Scapular stabilization surgery is a procedure aimed at correcting winged scapula—an uncommon but functionally debilitating condition that leads to shoulder weakness, discomfort, and in some cases, cosmetic deformity. This condition arises when muscles that stabilize the scapula (shoulder blade), such as the serratus anterior or trapezius, become paralyzed, often due to nerve injury.
Understanding the Winged Scapula
The scapula is a flat, triangular bone that moves in concert with the arm, anchored by a network of muscles including the serratus anterior and trapezius. Damage to the long thoracic nerve (which controls the serratus anterior) or the accessory nerve (which innervates the trapezius) can lead to a condition known as winged scapula, where the inner edge or lower corner of the scapula sticks out abnormally. This makes tasks like lifting the arm, reaching overhead, or even grooming difficult.
Some cases are caused by trauma, surgical complications, viral illnesses, or chronic strain. Patients with high-level cervical spinal cord injuries (SCI) can also develop scapular instability due to muscle weakness and paralysis.
Symptoms and Impact
Patients may experience:
- Weakness in lifting the arm
- Visible protrusion of the shoulder blade
- Pain or burning in the shoulder region
- Fatigue during daily tasks like combing hair or feeding
- Skin breakdown due to scapular prominence, particularly in patients using wheelchairs
Treatment Options
1. Non-Surgical Management
Initial treatment typically involves physical therapy, bracing, and activity modification. These options are helpful in mild cases or when symptoms are limited. However, in patients with severe weakness or nerve damage, conservative measures may fail to provide relief.
Surgical Treatment Options
Scapular stabilization surgeries can be broadly categorized into:
A. Muscle Transfer Techniques
These aim to substitute a functioning muscle for a paralyzed one.
• Pectoralis Major Transfer
- The sternal portion of the pectoralis major is rerouted from its original location to the lower portion of the scapula, sometimes with a fascia lata graft for added strength.
- This muscle mimics the serratus anterior and restores dynamic movement.
- Postoperative recovery includes shoulder immobilization, followed by gradual physical therapy.
- Outcomes are mixed: about 60% of patients report improvement, but some experience muscle weakness or graft failure due to scarring.
• Split Pectoralis Major Transfer
- Only the sternal head of the pectoralis major is used.
- A less invasive and more cosmetic approach.
- This method has yielded better outcomes with minimal visible scarring and improved range of motion.
• Eden-Lange and Modified Eden-Lange Procedures
- Designed for trapezius palsy.
- Transfers muscles like the levator scapulae and rhomboids to stabilize the scapula.
- The modified version involves placing the rhomboids into the infraspinatus and supraspinatus fossae for better mechanical advantage.
- This method often resolves winging and restores significant function without residual deformity.
B. Scapular Fixation (Wire or Plate)
• Scapulothoracic Arthrodesis
- A fusion between the scapula and ribs using metal plates and bone grafts.
- This procedure stabilizes the scapula permanently, but it eliminates its natural motion.
- Although effective, it comes with a high risk of complications, including pneumothorax, persistent pain, and hardware failure. It is considered only for patients with severe disability who do not respond to other treatments.
• Scapulopexy (Without Fusion)
- A fusionless technique using Mersilene tape or soft-tissue tethers to stabilize the scapula to the rib cage.
- Preserves some scapular mobility while reducing winging.
- Less invasive, with a quicker recovery and fewer complications.
- In spinal cord injury patients, this method significantly improved functional use of the upper limb, reduced pain, and resolved pressure ulcers caused by scapular prominence.
C. Nerve-Based Techniques
• Microneurolysis
- Decompression and internal cleaning of the long thoracic nerve.
- Performed when nerve compression (e.g., from scarring or muscle entrapment) is reversible.
- Up to 98% of patients showed improved scapular control in one study.
• Nerve Transfer
- A functional nerve (like the thoracodorsal or accessory nerve) is redirected to stimulate the paralyzed long thoracic nerve.
- Requires viable donor nerves and is not suitable for spinal cord injury patients with global upper limb weakness.
• Nerve Grafting (Experimental)
- Cadaveric studies suggest that healthy long thoracic or accessory nerves from the opposite side could be grafted to restore function.
- This is still largely theoretical and not yet standard clinical practice.
Case Highlights
- Patient with spinal cord injury undergoing fusionless stabilization showed improved arm elevation and reduction in pain, with restored function for grooming and feeding.
- Another patient with a traditional fusion experienced rigidity and less satisfaction, highlighting the advantages of fusionless approaches in active patients.
Summary Table of Techniques
| Procedure | Suitable For | Pros | Cons |
|---|---|---|---|
| Pectoralis Major Transfer | Serratus anterior palsy | Restores dynamic movement | Mixed outcomes, may need graft |
| Modified Eden-Lange | Trapezius palsy | High satisfaction, restores scapular control | More complex surgical approach |
| Scapulothoracic Arthrodesis | Severe/trapezius palsy | Very stable fixation | High complication rate, permanent fusion |
| Scapulopexy Without Fusion | SCI, muscular dystrophy | Preserves motion, low risk | May require hardware removal |
| Microneurolysis | Nerve compression cases | Minimally invasive, fast recovery | Only works if nerve is intact |
| Nerve Transfer/Grafting | Select nerve injuries | Potential for reanimation | Still investigational in many settings |
Final Thoughts
Scapular stabilization surgery is a life-changing option for patients suffering from winged scapula due to nerve or muscle injury. While fusion may be appropriate in select cases, fusionless techniques offer a promising solution that preserves shoulder mobility, minimizes complications, and enhances independence—especially in patients with spinal cord injury.
If you or a loved one is experiencing scapular winging, consult with an orthopedic specialist to explore which surgical option may be right for your specific condition.
