Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
Anatomical study of the innervation of glenohumeral
and acromioclavicular joint capsules: implications for
image-guided intervention
John Tran,1 Philip W H Peng,2 Anne M R Agur1

1
Division of Anatomy, ABSTRACT experience persistent pain following successful
Department of Surgery, Background and objectives In 2011, chronic shoulder arthroplasty.5
University of Toronto, Toronto,
Ontario, Canada shoulder joint pain was reported by 18.7 million Radiofrequency ablation (RFA) has emerged
2
Department of Anesthesia, Americans. Image-guided radiofrequency ablation has as an alternative intervention to manage chronic
Toronto Western Hospital, emerged as an alternative intervention to manage shoulder pain.6 To optimize the effectiveness of
Wasser Pain Management chronic shoulder joint pain. To optimize the effectiveness shoulder denervation, it is important to precisely
Center, University of Toronto,
of shoulder denervation, it requires a detailed localize and target articular branches supplying the
Toronto, Ontario, Canada
understanding of the nerve supply to the glenohumeral glenohumeral joints (GHJ) and acromioclavicular
Correspondence to and acromioclavicular joints relative to landmarks visible joints (ACJ). Previous anatomical studies, summa-
John Tran, Division of Anatomy, with image guidance. The purpose of this cadaveric rized in table 1, have identified several sources
Department of Surgery, study was to determine the origin, course, relationships of innervation of the GHJ and/or ACJ, including
University of Toronto, Toronto, to bony landmarks, and frequency of articular branches suprascapular nerves (SSN), lateral pectoral nerves
ON M5S 1A8, Canada;
innervating the glenohumeral and acromioclavicular (LPN), and axillary nerves (AN), as well as the
[email protected]
joints. nerves to subscapularis (NS).7–16 Of the 10 studies
Interim data from this work Methods Fifteen cadaveric specimens were found, the innervation of GHJ was reported in nine
were presented at the 2017 meticulously dissected. The origin, course, and and that of the ACJ in four (table 1). The frequency
World Academy of Pain termination of articular branches supplying the of each nerve was seldom reported, and the only
Medicine Ultrasonography
Annual Meeting and glenohumeral and acromioclavicular joints were comprehensive study was published by Gardner7
Workshop in Miami, 13–15 documented. The frequency of each branch was who reported findings with hand-drawn illustra-
January 2017; at the 2017 determined and used to generate a frequency map tions.7 Further investigation of the innervation of
Study in Multidisciplinary that included their relationships to bony and soft tissue GHJ and ACJ relative to bony and soft tissue land-
Pain Research–International
landmarks. marks identifiable with ultrasound/fluoroscopy are
Symposium of Ultrasound in
Regional Anesthesia Congress Results In all specimens, the posterosuperior quadrant needed, as presently, in the RFA literature the main
in Florence, 29 March to of the glenohumeral joint was supplied by suprascapular target has been the SSN.6 17–20 Therefore, the aims
1 April 2017; at the 2017 nerve; posteroinferior by posterior division of axillary of this cadaveric study were to (1) document the
Annual Meeting of American origin and frequency of articular branches inner-
nerve; anterosuperior by superior nerve to subscapularis;
Association of Clinical
Anatomist in Minneapolis, and anteroinferior by main trunk of axillary nerve. Less vating the GHJ and/or ACJ; (2) trace the course and
17–21 July 2017; and at the frequent innervation was found from lateral pectoral capsular distribution of each articular branch; and
2018 World Academy of Pain nerve and posterior cord. The acromioclavicular joint (3) define bony and soft tissue landmarks to localize
Medicine Ultrasonography was found to be innervated by the lateral pectoral and the articular branches.
Annual Meeting and Workshop
in Toronto, 23–24 June 2018. acromial branch of suprascapular nerves in all specimens.
Bony and soft tissue landmarks were identified to
Received 3 October 2018 localize each nerve. METHODS
Revised 29 November 2018 Conclusions The frequency map of the articular Ten formalin and five lightly embalmed cadaveric
Accepted 10 December 2018 specimens were used in this study. Due to lack of
branches supplying the glenohumeral and
acromioclavicular joints, as well as their relationship to sufficient data for the purposes of quantitative anal-
bony and soft tissue landmarks, provide an anatomical ysis, sample size calculation was not possible. The
foundation to develop novel shoulder denervation and specimens had no visible evidence of pathology,
perioperative pain management protocols. previous surgery, or trauma.
