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Dr. José Carlos Garcia Jr.

Especialista em cirurgia de ombro, cotovelo e artroscopia

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Descompressão Artroscópica do Nervo Supraescapular

A primeira técnica de descompressão do nervo supraescapular descrita nas américas.
Publicada a técnica
Dezembro de 2009 no periódico Techniques in Shoulder and Elbow Surgery, volume 10, número 4 páginas 157-159 
Seguimento
Arthroscopy, October 2013 Volume 29, Issue 10, Supplement, Pages e89–e90 
Suprascapular Nerve Arthroscopic Release Outcomes
Revista Brasileira de Ortopedia(Rev Bras Ortop. 2011;46(4):403-07).


Apresentado
Congresso da Associação de Artroscopia da América do Norte (AANA-Arthroscopy Association of North America)
2012-Orlando/EUA
Pôster
Congresso da Associação Internacional de Artroscopia e Trauma do Esporte (ISAKOS)
2013-Toronto/Canadá
Apresentação Oral
Congresso Brasileiro de Ombro e Cotovelo:
2012-Foz do Iguaçu - Brasil
Apresentação Oral
Congresso Brasileiro de Artroscopia e Traumatologia Desportiva:
2009-Belo Horizonte - Brasil
Apresentação Oral
Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo
2009-Porto de Galinhas/Brasil
Pôster

Abstract:
Suprascapular nerve compression at the transverse scapular notch is recognised as a shoulder pain cause. Some authors have developed open surgical techniques in order to release the compressed nerve, with good results, and arthroscopic techniques have been described recently as well. We have developped an arthroscopic technique using different portals from the other authors?. Our preliminary results reveal a change of the preoperative average UCLA from 10,4 to 19,8 in the 6-month-postoperative.The SF-36 114,6 and raw scale for pain was 74% in the 6-month-postoperative. Our preliminary results achieved satisfactory outcomes and can be also another option in terms of nerve compression treatment.


Publicado na Revista Brasileira de Ortopedia a avaliação a longo prazo

Liberação Artroscópica do Nervo Supraescapular: Técnica cirúrgica e avaliação de casos clínicos
 clínicos. Rev Bras Ortop. 2011;46(4):403-07

LIBERAÇÃO ARTROSCÓPICA DO NERVO SUPRAESCAPULAR: TÉCNICA CIRÚRGICA E AVALIAÇÃO DE CASOS CLÍNICOS
ARTHROSCOPIC RELEASE OF THE SUPRASCAPULAR NERVE: SURGICAL TECHNIQUE AND EVALUATION OF CLINICAL CASES
José Carlos Garcia Júnior1, Ana Maria Ferreira Paccola2, Cristiane Tonoli2, José Luis Amin Zabeu3, Jesely Pereira Myrrha Garcia4

RESUMO
Objetivo: Descrever uma técnica cirúrgica própria de descom- pressão artroscópica do nervo supraescapular (NSE) e avaliar seus resultados preliminares. Métodos: 10 ombros de nove pacientes foram operados com uma técnica que utiliza portais diferentes das técnicas conhecidas, não usa tração e faz uso de materiais disponíveis na rede pública de saúde. Resultados: 10 ombros de nove pacientes, sendo oito à direita e dois à esquer- da, com média de idade de 69,5 anos, apresentaram mudança no escore UCLA de 11,7 para 26,1 no seguimento de 16,6 meses de pós-operatório. O questionário SF-36 teve pontuação de 122,9 e a escala bruta de dor de 88%. Conclusão: A des- compressão artroscópica do NSE, segundo a técnica descrita, é reprodutível e menos traumática que as técnicas abertas. Os pacientes obtiveram melhora em vários parâmetros avaliados, principalmente no que se refere à dor. A descompressão artros- cópica do NSE pode ser uma opção terapêutica para a patologia compressiva do NSE.

