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Musculoskeletal Imaging
Review
MR Patterns of Denervation
Around the Shoulder
Sarah Yanny 1,2
Andoni P. Toms 2
Yanny S, Toms AP
OBJECTIVE. The diagnosis of denervation injury as a cause of shoulder pain is conventionally based on clinical findings and electrophysiologic studies. MRI has an important role
in identifying direct and indirect signs of neuropathy and can confirm the presence of nerve
compression, depict space-occupying lesions, and exclude other intrinsic lesions of the shoulder. In this article, the relevant anatomy, causes, clinical features, and MR appearances of
nerve injury and muscle denervation of the shoulder girdle are presented.
CONCLUSION. MRI is commonly performed in patients with shoulder pain of uncertain origin and can determine the morphologic cause, precise location, and duration of nerve
injury and muscle denervation. Knowledge of the relevant anatomy, cause, and clinical and
imaging findings is important in making a potentially treatable diagnosis, avoiding confusion
with inflammatory or neoplastic processes, and obviating biopsy or surgical intervention.
2
Department of Radiology, Norfolk and Norwich
University Hospital, Norwich, Norfolk, United Kingdom.
CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2010; 195:W157W163
0361803X/10/1952W157
American Roentgen Ray Society
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fixed position beneath the superior transverse scapular and spinoglenoid ligaments
and its close proximity to the glenohumeral
joint. The suprascapular notch and spinoglenoid notch and their respective spanning ligaments form narrow fibroosseous tunnels
that predispose the suprascapular nerve to
entrapment neuropathy.
Entrapment of the suprascapular nerve in
the suprascapular notch was first described
by Kopell and Thompson in 1959 [10]. In
1982, suprascapular nerve entrapment at
the spinoglenoid notch by a hypertrophied
spinoglenoid ligament was described by
Aiello et al. [3]. Since then, several causes of
entrapment neuropathy have been identified
including trauma, such as scapular and humeral fractures [11, 12] and anterior shoulder
dislocation [13]; anomalous, thickened, or
calcific superior or inferior transverse scapular ligaments [3, 14]; and iatrogenic injury.
Repetitive overhead activities and forceful rotational movements performed during sports
such as baseball, volleyball, and weight lifting may produce traction or stretching at the
potential sites of fixation [6, 1517].
Extrinsic compression may also be due to
space-occupying lesionsmost commonly,
cystsas well as hematomas, varices (Fig. 2),
lipomas, and malignant neoplasms including
Ewings sarcoma, metastatic renal cell carcinoma, and chondrosarcoma [5]. Paralabral cysts
around the glenohumeral joint are recognized
with increasing frequency. Ticker et al. [9]
found an incidence of 1% in a series of 79 cadaveric shoulders. Most paralabral cysts are associated with labral tears [18]. They are most
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cord of the brachial plexus in the axilla. It descends inferolaterally, anterior to subscapularis, before passing through the quadrilateral
space accompanied by the posterior humeral
circumflex artery. This space is located inferoposterior to the glenohumeral joint and is
bounded superiorly by the teres minor muscle,
inferiorly by the teres major muscle, medially
by the long head of the triceps, and laterally
by the humeral neck [25] (Fig. 5). After passing through the quadrilateral space, the axillary nerve divides into anterior and posterior trunks. The branches of the anterior trunk
supply the anterior and middle parts of the
deltoid muscle. The posterior trunk supplies
the posterior part of the deltoid and teres minor muscles before terminating as the superior lateral brachial cutaneous nerve. Branches
also supply the glenohumeral joint and surgical neck of the humerus.
Cause and clinical featuresQuadrilateral space syndrome is a rare condition referring to an isolated compressive neuropathy
of the axillary nerve. The syndrome was first
described by Cahill and Palmer [26] in 1983
in which the neurovascular bundle, comprising the axillary nerve and posterior humeral
circumflex artery, is compressed by fibrous
Fig. 5Quadrilateral
space anatomy in posterior
perspective. Axillary
nerve passes through
quadrilateral space (QLS)
accompanied by posterior
humeral circumflex
artery. Space is bounded
superiorly by teres minor
muscle, inferiorly by teres
major muscle, medially by
long head of triceps, and
laterally by humeral neck.
