The surgical anatomy of the axillary approach for nerve transfer procedures targeting the axillary nerve

Abstract

Purpose: The exact relational anatomy for the anterior axillary approach, targeting the axillary nerve for nerve transfers/grafts, has not been fully investigated. Therefore, this study aimed to dissect and document the gross anatomy surrounding this approach, specifically regarding the axillary nerve and its branches.

Methods: Fifty-one formalin-fixed cadavers (98 axilla) were bilaterally dissected simulating the axillary approach. Measurements were taken to quantify distances between identifiable anatomical landmarks and relevant neurovascular structures encountered during this approach. The musculo-arterial triangle, described by Bertelli et al., to aid in identification on localization of the axillary nerve, was also assessed.

Results: From the origin of the axillary nerve till (1) latissimus dorsi was 62.3 ± 10.7 mm and till (2) its division into anterior and posterior branches was 38.8 ± 9.6 mm. The origin of the teres minor branch along the posterior division of the axillary nerve was recorded as 6.4 ± 2.9 mm in females and 7.4 ± 2.8 mm in males. The musculo-arterial triangle reliably identified the axillary nerve in only 60.2% of the sample.

Conclusion: The results clearly demonstrate that the axillary nerve and its divisions can be easily identified with this approach. The proximal axillary nerve, however, was situated deep and therefore challenging to expose. The musculo-arterial triangle was relatively successful in localising the axillary nerve, however, more consistent landmarks such as the latissimus dorsi, subscapularis, and quadrangular space have been suggested. The axillary approach may serve as a reliable and safe method to reach the axillary nerve and its divisions, allowing for adequate exposure when considering a nerve transfer or graft.

Keywords: Anterior approach; Axillary nerve; Brachial plexus; Nerve graft; Nerve transfer; Quadrangular space.

Fig. 1

(a) A fresh cadaver dissection and (b) a diagram of a dissected axilla showing the placement of the pins used to measure the various distances. (AN axillary nerve, RN radial nerve; AD anterior division of axillary Nerve, PD posterior division of axillary nerve, AA axillary artery, AV axillary vein, SA subscapular artery, PA posterior circumflex humeral artery, LM latissimus dorsi muscle, SM subscapularis)