Combined endoscopic treatment of patient with «terrible triade»: decompression of brachial plexus in thoracic aperture and interscalene space and arthroscopic subacromial spacer implantation. Clinical case
Authors: Belyak Evgeniy A. , Paskhin Dmitrij  L. , Lazko Fjodor  L. , Prizov Aleksej  P. , Lazko Maksim  F. , Zagorodniy Nikolay  V. , Menshikov Valentin  V. 
Published: March 2023

BACKGROUND: Brachial plexus injury (plexopathy) is a fairly common problem in neurology, neurosurgery, traumatology and orthopedics. Compression of the brachial plexus usually develops in a narrow anatomical space: in the area of the small pectoral muscle, thoracic aperture, interspinous space. In several cases there is a combination of plexopathy and shoulder joint pathology. In a failure of conservative treatment, surgical intervention such as revision and decompression of the brachial plexus can be used. The development of endoscopic methods of decompression allows the minimization of soft tissue trauma, reduces the risk of complications, and accelerates and facilitates the recovery period.
CLINICAL CASE DESCRIPTION: Our aim was to describe a clinical case and monitor the results of combined endoscopic intervention in a patient with the "terrible triad": endoscopic decompression of the brachial plexus in the thoracic aperture and interlumbar space and arthroscopy of the shoulder joint with subacromial spacer placement at 6 months after surgery. Patient M., aged 64 years, with the consequences of right shoulder joint trauma: dislocation of the humeral head, damage of the shoulder rotator cuff and development of posttraumatic plexopathy of the right brachial plexus. The patient underwent repeated courses of conservative treatment without any pronounced effect for 1 year after injury. To confirm the diagnosis, the patient underwent electroneuromyography and ultrasound examination of the brachial plexus on the right side and magnetic resonance imaging of the right shoulder joint. After the examination, the patient underwent combined endoscopic intervention: arthroscopy of the shoulder joint with subacromial spacer placement and endoscopic decompression of the brachial plexus in the thoracic aperture and interlumbar space. According to the visual analogue scale (VAS) the intensity of pain syndrome before surgery was 7 cm, 6 months after surgery the intensity of pain decreased to 1 cm according to VAS. According to the disabilities of the arm, shoulder and hand scale (DASH), the degree of upper extremity dysfunction before surgery was 48 points; 6 months after surgery, it decreased to 16 points. The British Medical Research Council scale (BMRC) rated the degree of motor impairment at 3 preoperatively and 0 postoperatively. The degree of sensory impairment according to the Seddon Nerve Damage Rating Scale was 2 preoperatively and 3+ postoperatively. Range of motion in the shoulder joint before surgery: flexion 110, abduction 95, external rotation 15. Six months after surgery: flexion 165, abduction 165, external rotation 45.
CONCLUSION: The findings allow us to characterize the technique of one-stage arthroscopy of the shoulder joint and endoscopic decompression of the brachial plexus in the thoracic aperture and interlumbar space as low-traumatic and effective, creating conditions for restoration of the shoulder joint and upper extremity function as well as elimination of pain syndrome in the upper extremity.