ABSTRACT
BACKGROUND: Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. METHODS: This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. RESULTS: A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. CONCLUSIONS: Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.
ABSTRACT
BACKGROUND: Keloids and hypertrophic scars cause physical and psychosocial problems. Combination 5-fluorouracil (5-FU) with triamcinolone acetonide (TAC) may enhance the treatment of pathological scars, although the evidence base is limited. OBJECTIVES: We aimed to evaluate the efficacy and complication rates of combination intralesional TAC and 5-FU in comparison to monotherapy intralesional TAC or 5-FU for the treatment of keloids and hypertrophic scars. METHODS: EMBASE, MEDLINE and CENTRAL were searched by two independent reviewers. The primary outcome was treatment efficacy (51% to 100% improvement). Study quality and risk of bias were assessed using Cochrane's risk of bias tool, respectively. RESULTS: Of 277 articles screened, 13 studies were included comprising 12 randomised control trials (RCT) and 1 non-randomised study. There were six and nine studies comparing combination intralesional therapy versus monotherapy 5-FU and monotherapy TAC, respectively. The combined group demonstrated superior objective treatment efficacy compared to the monotherapy TAC group (OR 3.45, 95% C.I: [2.22-5.35], I 2=0%, P<0.00001) and monotherapy 5-FU group (OR 4.17, 95% C.I: [2.21-7.87], I 2=0%, P<0.0001). Telangiectasia was less frequent in combination therapy (OR 0.24, 95% CI: [0.11-0.52], I 2=0%, P=0.0003) compared to monotherapy TAC. CONCLUSIONS: Combined intralesional TAC and 5-FU administration demonstrated superior treatment efficacy outcomes compared to monotherapy TAC or 5-FU. Patient-reported outcome measures, lacking here, should be incorporated in the design of future research to justify clinical recommendations.