SSN, LPN, NS, and AN were meticulously
dissected using a 3.5× magnification lens. The
nerves were dissected from proximal to distal,
© American Society of Regional beginning at their point of origin at the brachial
Anesthesia & Pain Medicine INTRODUCTION plexus and continued to their termination. All
2019. No commercial re-use. In 2011, chronic shoulder joint pain was self-re- specimens were photographed. Articular branches
See rights and permissions.
Published by BMJ. ported by 18.7 million Americans.1 Osteoarthritis terminating in the capsule of GHJ and/or ACJ were
is a common cause of chronic shoulder pain and documented and their trajectory mapped.
To cite: Tran J, patients who experience moderate to severe symp- The SSN was traced distally to the suprascapular
Peng PWH, Agur AMR. notch, where it passed inferior to the transverse
toms are considered for shoulder arthroplasty.
Reg Anesth Pain Med Epub
ahead of print: [please In the USA, 66 995 shoulder replacements were scapular ligament to lie on the floor of the supra-
include Day Month Year]. performed in 2011,2 with the number of procedures spinous fossa. The medial and lateral trunks of SSN
doi:10.1136/rapm-2018- projected to increase exponentially.3 4 However, were identified, and any branches were followed to
100152 it has been reported that up to 22% of patients their termination, in short segments, by removing
Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152 1
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
origins of the medial trunk of SSN and the first articular branch
Table 1 Previous cadaveric studies of GHJ and ACJ innervation
from the lateral trunk of SSN, relative to the midpoint of the line
SSN LPN AN NS defined in 3, was quantified using calipers.
Reference Sp GHJ ACJ GHJ ACJ GHJ GHJ The LPN was traced from the lateral cord of the brachial
Gardner 7
11 ✓ ✓ ✓ ✓ ✓ ✓ plexus to the deltopectoral triangle. The branches of the thora-
Wrete8 5 ✓ NI x NI 5/5† ✓
coacromial artery and vein were removed to expose the branches
of LPN. Each nerve branch was followed to its termination in
Aszmann
et al9 25 ✓ ✓ x ✓ ✓ ✓ muscle or the joint capsule.
Akita et The NS were identified at their origin from the posterior
al10 125 NI 2/125 2/125 NI NI NI cord of the brachial plexus. Each of the nerves was traced to its
Gelber et 8/45 (Abr.) termination by removing fiber bundles of subscapularis. Motor
al11 45 NI NI NI NI 40/45 (Pbr.) NI branches to subscapularis and sensory branches innervating the
Vorster et joint capsule were identified.
al12 31 23/31 x NI NI NI NI The AN was traced from the posterior cord through the quad-
Ebraheim rilateral space with the posterior circumflex humeral artery and
et al13 12 NI 12/12 NI NI NI NI veins. The artery and veins were separated from the AN and
Nasu et subsequently removed, while maintaining the integrity of any
al14 20 NI NI NI NI 16/20 NI
branches. Branches of AN were followed to their termination
Nam et and documented.
al15 43 NI NI 29/43 NI NI NI
A frequency map of the innervation of the shoulder joint
Eckmann
et al16 33‡ 16/16 NI 12/14 NI 16/16 NI
capsule was generated by consolidating the innervation patterns
from each specimen onto a three-dimensional (3D) CT recon-
struction of the scapula, humerus and clavicle (Amira for Life
*May arise from posterior cord.
†
May have ‘second root’ from musculocutaneous nerve. Sciences, Thermo Scientific, Waltham, Massachusetts, USA;
‡
Reported findings in 14 and 16 specimens. Maya 2016, Autodesk, San Rafael, California, USA; Paint.Net,
ACJ, acromioclavicular joint; Abr, anterior branch; GHJ, glenohumeral joint; NI, not dotPDN LLC, Redmond, Washington, USA). The capsular distri-
investigated; Pbr, posterior branch; Sp, specimen number; x, not found. bution of the articular branches was documented and compared
between specimens. Based on the dissected specimens and
muscle fiber bundles from the overlying supraspinatus. The frequency map, bony and soft tissue landmarks to localize the
lateral trunk was followed along the floor of the supraspinous articular branches were identified.
fossa, around the spinoglenoid notch into the infraspinous fossa.
