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CASE REPORT
Minimally invasive cervical micro-endoscopic foraminotomy
for C6 radiculopathy with overlooked scapular winging- A case report Yoshihiro Ishihama, Fumitake Tezuka, Hiroaki Manabe, Kazuta Yamashita, Yoichiro Takata, Toshinori Sakai,
Takashi Chikawa, and Koichi Sairyo
Department of Orthopedics, Tokushima University, Tokushima, Japan

Abstract : A 73-year-old woman complained of right medial side of scapular pain associated with winged scapula to miss without observing the back in minute detail. Additional treatment was required due to overlooking
caused by insufficient examination. We performed micro-endoscopic foraminotomy that provided the disappearance of scapular pain and improvement of winged scapula in relatively early. It was commonly said that winged
scapula is an extremely rare condition that causes dysfunction of the upper extremities. We suggest that there
are the meaning of winged scapula in diagnosis and the importance of physical examination. Further studies
should be required to research the morbidity of winged scapula associated with cervical disease. By sharing
our experience of this attention arousing case, we provide information not to repeat the same mistakes. J. Med.
Invest. 66 : 340-343, August, 2019
Keywords : Winged scapula, Cervical radiculopathy, Minimally invasive surgery, micro-endoscopic foraminotomy

INTRODUCTION
Winged scapula is a symptom that the medial edge of thescapula protrudes in a rearward away from the thorax. The
trapezius, serratus anterior and rhomboid muscles act thatthe scapula doesn’t depart from the thorax and are involved inmovement of the scapula. Winslow originally reported the firstdescription of winged scapula in 1723 (1). Thereafter, Velpeau
first described winged scapula caused by isolated serratus anterior paralysis in 1837 (2). The neuropathy of either the long thoracic, spinal accessary or dorsal scapular nerves that innervate
the serratus anterior, trapezius and rhomboid muscles is mostly
the major cause of this pathogenesis (3, 4). Frequency of winged
scapula due to the palsy of serratus anterior muscle and trapezius muscles is relatively high. Winged scapula may present invarious disease such as acute trauma, brachial plexus, cervicalspondylosis, muscular dystrophy, idiopathic, and so on.
It is hardly reported that winged scapula associated with cervical spinal disease. Here, we show minimally invasive cervicalmicro-endoscopic foraminotomy for C6 radiculopathy with overlooked scapular winging.

posterior decompression and fusion surgery at local hospital(Fig.2, 3). Although, those symptoms partially improved, painaround her right scapula did not disappear. She was referredto our department for further examination and treatment in2017. Physical examination revealed positive of the Jackson neckcompression test and Spurling neck compression test. Except
for the serratus anterior muscle, any other muscle weakness ofthe upper limb was not observed. All deep tendon reflexes wereintact and no sensory deficit were observed. There were no symptoms attributable to cord compression. Parasagittal image of theMRI of the cervical spine showed no presence of spinal cord compression (Fig4). CT Scanning in the oblique axial planes and theoblique sagittal planes showed right foraminal stenosis at C5-C6

CASE REPORTThe patient was a 73-year-old woman who complained ofright shoulder pain, in particular, medial side of scapula, which
resulted in scapular winging on that side (Fig.1). She also hadback pain and dullness of the both legs for several years. She wasdiagnosed as having ossification of ligamentum flavum of thethoracic spine and lumbar spinal canal stenosis, and underwent
Received for publication February 7, 2019 ; accepted April 25, 2019.
Address correspondence and reprint requests to Yoshihiro Ishihama,
MD, Clinical Fellow, Department of Orthopedics, Tokushima
University, 3-18-15 Kuramoto, Tokushima 770-8503, Japan andFax : +81-88-633-0178.

Figure 1 Medial scapular winging due to serratus anterior palsy.

The Journal of Medical Investigation Vol. 66 2019

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The Journal of Medical Investigation Vol. 66 August 2019associated with encroachment on the neural foramina by bone
spur arising from the superior articular process of C6. (Fig.5).
That thought to be OA change of the Luschka joint for the causeof foraminal stenosis. Cervical spinal radiculopathy of C6 wasmade on the basis of the temporary effect of selective nerve root

block of right C6. The patient subsequently underwent a rightC5-C6 micro-endoscopic foraminotomy (Fig.6). Thereafter, painaround her right scapula disappeared in relatively early, andwinged scapula almost improved in 6 months after surgery(Fig.7). The clinical results would be satisfactory.

3A

3B

Figure 2 Plain lateral radiograph after
posterior lumbar interbody fusion.

Figure 3 Postoperaive 3-dimentional CT reconstruction (A) and the oblique axial view show

Figure 4 MR images of cervical spine show
no presence of spinal cord compression.

Figure 5 Preoperative CT Scanning in the oblique axial plane (A) and the oblique sagittal

the extension of the decompression (B).