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rilateral space syndrome caused by a paralabral cyst. Juxtaarticular cysts are a common
entity occurring adjacent to large joints and
are a well-documented cause of compressive
suprascapular neuropathy in the shoulder.
Glenoid labral cysts are thought to originate
from extrusion of joint fluid through labrocapsular tears. They occur most commonly in the superior and posterior regions and
are uncommon in the inferior aspect of the
joint [19]. When large, inferior labral cysts
can produce mass effect on the neurovascular bundle in the tightly bound quadrilateral space. Quadrilateral space masses such as
hematomas and soft-tissue tumors also have
been reported to result in this syndrome.
Other described cases of axillary nerve injury include trauma (humeral neck or scapular fractures), acute translational events such
as glenohumeral subluxation or anterior dislocation, and surgical (Fig. 6) or arthroscopic intervention [3133]. The relatively fixed
Fig. 7Quadrilateral space syndrome in 40-yearold man. Sagittal oblique (left image) and coronal
oblique (middle image) images with fat saturation
of shoulder show teres minor muscle (arrows) is
atrophied and infiltrated with fat, which creates
striated appearance on coronal oblique T1 image
(right image). Axillary nerve (arrowhead, right
image) appears normal. No mass was identified
in quadrilateral space. Denervation injury of teres
minor was thought to be secondary to fibrous bands
compressing axillary nerve.
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and surgery [48] have all been proposed. Antecedent infection has been reported in up to
25% of cases [40]. The overall incidence has
been estimated at 1.64 per 100,000 individuals in one population [49]. The age range of
affected patients is extremely wide, with most
patients presenting in the third to seventh decades of life [45, 50]. Males are predominantly affected; bilateral involvement is seen in up
to one third of patients [40, 49].
Imaging findings and treatmentNo test
is specific for the diagnosis of ParsonageTurner syndrome. Electromyography, nerve
conduction studies, and MRI must be interpreted in light of the patients clinical history. MRI is the technique of choice in patients
with shoulder pain and weakness. It is sensitive for the detection of signal abnormalities
in the shoulder girdle musculature related to
denervation injury. MRI is also useful in excluding intrinsic shoulder abnormalities that
can produce symptoms similar to ParsonageTurner syndrome such as rotator cuff tears,
impingement syndrome, and labral tears.
MRI can depict structural lesions that may
cause similar denervation changes in the rotator cuff musculature such as cuff tears or
masses impressing the brachial plexus (Fig.
8) or peripheral nerves and other causes of
intramuscular high signal including inflammatory myopathies, myositis, compartment
syndrome, rhabdomyolysis, and tumor involvement of muscle [51, 52].
The studies by Gaskin and Helms [53] and
Scalf et al. [45] are the largest reported series describing the MR features of Parsonage-Turner
syndrome to date. The diagnosis is suggested
when there is an abnormality of the muscles innervated by the brachial plexus in the absence of
Fig. 9Parsonage-Turner syndrome with involvement of suprascapular and axillary nerves in 54-year-old man.
A, Sagittal oblique T1 image (left image) shows fatty atrophy within supraspinatus (ss), infraspinatus (is), and teres minor (tm), giving characteristic striated appearance.
Sagittal oblique fast spin-echo T2 image (right image) with fat saturation shows increased signal intensity within these muscles, which is consistent with denervation
edema.
B, Coronal oblique T2 image (left image) with fat saturation and coronal oblique image T2 image (right image), which is anterior to left image, show diffuse increased
signal intensity within infraspinatus and teres minor (arrow, left image), supraspinatus (arrow, right image), and deltoid muscles; these findings are consistent with
denervation injury of suprascapular and axillary nerves.
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F O R YO U R I N F O R M AT I O N
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