Next, the infraspinatus was dissected at the fiber bundle level to RESULTS
expose branches of the lateral trunk as it coursed in the infraspi- The GHJ was found to be most consistently innervated by artic-
nous fossa. ular branches from SSN, NS, and AN, whereas the ACJ was
To further document the location of the origins of the medial supplied by LPN and acromial branch from SSN.
trunk of SSN and first articular branch from the lateral trunk
of SSN, the following methodology was carried out in each Glenohumeral joint
dissected specimen (figure 1): (1) midpoints of the suprascapular To provide a summary of the innervation of GHJ, the capsule
and spinoglenoid notches were identified; (2) linear distance was divided into quadrants: posterosuperior, posteroinferior,
between the midpoints of the notches was measured using cali- anterosuperior, and anteroinferior (figure 2).
pers; (3) midpoint of the line quantified in two was demarcated
on each specimen with a point using a thin marker; and (4)

Figure 1 Distance measurements of the MT (purple line) and first AB (dark blue line) of SSN relative to the midpoint (red dot) of a line between
the suprascapular (light blue curve) and spinoglenoid (green curve) notches. AB is the first articular branch from LT of SSN. AB, articular branch;
AC, acromion process; CP, coracoid process; G, glenoid fossa; LT, lateral trunk; MT, medial trunk; SS, spine of scapula; SSF, supraspinous fossa; SSN,
suprascapular nerve. Reprinted with permission from Philip Peng Educational Series.
2 Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
Figure 3 Innervation of ACJ and posterosuperior quadrant of GHJ. (A
and B) Articular branches to GHJ originating from the lateral trunk of
SSN and acromial branch (br) of SSN and LPN to ACJ. Note the clavicle
Figure 2 Innervation of quadrants of glenohumeral joint capsule. AC,
has been disarticulated and removed in A. (C) SSN articular branches
acromion process; AN, axillary nerve; CP, coracoid process; LPN, lateral
to GHJ and ACJ. Articular branches to GHJ originate from bifurcation of
pectoral nerve; NS, nerves to subscapularis; PC, posterior cord; SSN,
SSN into medial and lateral trunks and acromial branches to ACJ from
suprascapular nerve. Red dash lines indicate outline of glenoid fossa.
SSN. AC, acromion process; ACJ, acromioclavicular joint; CL, clavicle;
Reprinted with permission from Philip Peng Educational Series.
CP, coracoid process; GHJ, glenohumeral joint; HH, humeral head; LPN,
lateral pectoral nerve; SS, spine of scapula; SSF, supraspinous fossa; SSN,
Posterosuperior quadrant main trunk of suprascapular nerve; black arrow heads, medial trunk of
The posterosuperior quadrant was innervated by SSN in all SSN; *, transverse scapular ligament. Reprinted with permission from
15 specimens. The SSN, after giving off the acromial branch, Philip Peng Educational Series.
passed deep to the transverse scapular ligament and immedi-
ately divided into medial and lateral trunks (figure 3A). The
mean distance of the bifurcation of SSN, from the midpoint of branches, including articular, travel together in a neurovascular
a line connecting the suprascapular and spinoglenoid notches, bundle, enshealthed with connective tissue. The suprascapular
was 1.07±0.14 cm. Branches from the medial trunk innervated artery and its branches could be identified using doppler ultra-
the anterior region of supraspinatus; no articular branches were sound facilitating identification of the neurovascular bundle as it
found. The lateral trunk coursed along the floor of the supra- passes at the midpoint of the line between the suprascapular and
spinous fossa to the spinoglenoid notch, with the suprascapular spinoglenoid notches.
