Arthroscopic Axillary Nerve Neurolysis From the Anteroinferior Glenoid Through the Quadrilateral Space to the Terminal Deltoid Branches

Abstract

Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess.

Fig 1

Arthroscopic view of the left shoulder from the posterior viewing portal using a 30° arthroscope. A switching stick (A) and arthroscopic shaver (B) can be seen during diagnostic arthroscopy and debridement of the inferior capsule before the introduction of an 18-gauge spinal needle and subsequent establishment of the posterior inferior portal.

Fig 2

Arthroscopic images from a 30° arthroscope of a left shoulder from the posterior viewing portal showing dissection to the axillary nerve. An arthroscopic hook-probed electrocautery device (Arthrex, Naples, FL) is demonstrated opening the inferior capsule (A) and after careful dissection, the axillary nerve branches are encountered just below the inferior capsule (B).

Fig 3

Arthroscopic images from a 30° arthroscope of a left shoulder from the posterior viewing portal showing the release of the axillary nerve. Blunt release of the axillary nerve is carried out in the anterior to posterior direction with a switching stick (A) and an arthroscopic punch (B) as to no disrupt any branches of the axillary nerve.

Fig 4

Arthroscopic image from a 30° arthroscope of a left shoulder from the posterior viewing portal showing the final release of the axillary nerve and its arborization, visualization of all arborizations is imperative to ensure no tethering is present. This concludes the intraarticular portion of the procedure.

Fig 5

Arthroscopic image from a 30° arthroscope of a left shoulder from the anterolateral portal into the subdeltoid space demonstrating a 4-mm arthroscopic shaver being used to expose the space.

Fig 6

Arthroscopic image from a 30° arthroscope of a left shoulder from the anterolateral portal into the subdeltoid space during blunt dissection to the axillary with a switching stick. Blunt dissection is used as to not damage the axillary nerve, which can be visualized in the lower left quadrant of the figure.

Fig 7

Arthroscopic images from a 30° arthroscope of a left shoulder from the anterolateral portal into the subdeltoid space during release. An arthroscopic hook-probed electrocautery device (Arthrex, Naples, FL) (A) and an arthroscopic shaver (B) are used via the posterior portal to free the axillary nerve within the subdeltoid region.

Fig 8

Arthroscopic image through a 30° arthroscope of a left shoulder from the anterolateral portal into the subdeltoid space showing the released axillary nerve with its arborization. The axillary nerve arborizations can be visualized without any tethering after careful and thorough release.