Descritores: Compressão Nervosa; Descompressão Cirúrgica; Dor de Ombro; Artroscopia/métodos; Ombro

Arthroscopy

Summary
Arthroscopic release of the suprascapular nerve is another therapeutic option for persistent shoulder pain in massive irreparable rotator cuff tears.Jump to

Introduction
Suprascapular nerve (SSN) entrapment at the suprascapular notch is a well-known cause of persistent chronic shoulder pain in patients with irreparable massive rotator cuff tears. Exploration of the SSN and release of the superior transverse scapular ligament have recently been proposed as treatment, achieving good functional outcomes and pain relief.
Natsis classified suprascapular notches based on anatomic measurements of vertical and transverse diameters. According to him, types III, IV and V are more likely to cause a suprascapular nerve entrapment.
We performed an all-arthroscopic technique for SSN decompression and presented our outcomes for this procedure.
We also correlated the Natsis' suprascapular notch classification with SSN entrapment.Jump to Section

Methods
A series of 20 patients with massive rotator cuff tears and consistent findings for SSN compression were operated between May 2008 and November 2011.
All patients had undergone an unsuccessful physiotherapy for a minimum of 6 month.
All had MRI, EMG and positive SSN Stretch Test (Lafosse) confirming SSN entrapment.
Our surgical technique uses different portals from other Authors, a 30° angled lens arthroscope and we do not use traction to the arm.
We use a postero-medial portal for releasing the SSN.
Using a calibrated probe we measured the transversal and vertical diameters of suprascapular notches so we could classify them as Natsis' types.
The clinical outcomes were assessed preoperatively and 6 months after surgery with UCLA scale, SF-36, raw pain scale and Simple Shoulder Test.
Results were compared using the non-parametric Wilcoxon T test, with a level of significance of 0.1% (P<.001).Jump to Section

Results
We operated 20 shoulders from 19 patients: 14 female and 5 male; 15 right and 5 left sided shoulders. Two patients were lost to follow-up and were excluded.
The mean age was 65,50 year-old (range, 42 to 81). The mean follow-up was 32,60 months (range, 6 to 56 months).
All patients had an unsatisfactory preoperative UCLA (lower than 27).
The mean preoperative and postoperative UCLA scores had risen from 13,27 to 28,27 (P<.001).
All patients were satisfied with the surgery, except one, which had increased only 2 points in postoperative UCLA and graded her outcome as poor. This patient had a Natsis type II notch.
Fourteen out of seventeen patients (82,35%) had satisfactory postoperative UCLA score (greater than 27).
The two patients whose postoperative UCLA were below 27, rated their surgical outcome as good (satisfied). Both had a preoperative UCLA lower than 8. We believe these cases were more severe and, in spite of having elevation ROM above 70 degree, would have probably been a better indication for reverse total shoulder prosthesis.
The raw pain scale improvement was 86,07% (P<.001) and the mean postoperative SF-36 was 122,90 (P>.001).
The mean postoperative Simple Shoulder Test was 8,84 (P<.001).
We performed 10 arthroscopic Mumphord procedures and 11 biceps tenodesis in association with the SSN release.
We found one Natsis Type II notch (transverse diameter greater than vertical), fifteen Type III (vertical diameter greater) and two Type IV (osseous foramen).Jump to Section

Conclusion
Arthroscopic release of the SSN can be performed and reproduced safely and effectively. It is another therapeutic option for persistent shoulder pain in massive irreparable rotator cuff tears with the benefits of been minimally invasive and having a nice esthetic outcomes.
SSN release seems to be related to the anatomic aspect of the suprascapular notch. Natsis believes notche types III, IV and V are more likely to SSN entrapment.
We confirmed that in our study. We found 94,44% notches types III and IV in our series.
The only Natsis type II notch in our study had a poor outcome. We believe there was a misdiagnosis in this case. Despite of the positive electromyographic findings for SSN entrapment, the pain origin might not had been the SSN entrapment, but arthrosis.
Probably type II notches are a contraindication to SSN decompression.
Further controlled studies comparing biceps tenodesis, arthroscopic Mumphord and SSN release will be necessary to identify which association of procedures has the better outcome.
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