artery, supplying the posterior region of supraspinatus and GHJ
capsule. In 13 specimens, the GHJ capsule was innervated by Posteroinferior quadrant
articular branches that originated from the lateral trunk starting The AN divided into anterior and posterior divisions as it coursed
at the midpoint between the suprascapular notch and the spino- through the quadrangular space with the posterior circumflex
glenoid notch (figure 3A,B). The mean distance of the origin of humeral artery. In all 15 specimens, the posterior division, after
the first articular branch from the lateral trunk of SSN, from the emerging from the quadrangular space, gave off 1–3 articular
midpoint of a line connecting the suprascapular and spinogle- branches to the posteroinferior capsule (figure 4). The articular
noid notches, was 0.41±0.18 cm. In two specimens, the artic- branches coursed superiorly to reach the capsule deep to the
ular branches originated from the bifurcation of the SSN into teres minor. To localize articular branches from posterior divi-
the medial and lateral trunks (figure 3C). Additional innerva- sion of AN, the junction of inferior border of teres minor and
tion to GHJ from the acromial branch of SSN was found in two medial border of surgical neck of humerus, that is, at quadran-
specimens (figure 3A,C). As the lateral trunk coursed around gular space was identified as a consistent landmark.
the spinoglenoid notch and entered the infraspinous fossa,
it gave off 1–2 articular branches that coursed directly to the Anterosuperior quadrant
joint capsule (figure 4). Regardless of the origin, the articular In 14 specimens, the most superior nerve to subscapularis gave off
branches terminated in the posterosuperior capsule. The identi- 1–2 articular branches that coursed with the subcoracoid branch
fied landmark to localize the articular branches from the lateral of the axillary artery, along the superior border of subscapularis,
trunk of SSN was the suprascapular artery, in the supraspinous deep to the coracoid process (figure 5A,B). At the margin of the
fossa, at the midpoint between the suprascapular and spinogle- glenoid fossa, the articular branch(es) coursed deep to subscapu-
noid notches. The suprascapular artery, veins, nerve and their laris to innervate the anterosuperior quadrant of GHJ. In one
Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152 3
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
Figure 4 Nerve supply to posterior GHJ capsule. (A–C) Inferior branch Figure 5 Innervation of ACJ and anterior GHJ capsule. (A and B)
of SSN and posterior division of AN. Note infraspinatus and teres minor Superior nerve to subscapularis and AN innervate GHJ and lateral
have been removed. AC, acromion process; AD, anterior division of AN; pectoral nerve innervates the ACJ. Inset photo is enlargement of area
AN, axillary nerve; br, branch; GHJ, glenohumeral joint; HH, humeral in white box in A. (C) Articular branches from PC innervating the GHJ.
head; ISF, infraspinous fossa; LHT, long head of triceps brachii; PD, Yellow dash lines outline the PC and its bifurcation into AN and RN.
posterior division of AN; SS, spine of scapula; SSN, suprascapular nerve; ACJ, acromioclavicular joint; AN, axillary nerve; BT, tendon of long head
TM, teres major; black arrow heads, motor branches of SSN supplying of biceps brachii; CP, coracoid process; GHJ, glenohumeral joint; HH,
infraspinatus; x, spinoglenoid ligament. Reprinted with permission from humeral head; LDT, tendon of latissimus dorsi; LPN, lateral pectoral
Philip Peng Educational Series. nerve; PC, posterior cord; RN, radial nerve; SBS, subscapularis. Reprinted
with permission from Philip Peng Educational Series.
specimen, there were no articular branches from the nerves to
subscapularis; however, the posterior cord provided an artic- ► The anterior division of AN, after coursing through the quad-
ular branch with a similar course (figure 5C). Additionally, in rangular space, gave off 2–3 articular branches (n=2) that
one specimen, the LPN gave off an articular branch to the GHJ terminated in the transverse humeral ligament (figure 6A).
capsule (figure 3B). ► The PC and LPN gave off an articular branch, in one spec-
To target the articular branches supplying the anterosuperior imen each, that coursed on the anterior surface of subscapu-
quadrant, the superior margin of subscapularis just medial to its laris to the GHJ capsule (figures 5C and 6B).
