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Holan CA, Egeland BM, Henry SL. Isolated Spinal Accessory Nerve Palsy from Volleyball Injury. Arch Plast Surg 2022; 49:440-443. [PMID: 35832161 PMCID: PMC9142255 DOI: 10.1055/s-0042-1748660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Spinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy.
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Affiliation(s)
- Cole A. Holan
- The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Brent M. Egeland
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Steven L. Henry
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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Martínez-Catalán N, Valencia M, Del Palacio M, Fernández-Jara J, Calvo E. Isolated spinal accessory nerve mononeuropathy causing winging scapula: an unusual peripheral nervous system manifestation of dengue fever. JSES Int 2020; 4:491-494. [PMID: 32939473 PMCID: PMC7479028 DOI: 10.1016/j.jseint.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Natalia Martínez-Catalán
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain
| | - Maria Valencia
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain
| | - Marta Del Palacio
- Department of Internal Medicine, Hospital Universitario Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain
| | - Javier Fernández-Jara
- Department of Musculoskeletal Radiology, Hospital Universitario Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain
| | - Emilio Calvo
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain
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Arabi H, Ahizoune A, Benchanna R, Abida N, Belasri S, Slioui B, Benjelloun A. Accessory spinal nerve damage during a cervical lymph node biopsy: case report. Pan Afr Med J 2020; 36:378. [PMID: 33235655 PMCID: PMC7666691 DOI: 10.11604/pamj.2020.36.378.25292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/16/2022] Open
Abstract
The lesion of the accessory spinal nerve is often of iatrogenic origin. We report the case of an injury after a right jugulocarotid lymph node biopsy. A 30-year-old patient was referred for the treatment of right cervical lymphadenopathy suspected of tuberculosis. After the intervention and confirmation of tuberculosis diagnosis, the patient presented a functional impotence of the right shoulder and swarming of the right hand. The clinical examination found an active limitation of the shoulder, and a wasting of the upper bundle of the right trapezius muscle and the sternocleidomastoid. The EMG showed axonotmesis of the accessory spinal nerve and the MRI an amyotrophy of the trapezius with denervation edema. A simple rehabilitation has been scheduled. Damage of the accessory spinal nerve most often occurs after local surgery. EMG is essential for diagnosis. Rehabilitation is the first therapeutic option. Surgery can be considered if it fails. The surgeons must consider the protection of the accessory spinal nerve in case of cervical lymph node surgery.
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Affiliation(s)
- Hafid Arabi
- Physical Medicine and Rehabilitation Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Aziz Ahizoune
- Neurology Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Rachid Benchanna
- Pulmonology Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Nabil Abida
- Neurology Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Salah Belasri
- Radiology Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Badr Slioui
- Radiology Unit, Avicenne Military Hospital, Marrakech, Morocco
| | - Amine Benjelloun
- Pulmonology Unit, Avicenne Military Hospital, Marrakech, Morocco
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Elsawi RS, Vancolen SY, Horner NS, Khan M, Alolabi B. Surgical treatment of trapezius palsy: A systematic review. Shoulder Elbow 2020; 12:153-162. [PMID: 32565916 PMCID: PMC7285977 DOI: 10.1177/1758573219872730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Trapezius palsy results from injury to the spinal accessory nerve. The condition presents with loss of shoulder abduction, pain, and winging of the scapula. Surgical treatment may improve functional outcomes and quality of life. PURPOSE The purpose of this study was to report and evaluate the clinical outcomes following surgical management of trapezius palsy. STUDY DESIGN Systematic review. METHODS The electronic databases EMBASE, MEDLINE, and PubMed were searched for studies and relevant data were abstracted. Only studies reporting on outcomes after the surgical treatments of trapezius palsy were included. RESULTS A total of 10 studies including 192 patients were included in this review. All surgical interventions resulted in improved function and pain reduction. Patients reported high satisfaction (90-92%) following nerve reconstruction or the Eden-Lange procedure, in comparison to neurolysis. The most common procedure reported was the Eden-Lange muscle transfer (32% reported cases) demonstrating the highest patient satisfaction rates with low complication rate of 7.7%. CONCLUSION Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy. All reported surgical procedures demonstrate reduction in pain the best results from the Eden-Lange muscle transfer. Further high-quality comparative studies are required to make definitive conclusions regarding the comparative efficacy of each surgical procedure.
