To The Editor:
In your esteemed journal, or better said, our journal,
since orthopaedic physicians all around the world consider The
Journal of Bone and Joint Surgery our best journal, the
article "Suprascapular Nerve Entrapment" (82-A:
415-424, March 2000), by Cummins et al., was excellent, as is usual
for your Current Concepts Reviews. I found it to be very useful
since I have been studying the so-called tunnel syndromes (peripheral
nerve compression syndromes or entrapment neuropathies) for a great number
of years. There was a minor drawback in that the authors were oriented
exclusively toward papers published in English, a practice that is becoming
almost universal. I do not wish, however, to bemoan the unchangeable
fact that nowadays a paper must be published in English for it to
have any chance for recognition. Similarly, the authors failed to
consult books dealing with nerve entrapment syndromes (tunnel syndromes
or peripheral nerve compression syndromes), which may have been
due to difficulty in getting access to these books. With your help,
I would like to correct a historical injustice regarding citation
of the first description of suprascapular nerve entrapment. I would
also like to indicate how clinicians made their diagnoses long ago without
the help of the sophisticated techniques that we use now. It may
be that their knowledge of anatomy was superior to ours and that
they had more time to dedicate to each patient than we have today.
Kopell and Thompson1 are always
credited with providing the first description of the suprascapular nerve
entrapment syndrome2,3. However,
there is no doubt that André Thomas was the first to describe
the mechanisms leading to the development of suprascapular nerve
entrapment syndrome4. His paper
is cited in both the first and second editions of a book on tunnel syndromes
that was recently published in English5,6.
In his original article, Thomas described the case of a twenty-five-year-old
man who presented with the complaint of weakness in the left shoulder
during certain activities. In conversation with the patient, Thomas
learned that while attempting to cut down a tree, the patient had
extended his left upper extremity forward while it was in a position
of external rotation when his ax slipped along the trunk of the
tree. At that time, he experienced deep pain in the shoulder area
below the deltoid muscle, which prevented his returning to work.
For several more days he was troubled by pain intense enough to
disturb his sleep. There were no external signs of damage to the
soft tissues of the shoulder, and the pain gradually diminished,
but the patient was left with a weakness in the left shoulder that manifested
in everyday activities, such as dressing and undressing. A detailed
clinical examination, characteristic of the famous French school
of neurology, showed that the patient suffered from paralysis of
the infraspinatus muscle ("la paralysie du muscle sous-épineux").
It would be worthwhile to translate the complete text of the original
paper to gain an appreciation of the way that the clinical examination
alone determined the exact nerve and muscle involved.
In his article, Thomas depicted in detail the passage of the
suprascapular nerve through two narrow osteofibrous openings ("deux
canaux étroits ostéofibreux"), the suprascapular
and spinoglenoid notches, which in effect represent rings over which
the nerve is pulled. Thomas surmised that the concomitant extension
and external rotation of the patient’s left arm had led
to traction (allongement) and friction of the nerve in the narrow
fibro-osseous tunnel. Paralysis is caused by the application of
mechanical forces on the nerve, either through compression or traction,
or possibly both. Thomas, then, anticipated and combined the explanations
offered by Kopell and Thompson1 and
Rengachary et al.7 regarding the
development of suprascapular nerve entrapment syndrome. Kopell and
Thompson proposed a friction-related injury that arises as a result of
the sliding action of the nerve within the suprascapular notch.
Rengachary et al. suggested the mechanism of injury to be traction
resulting from a "sling effect" (which corresponds
to Thomas’s explanation of a "ring effect").
In Thomas’s article, the description of the provocation
test is of interest. The test is carried out with the arm of the
patient in abduction and pushed backward to relax the deltoid muscle,
which attaches to the spine of the scapula. The physician then firmly
presses his or her index finger into the neck of the spinae scapulae
where the spinoglenoid notch is presumably located. This will cause
an unpleasant feeling in the patient’s shoulder area with
painful radiation to the outer part of the upper arm.
On the basis of the case study summarized above and published
in 1936, I believe that we can unhesitatingly answer the question
posed at the beginning of this letter. Suprascapular nerve entrapment
syndrome (of course, not under this name) was first described and
correctly interpreted by André Thomas.
C.A. Cummins, T.M. Messer, and G.W. Nuber reply:
In our article we attributed the first description of a suprascapular
nerve injury to Kopell and Thompson1 (1959)
on the basis of a review of the English-language literature. Dr.
Peæina nicely cites an earlier description (1936) by André Thomas
in La Presse Médicale, entitled "La
paralysie du muscle sous-épineux"4. Clearly, from this information Dr. Thomas
should be credited with providing the first description of suprascapular
nerve entrapment syndrome.
I believe that many authors, including this one, commonly limit
their literature reviews to sources in the English language. The
reasons for this are manifold, but the primary one is difficulty
in obtaining and translating articles and texts written in another
language. Unfortunately, this approach may result in the exclusion
of some excellent literature. Having said this, for practical reasons
I still believe that this approach is reasonable. However, authors
should clearly state the methods used in their literature review
in order to avoid the error made in our recent Current Concepts
Review.
We thank Dr. Peæina for taking the time and effort to
point out this mistake.