attachment to the lesser tubercle or the underlying margin of the
rim of anterior glenoid fossa could be used. Another landmark Acromioclavicular joint
to assist in locating the articular branches is the neurovascular The ACJ was innervated in all 15 specimens by 1–2 articular
bundle, containing the subcoracoid artery, veins, and articular branches of LPN and by the acromial branch of SSN. The artic-
branches of the superior nerve to subscapularis, just superior to ular branches of LPN coursed in a neurovascular bundle with the
subscapularis. acromial branch of the thoracoacromial artery and the accom-
panying veins, superior to the coracoid process, prior to termi-
Anteroinferior quadrant nating in the joint capsule (figures 6C,D and 7A,C). The acromial
The main trunk of AN provided 1–3 articular branches to the branch originated from the main trunk of SSN, prior to its bifur-
anteroinferior quadrant (n=15) prior to its bifurcation into the cation, and coursed along the posterior margin of the coracoid
anterior and posterior divisions (figure 5A,B). These branches process to the ACJ (figures 3A,C and 7A,B). The neurovascular
traveled with the anterior circumflex humeral artery and bundle consisting of the articular branches of LPN, acromial
coursed laterally between the tendons of subscapularis and latis- branches of the thoracoacromial artery and corresponding veins
simus dorsi. At the medial border of the humerus, the articular course anterior to the coracoclavicular ligament. This neurovas-
branches coursed superiorly, deep to the tendon of subscapu- cular bundle could be used to localize the articular branches. The
laris, to innervation the GHJ capsule. The articular branches superior border of scapula at lateral margin of the suprascapular
lie in close proximity to the junction of the inferior border of notch could be used to locate the acromial branch of SSN.
subscapularis and medial border of the surgical neck of humerus. The pattern of innervation of the GHJ was broken down by
At this location, the anterior circumflex humeral artery crosses territory: posterosuperior, posteroinferior, anterosuperior, and
this junction point and may be used to help localize the articular anteroinferior quadrants (figure 2). The course of each nerve in
branches of the main trunk of AN. all 15 specimens was consolidated to generate a frequency map
Additionally, the following innervations were found: (figure 7). The primary findings are summarized as follows:
4 Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
Figure 6 Course of articular branches of anterior division of AN and Figure 7 Frequency map of innervation of GHJ and ACJ. Numbered
LPN. (A and B). Innervation of ACJ and posteroinferior/anteroinferior arrows in A–C indicate course of: (1) medial trunk of SSN; (2) motor
quadrants of GHJ. (C and D). Innervation of ACJ by LPN. AC, acromion branches of SSN supplying infraspinatus; (3) anterior and posterior
process; ACJ, acromioclavicular joint; AD, anterior division of AN; AN, divisions of AN. AC, acromion process; ACJ, acromioclavicular joint; AN,
axillary nerve; br, branch; BT, tendon of long head of biceps brachii; CL, axillary nerve; BG, bicipital groove; br, branch; CL, clavicle; CP, coracoid
clavicle; CP, coracoid process; div, division; GHJ, glenohumeral joint; HH, process; div, division; GHJ, glenohumeral joint; HH, humeral head; ISF,
humeral head; INF, infraspinatus; LC, lateral cord; LPN, lateral pectoral infraspinous fossa; LPN, lateral pectoral nerve; SBF, subscapular fossa;
nerve; MCN, musculocutaneous nerve; PD, posterior division of AN; V, SGN, spinoglenoid notch; SN, suprascapular notch; SS, spine of scapula;
acromial branches of thoracoacromial artery and vein. Reprinted with SSF, supraspinous fossa; SSN, suprascapular nerve; *, coracoid process.
permission from Philip Peng Educational Series. Reprinted with permission from Philip Peng Educational Series.