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Affiliation(s)
| | | | | | - Moin Khan
- Moin Khan, Division of Orthopedic Surgery, Department of Surgery, McMaster University, Medical Centre, 1200 Main St West, 4E15 Hamilton, Ontario L8N 3Z5, Canada.
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Mayer JA, Hruby LA, Salminger S, Bodner G, Aszmann OC. Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk. J Neurosurg Spine 2019; 31:133-138. [PMID: 30952116 DOI: 10.3171/2018.12.spine18498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 12/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle. METHODS Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented. RESULTS All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients. CONCLUSIONS Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.
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Affiliation(s)
- Johannes A Mayer
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
| | - Laura A Hruby
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
| | - Stefan Salminger
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
| | | | - Oskar C Aszmann
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
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Complex Scapular Winging following Total Shoulder Arthroplasty in a Patient with Ehlers-Danlos Syndrome. Case Rep Orthop 2015; 2015:680252. [PMID: 26347841 PMCID: PMC4549537 DOI: 10.1155/2015/680252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 11/24/2022] Open
Abstract
This is a unique case of a female patient with features of classical and hypermobile types of Ehlers-Danlos syndrome (EDS) who developed complex scapular winging from spinal accessory and long thoracic neuropathies. These neurological problems became manifest after an uncomplicated total shoulder arthroplasty (TSA). The patient had a complex postoperative course with extensive work-up in addition to revision shoulder surgery and manipulations to treat shoulder stiffness. It was eventually suspected that the periscapular nerve impairments occurred during physical therapy sessions after her TSA. This interpretation was further supported by genetic evidence that, in addition to EDS, the patient had an unrecognized genetic propensity for nerve palsies from stretch or pressure (“hereditary neuropathy with liability to pressure palsies” (HNPP)). By two years after the TSA the neuropathies had only partially improved, leaving the patient with persistent scapular winging and shoulder weakness. With this case we alert surgeons and physical therapists that patients with EDS can have not only a complicated course after TSA, but rare concurrent conditions that can further increase the propensity of neurological injuries that result in compromised shoulder function.
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Kirdi N, Yakut E, Firat T, Turan D, Leblebicioglu G. Physiotherapy approaches for iatrogenic injury of the spinal accessory nerve: a case report. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856903321196492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sergides NN, Nikolopoulos DD, Polyzois IG. Idiopathic spinal accessory nerve palsy. A case report. Orthop Traumatol Surg Res 2010; 96:589-92. [PMID: 20580628 DOI: 10.1016/j.otsr.2010.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 12/25/2009] [Accepted: 03/16/2010] [Indexed: 02/02/2023]
Abstract
Spinal accessory nerve palsy may lead to dysfunction or paralysis of the trapezius muscle. Common causes are iatrogenic or secondary due to trauma, infection or tumour. Idiopathic palsy is considered extremely rare. We present the case of a 42-year-old Caucasian male suffering from a unilateral, isolated paralysis of his ipsilateral trapezius muscle. There was no related trauma, nor any past history of surgical procedures. An electromyographic study confirmed the idiopathic paralysis of the distal segment of the spinal accessory nerve.
