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A "Common Sense" Surgical Approach to Motor Shoulder Dysfunction Diagnosed as CRPS I/II Following Projectile Injuries
Alexander A Gatskiy1, Ihor B Tretyak1, Vitaliy I Tsymbaliuk2
1Restorative Neurosurgery Department, Romodanov Neurosurgery Institute, Kyiv, Ukraine.
Background:
High-velocity projectile injuries to the regio deltoidea (RD) can result in persistent pain and motor shoulder dysfunction (MSD). The underlying mechanisms may involve direct axillary nerve (Ax) trauma or remote nociceptor irritation caused by cavitation effects.
Objective:
To characterize the anatomical basis of MSD and to establish a reliable diagnostic and surgical strategy for its management.
Methods:
Twenty-seven patients presenting with painful MSD following projectile trauma to the RD were included. Eight patients exhibited deltoid palsy associated with Ax injury, of whom three underwent Ax reconstruction. After positive diagnostic nerve blocks, 25 patients proceeded to denervation of the glenohumeral joint (GHJ): anterior ( n = 15) or posterior ( n = 3). Surgical procedures included neurotomy of the lateral pectoral nerve ( n = 18), suprascapular nerve ( n = 3), and Ax ( n = 4). In patients with persistent CRPS-like symptoms, neurotomy of the intercostal nerves (ICN) was performed.
Results:
Pain relief following Ax surgery was achieved in 25%. Anterior GHJ denervation resulted in 60% pain improvement, whereas posterior showed no significant benefit. RD injuries in 45% cases exhibited CRPS type I-like manifestations. Subsequent ICN neurotomy in 12 patients effectively resolved these symptoms.
Conclusion:
High-velocity projectile injuries to the RD may provoke nociceptor irritation at a distance from the entry site through a cavitation mechanism. Direct Ax injury accounted for only 25% of MSD cases. Irritated nociceptors generate CRPS-like symptoms at painful MSD without overt nerve disruption. Targeted neurotomy of the involved nociceptors represents a reasonable therapeutic option for pain alleviation in selected patients.