► Posterosuperior quadrant: superiorly by articular branches of of the musculocutaeneous nerve reported by Wrete (1948) were
SSN in supraspinous fossa; posteriorly by articular branches not found.8
of SSN in the infraspinous fossa. The ACJ, consistent with the previous literature, was found to
► Posteroinferior quadrant: articular branches from posterior be innervated by articular branches of LPN and acromial branch
division of AN. of SSN. Of the four previous cadaveric studies that investigated
► Anterosuperior quadrant: articular branches from superior the innervation of ACJ, two reported articular branches from
nerve to subscapularis. both the LPN and SSN,7 9 and two other studies reported inner-
► Anteroinferior quadrant: articular branches from main trunk vation from only SSN.10 13
of AN. Clinically, localization of the nerve throughout its course and
Additionally, less frequent innervation (1–2 specimens) was identifying its relation to bony and soft tissue landmarks are
provided by the PC and LPN both supplying the anterosuperior important for image-guided intervention. The current study is
and anteroinferior quadrants. unique in that both bony and soft tissue landmarks, visible with
image guidance systems, have been defined relative to the nerves
DISCUSSION supplying the GHJ and ACJ. The frequency map, along with the
This novel cadaveric study has documented the articular branches dissected specimens, enable identification of bony and soft tissue
innervating the GHJ and ACJ simultaneously in relation to bony, landmarks relevant to all specimens included in this study. The
vascular, and soft-tissue landmarks visible with image guidance. key landmarks identified include the coracoid process, midpoint
The frequency map of articular branches provides an anatomical between the suprascapular and spinoglenoid notches, rim of
basis to propose novel interventions. the anterior glenoid fossa, and acromial branch of the thora-
The innervation of GHJ, in the current study, was found to coacromial artery. In previous studies, Nam et al15 reported the
originate from SSN, AN, LPN, and NS, concurring with the course of the articular branch from LPN in relation to the cora-
previous literature.7–16 Gardner7 was the first to report the inner- coid process and coracoclavicular ligament,15 and Eckmann et
vation of GHJ from all four articular branches (SSN, AN, LPN al16 related the articular branches of SSN, LPN and AN to the
and NS).7 More recently, Nasu et al14 found an articular branch spine of scapula, thoracoacromial artery and head of humerus,
terminating in the transverse humeral ligament that originated respectively.16
from the anterior division of AN,14 and Eckmann et al16 found Presently, the SSN is the main target for shoulder denerva-
additional articular branches from SSN that coursed along the tion with the suprascapular notch used as the landmark for
superior border of the spine of scapula to supply the posterosu- radiofrequency cannula placement.6 17–20 In the current study,
perior GHJ capsule.16 However, in the current study, branches the articular branches of SSN innervating the posterosuperior
Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152 5
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
GHJ capsule were found to originate from the lateral trunk of posteroinferior from posterior division of AN; anterosuperior
SSN. The motor branches of the medial and lateral trunks of from superior nerve of subscapularis; and anteroinferior from
SSN supply the anterior and posterior regions of supraspinatus, the main trunk of AN. The ACJ was innervated in all specimens
respectively.21 In a follow-up study, Kim et al22 suggested that by the LPN and acromial branch of SSN. Detailed knowledge
the anterior region is responsible for shoulder abduction while of the innervation of the GHJ and ACJ are important for plan-
the posterior region plays a greater role in joint stabilization.22 ning and optimizing perioperative analgesia and shoulder RFA
Therefore, lesioning the SSN at the suprascapular notch would procedures.
likely capture both medial and lateral trunks resulting in paralysis
of supraspinatus. If the medial trunk could be spared, shoulder Acknowledgements The authors wish to thank Ian Bell, Trevor Robinson, and
abduction may be preserved. This may be possible by targeting Harun Bola for their valuable technical assistance. We also wish to thank the
individuals who donate their bodies and tissue for the advancement of education
the midpoint between the suprascapular and spinoglenoid
and research.
notches, the location where articular branches originate from
the lateral trunk (n=13/15 specimens). The posterior region of Contributors JT, PWHP and AMRA are guarantors. JT is a PhD candidate who
is supervised by AMRA and PWHP. Therefore, as mandated by the School of
supraspinatus and infraspinatus would be denervated; however, Graduate Studies at the University of Toronto, the supervisors must be actively
other external rotators of the GHJ are preserved, that is, those involved in all aspects of the research including literature search, experimental
innervated by AN.20 Clinically, while sparing of the medial design, collecting and analyzing data, interpreting results, and manuscript
trunk is theoretically possible in this area, clinical correlation is preparation.
required to assess the motor effects of radiofrequency or other Funding The authors have not declared a specific grant for this research from any
methods of ablation in this area. Similarly, the articular branches funding agency in the public, commercial or not-for-profit sectors.
originating from LPN could be targeted with ultrasound using Competing interests PWHP received equipment support from Sonosite Fujifilm
the coracoid process and the accompanying acromial branch of Canada.
the thoracoacromial artery located anterior to the coracoclavic- Patient consent for publication Not required.
ular ligament. The articular branches from AN and NS would be Ethics approval University of Toronto Health Sciences Research Ethics Board
more challenging to capture as they lie adjacent to major motor (#27210).
nerves or neurovascular bundles. Further studies are needed to Provenance and peer review Not commissioned; externally peer reviewed.
investigate the feasibility of the RFA approaches. Additionally, Data sharing statement This is a cadaveric study and all data/findings have been
peripheral nerve stimulation, a more recent technique that has reported in the manuscript.