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Affiliation(s)
- N N Sergides
- Orthopaedic Department, Central Clinic of Athens, Diagnostic and Treatment Center, Asklepiou 31 STR, ZC 10680, Athens, Greece
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Charopoulos IN, Hadjinicolaou N, Aktselis I, Lyritis GP, Papaioannou N, Kokoroghiannis C. Unusual insidious spinal accessory nerve palsy: a case report. J Med Case Rep 2010; 4:158. [PMID: 20507553 PMCID: PMC2890620 DOI: 10.1186/1752-1947-4-158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 05/27/2010] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Isolated spinal accessory nerve dysfunction has a major detrimental impact on the functional performance of the shoulder girdle, and is a well-documented complication of surgical procedures in the posterior triangle of the neck. To the best of our knowledge, the natural course and the most effective way of handling spontaneous spinal accessory nerve palsy has been described in only a few instances in the literature. CASE PRESENTATION We report the case of a 36-year-old Caucasian, Greek man with spontaneous unilateral trapezius palsy with an insidious course. To the best of our knowledge, few such cases have been documented in the literature. The unusual clinical presentation and functional performance mismatch with the imaging findings were also observed. Our patient showed a deterioration that was different from the usual course of this pathology, with an early onset of irreversible trapezius muscle dysfunction two months after the first clinical signs started to manifest. A surgical reconstruction was proposed as the most efficient treatment, but our patient declined this. Although he failed to recover fully after conservative treatment for eight months, he regained moderate function and is currently virtually pain-free. CONCLUSION Clinicians have to be aware that due to anatomical variation and the potential for compensation by the levator scapulae, the clinical consequences of any injury to the spinal accessory nerve may vary.
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Isolated spinal accessory mononeuropathy associated with neurogenic muscle hypertrophy: restricted neuralgic amyotrophy or stretch-palsy? A case report. Arch Phys Med Rehabil 2008; 89:559-63. [PMID: 18295637 DOI: 10.1016/j.apmr.2007.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 55-year-old man developed transient bi-brachial paresthesias followed by severe pain over his left shoulder ridge and periscapular region within 8 hours of rigorous hand-over-hand hoisting of a 33.8-kg (75-lb) object. He experienced weakness in shoulder abduction followed several weeks later by focal hypertrophy of the left trapezius. Electrophysiologic studies showed significant spontaneous motor activity in the form of denervation potentials, fasciculations, and complex repetitive discharges. The 2 major diagnostic considerations were restricted neuralgic amyotrophy versus stretch palsy of the spinal accessory nerve. The clinical similarities and differences between restricted forms of neuralgic amyotrophy and stretch palsies are discussed.
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11
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Durmaz B, Kirazli Y, Atamaz F. Isolated spinal accessory nerve palsy after coronary artery bypass: an unusual complication. Am J Phys Med Rehabil 2007; 86:865-7. [PMID: 17581478 DOI: 10.1097/phm.0b013e3181153dde] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Isolated spinal accessory nerve palsy after coronary artery bypass graft (CABG) surgery is a rare complication. We report a case of a 52-yr-old male patient who presented with right shoulder weakness, drooping of shoulder, and weakness of forward elevation after CABG. A program of neuromuscular electrical stimulation and exercises was started after the diagnosis of right isolated spinal accessory nerve palsy by physical examination and electromyographic study. Involved muscle function recovered after 6 mos of physical therapy and rehabilitation. This case report suggests that isolated spinal accessory nerve palsy should be considered in cases of shoulder pain or weakness after CABG, and conservative treatment is recommended if palsy develops.
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Affiliation(s)
- Berrin Durmaz
- Department of Physical Medicine and Rehabilitation, Medical Faculty of Ege University, Bornova-Izmir, Turkey
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12
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Ozdemir O, Kurne A, Temuçin C, Varli K. Spontaneous unilateral accessory nerve palsy: a case report and review of the literature. Clin Rheumatol 2006; 26:1581-3. [PMID: 17661123 DOI: 10.1007/s10067-006-0469-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Revised: 10/10/2006] [Accepted: 10/10/2006] [Indexed: 10/23/2022]
Abstract
Isolated spinal accessory nerve (SAN) palsy is a well-recognized complication of surgical prodecures in the posterior triangle of the neck. Various rare etiological factors were also described. Whatever the etiology, the typical clinical features of SAN palsy can be listed as atrophy/weakness of the trapezius muscle and moderate winging of the scapula. It is imperative to promptly diagnose this condition in the early stage to avoid long-term impairment and to have a better functional outcome. Herein, we present a patient with a diagnosis of spontaneous spinal accessory nerve palsy, which was rarely reported in the relevant literature.
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Affiliation(s)
- Oya Ozdemir
- Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey.
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Abstract
BACKGROUND Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.