5A

6A

5B

plane(B) demonstrating the right side of foraminal stenosis at C5-C6.

6B

Figure 6 A : Intraoperative lateral fluoroscopic image of micro-endoscopic foraminotomy.

6C

B : The foraminotomy on the right side of C5-C6 in the oblique axial view is shown.
C : CT cervical spine sagittal reconstruction demonstrating the postoperative result after endoscopic foraminal decompression at C5C6.

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Y. Ishihama, et al. C6 radiculopathy with winged scapula
mobility of the cervical spine without any instrumentation.
The utilization of endoscopy can minimize soft tissue injury. A
systematic review by Song et al. (14) reported clinical outcomesof micro-endoscopic foraminotomy compared with traditional
open method. They identified using of micro-endoscopy have lessblood loss and shorter surgical time compared to the standard
open surgery. Minimally invasive cervical micro-endoscopic
foraminotomy is useful for cervical foraminal stenosis as one of
the treatment options.

CONCLUSION

Figure 7 Improvement of winged scapula about 6 months aftersurgery.

Although it was said that winged scapula is rare, there may
be a possibility of misdiagnosis without a detailed observation.
Improvement of symptoms can be expected by reliable treatment
based on correct diagnosis. Our report shall be the attention
arousing case of C6 radiculopathy with overlooked scapularwinging.

REFERENCESDISCUSSION
Winged scapula can be missed without carefully making aphysical examination. In this case, lumbar spinal canal stenosis
and ossification of ligamentum flavum of thoracic spine was focused on radiological diagnosis, despite presenting winged scapula. Surgical treatment based on misdiagnosis was performed,
and as a result, her symptom didn’t improve satisfyingly. Necessary and sufficient information is required for spinal diagnosis
and management. Overpeck and Ghormley (5) reported thatwinged scapula is rare disorder, which is incidence of 0.0026% at
Mayo Clinic. However, there may be misdiagnosis without a sufficient and detailed observation. The prevalence of winged scapula, while still uncommon, is higher than previously believed(6). The presentation of winged scapula may help diagnosis, andfurthermore, we reconfirmed the importance of physical examination. The morbidity of winged scapula as for cervical diseaseremains to be evaluated.
There are few reports as for winged scapula associated withcervical spinal disease. Yaguchi et al. (7) reported a case of
unilateral scapular winging caused by weakness of the triceps
muscle and the serratus anterior muscle due to cervical flexion
myelopathy. Ando et al. (8) reported 6 cases with winged scapula
associated with cervical spondylosis, which occurred mainly
in C7 myelomere. Makin et al. (9) deduced that winged scapula
would be identified as matched with a diagnosis of C7 radiculopathy. Winged scapula is caused by the neuropathy of either
the long thoracic, spinal accessary or dorsal scapular nerves.
The long thoracic nerve arises from the anterior rami of C5, C6and C7 roots, the spinal accessary from eleventh cranial nerve
and the dorsal scapular nerve from the ventral ramus of C5 orinfrequently C4 (10-12). Therefore, C6 radiculopathy can cause
winged scapula.
For the patients who do not recover well by conservative
treatment, surgical treatment would be needed. The decision
as for approach and surgical method is based on patient andsurgeon-specific considerations. Micro-endoscopic foraminotomy
for the treatment of cervical radiculopathy has been reported tobe effective (13). The posterior approach is theoretically suited
for unilateral radiculopathy, which direct decompression canbe obtained. Moreover, it avoids the complication as related
to anterior structure such as the trachea or esophagus unlike
anterior approach. Furthermore, this procedure can preserve1.

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H : A case of flexion myelopathy presenting with reversible
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Neurosurg Psychiatry 49 : 640-644, 1986
10. Hamada J, Igarashi E, Akita K, Mochizuki T : A cadaveric
study of the serratus anterior muscle and the long thoracic
nerve. J Shoulder Elbow Surg 17 : 790-794, 2008
11. Lu L, Haman SP, Ebrahelm NA : Vulnerability of the spinalaccessory nerve in the posterior triangle of the neck: a cadaveric study. Orthopedics 25 : 71-74, 2002
12. Osterman AL, Babhulkar S : Unusual compressive neuropathies of the upper limb. Orthop Clin North Am 27 : 389408, 1996
13. Wu PF, Liu BH, Wang B, Li YW, Dai YL, Qing YL, Lv
GH : Complications of Full-endoscopic versus Microendoscopic Foraminotomy for Cervical Radiculopathy : aThe Journal of Medical Investigation Vol. 66 August 2019
Systematic Review and Meta-analysis. World Neurosurg
114 : 217-227, 201814. Song Z, Zhang Z, Hao J, Shen J, Zhou N, Xu S, Ni W,

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