been used to treat chronic shoulder pain, requires accurate lead
placement with precise knowledge of anatomical landmarks.23
Based on the results of the current study, AN stimulation likely REFERENCES
targets the capsular nerves supplying the inferior half of the 1 United States Bone and Joint Initiative. The burden of musculoskeletal diseases in
GHJ, whereas SSN stimulation may target the posterosuperior the United States (BMUS). 3rd edn. Rosemont, IL: 1. United States Bone and Joint
Initiative, 2014.
quadrant. 2 HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project
In the context of perioperative pain management, there (HCUP). Rockville, MD: Agency for Healthcare Research and Quality, 2011.
has been much discussion and research regarding the optimal 3 Day JS, Lau E, Ong KL, et al. Prevalence and projections of total shoulder and elbow
block(s) for shoulder surgery.24–31 Interscalene block (ISB) is arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115–20.
4 Kim SH, Wise BL, Zhang Y, et al. Increasing incidence of shoulder arthroplasty in the
most commonly performed; however, ISB targets the brachial
United States. J Bone Joint Surg Am 2011;93:2249–54.
plexus resulting in both sensory and motor blockade of the 5 Bjørnholdt KT, Brandsborg B, Søballe K, et al. Persistent pain is common 1-2 years
upper limb.32 Similarly, alternative approaches such as the after shoulder replacement. Acta Orthop 2015;86:71–7.
suprascapular nerve block and the combined suprascapular and 6 Rohof OJ. Radiofrequency treatment of peripheral nerves. Pain Pract 2002;2:257–60.
axillary nerve block (SSAXB) targets mixed nerves which results 7 Gardner E. The innervation of the shoulder joint. Anat Rec 1948;102:1–18.
8 Wrete M. The innervation of the shoulder-joint in man. Cells Tissues Organs
in sensory and motor blockade.24 33 In the current study, the
1949;7:173–90.
localization of articular branches supplying the GHJ and ACJ 9 Aszmann OC, Dellon AL, Birely BT, et al. Innervation of the human shoulder joint and
capsules have been related to bony and soft tissue landmarks. its implications for surgery. Clin Orthop Relat Res 1996;330:202–7.
This anatomical data provides anesthesiologists with the knowl- 10 Akita K, Kawashima T, Shimokawa T, et al. Cutaneous nerve to the subacromial region
edge to develop novel blocks that mainly target the sensory affer- originating from the lateral pectoral nerve. Ann Anat 2002;184:15–19.
11 Gelber PE, Reina F, Monllau JC, et al. Innervation patterns of the inferior glenohumeral
ents to the GHJ and ACJ thereby minimizing motor blockade. ligament: anatomical and biomechanical relevance. Clin Anat 2006;19:304–11.
For example, pericapsular infiltration of local anesthetic deep 12 Vorster W, Lange CP, Briët RJ, et al. The sensory branch distribution of the
to subscapularis could cover the articular branches from the suprascapular nerve: an anatomic study. J Shoulder Elbow Surg 2008;17:500–2.
AN and NS supplying the anteroinferior/superior quadrants of 13 Ebraheim NA, Whitehead JL, Alla SR, et al. The suprascapular nerve and its articular
GHJ. This information may provide insight for the reason and branch to the acromioclavicular joint: an anatomic study. J Shoulder Elbow Surg
2011;20:e13–e17.
possible solution to the residual anterior shoulder pain following 14 Nasu H, Nimura A, Yamaguchi K, et al. Distribution of the axillary nerve to the
SSAXB.34 subacromial bursa and the area around the long head of the biceps tendon. Knee
A limitation of this study includes the small sample size Surg Sports Traumatol Arthrosc 2015;23:2651–7.
(n=15). Sample size calculation was not possible due to lack of 15 Nam Y-S, Panchal K, Kim I-B, et al. Anatomical study of the articular branch of the
previous data. In the absence of previous data, Julious35 justified lateral pectoral nerve to the shoulder joint. Knee Surg Sports Traumatol Arthrosc
2016;24:3820–7.
a sample size of 12 as being appropriate for a pilot study.35 Addi- 16 Eckmann MS, Bickelhaupt B, Fehl J, et al. Cadaveric study of the articular branches of
tionally, a small sample size may not be reflective of all anatom- the shoulder joint. Reg Anesth Pain Med 2017;42:564–70.
ical variations in innervation pattern. However, the frequency 17 Shah RV, Racz GB. Pulsed mode radiofrequency lesioning of the suprascapular nerve
map compiled in the current study suggests the innervation for the treatment of chronic shoulder pain. Pain Physician 2003;6:503–6.
18 Liliang PC, Lu K, Liang CL, et al. Pulsed radiofrequency lesioning of the suprascapular
pattern is consistent.
nerve for chronic shoulder pain: a preliminary report. Pain Med 2009;10:70–5.
In conclusion, the capsular distribution of articular branches, 19 Gofeld M, Restrepo-Garces CE, Theodore BR, et al. Pulsed radiofrequency of
supplying the GHJ can be defined by quadrants. The posterosu- suprascapular nerve for chronic shoulder pain: a randomized double-blind active
perior quadrant consistently received innervation from the SSN; placebo-controlled study. Pain Practice 2013;13:96–103.

6 Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152

 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-100152 on 11 January 2019. Downloaded from file:/ on 16 January 2019 by guest. Protected by copyright.
20 Simopoulos TT, Nagda J, Aner MM. Percutaneous radiofrequency lesioning of the 28 Hussain N, Goldar G, Ragina N, et al. Suprascapular and interscalene nerve block
suprascapular nerve for the management of chronic shoulder pain: a case series. J for shoulder surgery: A systematic review and meta-analysis. Anesthesiology
Pain Res 2012;5:91–7. 2017;127:998–1013.
21 Hermenegildo JA, Roberts SL, Kim SY. Innervation pattern of the suprascapular nerve 29 Wiegel M, Moriggl B, Schwarzkopf P, et al. Anterior suprascapular nerve block versus
within supraspinatus: a three-dimensional computer modeling study. Clin Anat interscalene brachial plexus block for shoulder surgery in the outpatient setting:
2014;27:622–30. a randomized controlled patient- and assessor-blinded trial. Reg Anesth Pain Med
22 Kim S, Bleakney R, Boynton E, et al. Investigation of the static and dynamic 2017;42:310–8.
musculotendinous architecture of supraspinatus. Clin Anat 2010;23:48–55. 30 Zhou C, Choi S, Brull R, et al. Anterior suprascapular nerve block versus interscalene
23 Gofeld M, Agur A. Peripheral nerve stimulation for chronic shoulder pain: a proof of brachial plexus block for shoulder surgery in the outpatient setting. Reg Anesth Pain
concept anatomy study. Neuromodulation 2018;21:284–9. Med 2018;43:99–100.
24 Price DJ. The shoulder block: a new alternative to interscalene brachial plexus 31 Neuts A, Stessel B, Wouters PF, et al. Selective suprascapular and axillary nerve block
blockade for the control of postoperative shoulder pain. Anaesth Intensive Care versus interscalene plexus block for pain control after arthroscopic shoulder surgery:
2007;35:575–81. a noninferiority randomized parallel-controlled clinical trial. Reg Anesth Pain Med
25 Dhir S, Sondekoppam RV, Sharma R, et al. A Comparison of Combined 2018;43:738–44.
Suprascapular and Axillary Nerve Blocks to Interscalene Nerve Block for Analgesia 32 Winnie AP. Interscalene brachial plexus block. Anesthesia Analgesia
in Arthroscopic Shoulder Surgery: An Equivalence Study. Reg Anesth Pain Med 1970;49:455???466–66.
2016;41:564–71. 33 Price DJ, Axillary PDJ. Axillary (circumflex) nerve block used in association with
26 Price D. Optimizing the Combined Suprascapular and Axillary Nerve (SSAX) Block. Reg suprascapular nerve block for the control of pain following total shoulder joint
Anesth Pain Med 2017;42:122. replacement. Reg Anesth Pain Med 2008;33:280–1.
27 Marty P, Rontes O, Delbos A. A comparison of combined suprascapular and axillary 34 Price D. How many nerves supply the shoulder? Reg Anesth Pain Med 2018;43:334.
nerve blocks to interscalene block: interpret With Caution. Reg Anesth Pain Med 35 Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharm Stat
2017;42:273–4. 2005;4:287–91.

Tran J, et al. Reg Anesth Pain Med 2019;0:1–7. doi:10.1136/rapm-2018-100152 7