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Figure 21 14 Spinal accessory neuropathy Winging of the left scapula is appreciated and is brought out by abduction of the shoulder (Photo courtesy of Steven A Greenberg MD Reproduced with permission from Greenberg SA, Amato AA EMG Pearls Philadelphia: Hanley & Belfus, 2004, Fig 1A, p 37)

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Trauma Surgical injury (post-thoracotomy, radical mastectomy, axillary surgery, and rib resection) Immune-mediated brachial plexus neuropathy

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Figure 21 15 Long thoracic neuropathy Winging of the right scapula is appreciated and is enhanced by having the patient ex the arm forward at the shoulder There is also atrophy of the infraspinatus secondary to a superimposed suprascapular nerve injury (Photo courtesy of Steven A Greenberg MD Reproduced with permission from Greenberg SA, Amato AA EMG Pearls Philadelphia: Hanley & Belfus, 2004, Fig 2, p 42)

90 Most lesions are distal to the innervation of the sternocleidomastoid muscles; however, proximal damage may result in weakness of turning the head to the contralateral side CMAPs recorded from the trapezius muscle may demonstrate reduced amplitude compared to the contralateral side, but electrodiagnosis usually relies on demonstrating denervation changes in this muscle

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and it innervates the serratus anterior muscle (Fig 21 3) This muscle stabilizes the scapula and helps hold it tight against the posterior thoracic trunk during movement of the shoulder girdle A long thoracic neuropathy manifests as scapular winging with the scapula as a whole and the inferior angle rotated medially (Fig 21 15) This winging is accentuated by having the patient ex the arm forward at the shoulder The long thoracic nerve may be damaged from trauma 119 121 or during surgical procedures, particularly mastectomies and thoracotomies (Table 21 5)122,123 Most often, we see long thoracic neuropathies either isolated or in combination with other neuropathies in the setting of IBPN54 Motor NCS of the long thoracic nerve is not typically performed, and electrodiagnostic con rmation of a long thoracic neuropathy requires demonstration of EMG abnormalities isolated to the serratus anterior muscle Needle EMG of this muscle should be done cautiously due to risk of pneumothorax Long thoracic neuropathies are usually managed conservatively depending on etiology Open injuries due to trauma may require surgery Otherwise, in most instances we start with physical and occupational therapy along with bracing Braces can be used to help keep the shoulder abutted against the thorax If the shoulder function does not improve over time, surgery can be considered to stabilize the scapula124,125

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The dorsal scapular arises mainly from C5 spinal root but may have contributions from the C4 segment (Fig 21 15) The nerve innervates the rhomboid major and minor along with the levator scapula, which assist in retraction, elevation, and medial inferior angle rotation of the scapula Therefore, damage to the dorsal scapular nerve leads to scapular winging, with the inferior angle rotated laterally Elevation of the arm overhead will accentuate the scapular winging It is very unusual to have an isolated dorsal scapular nerve injury NCS are not particularly helpful Electrodiagnostic con rmation requires demonstration of EMG abnormalizes isolated to the rhomboid and levator scapula muscles The suprascapular nerve arises from the upper trunk and innervates the supraspinatus and infraspinatus muscles (Fig 21 5) The supraspinatus muscle assists in shoulder abduction, while the infraspinatus muscle is used to externally rotate the arm at the shoulder Thus, these movements are limited, depending on the location of the suprascapular nerve injury The nerve may be damaged with trauma to the shoulder region, particularly if there is a dislocation or fracture of the shoulder126 130 The branch to the infraspinatus muscle might rarely become compressed within the spinoglenoid notch131,132 More commonly, this suprascapular nerve is affected in the setting of IBPN and involvement may be isolated to this nerve54,55 Motor conduction studies to this nerve are technically limiting, so electrodiagnosis relies on EMG demonstration of denervation changes in the supraspinatus and

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The long thoracic nerve originates from the fusion of branches from the C5, C6, and often C7 spinal roots,

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