilateral space syndrome among young athletes, compression due to an inferior glenohumeral osteophyte in early osteoarthritis and isolated teres minor atrophy secondary to triceps hypertrophy. The diagnosis is clinical, but may be reinforced by an electromyogram or corticosteroid injection. The usual surgical treatment is open nerve decompression using a posterior approach. Arthroscopy is a less invasive approach that should be useful in theory.

HYPOTHESIS

Arthroscopic decompression of the axillary nerve is safe and less invasive than open techniques.

MATERIAL AND METHODS

Arthroscopic nerve decompression was performed as described by PJ Millet and TR Gaskill on 10 shoulders from 6 frozen cadavers. An open posterior approach was then made to verify the effectiveness of the nerve decompression.

RESULTS

The axillary nerve and its branches, the circumflex artery and the triceps were always sufficiently released in the space below the joint capsule. When the joints were subsequently opened by a posterior approach, complete nerve decompression was confirmed in all cases with no iatrogenic lesions.

DISCUSSION

The good results of this study are encouraging, but should be supplemented with a comparative study in patients of open versus arthroscopic axillary nerve release.

CONCLUSION

We think this arthroscopic technique is a good option for treating axillary nerve compressions. The complication risk is expected to be low.

LEVEL OF EVIDENCE

IV.

Quadrilateral Space Syndrome: Diagnosis and Clinical Management

Quadrilateral space syndrome (QSS) is a rare disorder characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space. Impingement is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders. Diagnosis can be complicated by the presence of concurrent traumatic injuries, particularly in athletes. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Conservative treatment is often first trialed, including physical exercise modification, physical therapy, and therapeutic massage. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated.