Scapular Block: An Innovative Procedure-Specific Regional Anesthesia Technique for Scapula Surgery-A Case Report.

A 40-year-old healthy male patient underwent open reduction and internal fixation with screws and plate for a comminuted fracture of the right scapula under ultrasound-guided "scapular block" with optimal sedation. We coined the term "scapular block" for an innovative combination of previously described regional anesthesia techniques to cover all dermatomes, myotomes, and osteotomes involved in scapula surgery. It is a combination of 5 target blocks (selective superior trunk block, selective supraclavicular nerve block, subclavian perivascular block, suprascapular nerve block, and erector spinae plane block) via 3 approaches (interscalene, supraclavicular, and paraspinal).

Open Surgical Treatment for Snapping Scapula Provides Durable Pain Relief, but so Does Nonsurgical Treatment.

BACKGROUND: Resection of the medial upper corner of the scapula is one option for treating patients with a painful chronic snapping scapula. However, the degree to which this procedure results in sustained relief of pain during long-term followup, and whether surgical treatment offers any compelling advantages over nonsurgical approaches at long-term followup, are not known. QUESTIONS/PURPOSES: We asked: (1) At long-term followup after surgical treatment of a painful snapping scapula, did patients' pain decrease? (2) Did scapulocostal crepitation improve? (3) Did patients return to work? METHODS: Between 1971 and 1992, 15 patients underwent surgery by one surgeon for persistent (> 1 year) and severely painful crepitus around the superomedial scapula that did not respond to nonsurgical approaches. The procedure consisted of an open resection of the superomedial corner of the scapula and release of the levator scapulae muscle. Patients treated surgically were compared with a group of nine patients treated nonsurgically between 1975 and 1997; their treatments included temporary physiotherapy, massage, and NSAIDs. In general, the patients treated nonsurgically presented with less pain. However, during much of this study period, objective pain and functional scales were not in common use, and so baseline scores were not available. Of the 15 patients treated surgically, nine participated in a clinical and questionnaire survey at a mean of 22 years (range, 16-35 years), and 12 participated in a questionnaire survey a mean 27 years after surgery (range, 23-43 years). Of the nine patients treated nonsurgically, seven participated in a clinical followup and questionnaire survey at a mean followup of 16 years (range, 10-25 years), and all nine completed a questionnaire survey at a mean of 22 years (range, 17-33 years). Patient age at onset of symptoms was a mean of 27 years. The clinical followup and questionnaires focused on pain, crepitation, and work status. RESULTS: With the numbers available, there was no difference in pain scores between patients treated surgically and those treated nonsurgically (mean VAS pain with exertion 0.8 ± 1.3 versus 1.5 ± 1.6; p = 0.357); in fact, pain scores were quite low in both groups. Pain improved promptly in seven of 12 patients treated surgically, but lasted for at least several years in all patients treated nonsurgically. Crepitus persisted variably in both groups at final followup, with no apparent difference between the groups in terms of its frequency, but it was not consistently associated with pain at final followup in either group (six of 12 patients treated surgically, all painless; and all of seven clinically examined patients treated nonsurgically, two without pain, had crepitus at latest followup; p = 0.004), whereas at initial presentation, the crepitus had been painful in all patients. All patients in both groups had returned to work after surgery or the first consultation. CONCLUSIONS: Carefully selected patients who undergo this procedure appear to obtain sustained relief of painful crepitus at long term, but so do patients treated nonsurgically. Since the decision to treat these patients surgically was somewhat subjective, and since patients treated nonsurgically did so well (although the surgically treated patients improved faster), we cannot conclude that surgery is better than nonsurgical treatment. Multicenter comparative studies with carefully applied indications are needed. LEVEL OF EVIDENCE: Level III, therapeutic study.

Atlantoaxial rotatory subluxation after surgical relocation of Sprengel deformity: a case report.

We report a case of atlantoaxial rotatory subluxation developed after scapular relocation for Sprengel deformity in a 5-year-old girl. Scapular relocation descended the scapula by 60%, and achieved a normal shoulder joint motion. However, atlantoaxial rotatory subluxation developed, probably by pulling force of the tightened anterior fibers of upper trapezius muscle. Atlantoaxial joint was reduced easily under general anesthesia and muscle relaxant, along with surgical release of the tight band at the anterior part of trapezius muscle, which was maintained by halovest immobilization.

Intraoperative microwave inactivation in-situ of malignant tumors in the scapula.

OBJECTIVE: To explore the feasibility and effect of microwave in situ inactivation of malignant primary or metastatic tumors in the scapula. METHODS: Seventeen patients (12 men, 5 women, mean age 48 years [range, 13-59 years]) with malignant primary or metastatic tumors involving the scapula were treated by microwave inactivation between June 1998 and February 2008. There were 12 malignant primary bone and 5 metastatic tumors. In 14 cases Area Sl was involved and in 3 cases both Areas S1 and S2. All 17 cases were by making a dorsal arc- or "∩-" shaped incision to expose the tumor, protecting the surrounding soft tissues with a copper grid, and then heated the tumors locally with 2450 MHz microwave to 50°C for 20 min, after which all or some of the necrotic tumor tissue was removed, preserving the support role of the scapula. RESULTS: The operation time was 60-180 min (mean 120 min) and blood loss was 300-1000 mL (mean 460 mL). No serious intraoperative or postoperative complications occurred in any patient. The patients were followed up for 3 months to 10 years (mean 4.2 years). Three patients with Ewing's sarcoma in the scapula had pulmonary, cerebral and systemic multiple metastases and died 8~24 months after surgery. Three patients with malignant fibrous histiocytoma died of pulmonary and systemic multiple metastases 10~22 months after surgery; one patient had recurrence 6 months after surgery and survived with tumor. Five patients with metastatic tumor in the scapula died of non-scapular metastatic tumor 6~14 months after surgery. The other five patients with primary malignant bone tumors had no recurrence or metastasis during follow-up. Three cases had restricted extension of the shoulder joint with unrestricted protraction and retroflexion after surgery. CONCLUSION: In situ microwave inactivation features simple surgery, reliable effects and patient acceptability, making it an ideal surgical method for malignant tumors in the scapula.

Scapulectomy for soft tissue sarcoma.

Between 1961 and 1978, 19 patients with primary soft tissue sarcomas were treated by resection of part or all of the scapula and musculoaponeurotic attachments. Recurrence-free survival was from 2 to 18 years (mean 10.7 years) in all six patients with a histologically low-grade fibrosarcoma and from 2.5 to 9 years (mean 4.9 years) in three of six patients with high-grade tumours. In all 12 patients the margin of resection was satisfactory. In contrast, only two of seven patients with high-grade sarcomas and gross or microscopically involved resection margins were alive 1 year after operation. Long-term salvage or cure of soft tissue sarcomas at this or other sites depends upon the histologic grade of the tumour and the feasibility of an adequately wide monobloc excision. Adjunctive measures to diminish the likelihood of local recurrence and to avoid amputation in marginal situations include intraoperative brachytherapy (with iodine-125 or iridium-192) and supplemental external radiotherapy. Recent experience with intensive multiple-agent chemotherapy indicates an appreciable reduction in the occurrence of systemic metastases from tumours with this potential.