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Affiliation(s)
- F Teboul
- Department of Orthopaedics, Hôpital Lariboisière, Paris, France.
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14
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Kim DH, Cho YJ, Tiel RL, Kline DG. Surgical outcomes of 111 spinal accessory nerve injuries. Neurosurgery 2004; 53:1106-12; discussion 1102-3. [PMID: 14580277 DOI: 10.1227/01.neu.0000089058.82201.3d] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2003] [Accepted: 06/25/2003] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Iatrogenic injury to the spinal accessory nerve is not uncommon during neck surgery involving the posterior cervical triangle, because its superficial course here makes it susceptible. We review injury mechanisms, operative techniques, and surgical outcomes of 111 surgical repairs of the spinal accessory nerve. METHODS This retrospective study examines clinical and surgical experience with spinal accessory nerve injuries at the Louisiana State University Health Sciences Center during a period of 23 years (1978-2000). Surgery was performed on the basis of anatomic and electrophysiological findings at the time of operation. Patients were followed up for an average of 25.6 months. RESULTS The most frequent injury mechanism was iatrogenic (103 patients, 93%), and 82 (80%) of these injuries involved lymph node biopsies. Eight injuries were caused by stretch (five patients) and laceration (three patients). The most common procedures were graft repairs in 58 patients. End-to-end repair was used in 26 patients and neurolysis in 19 patients if the nerve was found in continuity with intraoperative electrical evidence of regeneration. Five neurotizations, two burials into muscle, and one removal of ligature material were also performed. More than 95% of patients treated by neurolysis supported by positive nerve action potential recordings improved to Grade 4 or higher. Of 84 patients with lesions repaired by graft or suture, 65 patients (77%) recovered to Grade 3 or higher. The average graft length was 1.5 inches. CONCLUSION Surgical exploration and repair of spinal accessory nerve injuries is difficult. With perseverance, however, these patients with complete or severe deficits achieved favorable functional outcomes through operative exploration and repair.
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Affiliation(s)
- Daniel H Kim
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305-5327, USA.
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Rescigno JA, Felice KJ. Spinal accessory mononeuropathy following posterior fossa decompression surgery. Acta Neurol Scand 2002; 105:326-9. [PMID: 11939948 DOI: 10.1034/j.1600-0404.2002.1c218.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Isolated injury of the spinal accessory nerve is a well-recognized complication of surgeries involving the posterior triangle of the neck. The procedures most commonly implicated are lymph node biopsy and carotid endarterectomy. We present a patient with isolated injury to the spinal accessory nerve, localized proximal to the innervation of the sternocleidomastoid muscle, which was noted following suboccipital decompression for an Arnold-Chiari malformation. To our knowledge, this association has not been previously reported.
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Affiliation(s)
- J A Rescigno
- Department of Neurology, University of Connecticut School of Medicine, Farmington, CT 06030, USA
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16
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Lu L, Haman SP, Ebraheim NA. Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study. Orthopedics 2002; 25:71-4. [PMID: 11811246 DOI: 10.3928/0147-7447-20020101-20] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Injury to the accessory nerve results in an obvious shoulder droop, loss of shoulder elevation, and pain. Prevention of inadvertent injury to the accessory nerve is critical in neck dissection. No previous study, however, anatomically demonstrates the mechanism of the spinal accessory nerve traction injury. Anatomic determination of the location and course of the spinal accessory nerve may be helpful for a better understanding of the mechanism of the nerve injury. The accessory nerve courses obliquely across the posterior triangle on the surface of the levator scapula muscle and reaches the trapezius. The length of the spinal accessory nerve in the posterior triangle is 34.7+/- 6.3 mm. The nerve passes through the posterior border of the sternocleidomastoid muscle 50.7+/- 12.9 mm below the tip of the mastoid process and reaches the anterior border of the trapezius 49.8 +/- 5.9 mm above the clavicle. It makes a posterior angle of 73.1 degrees +/- 19.4 degrees, on average, relative to the posterior border of the sternocleidomastoid. When the shoulder is pulled down and the head is turned to the opposite direction, the spinal accessory nerve is stretched in the posterior triangle. In the posterior triangle, the nerve is vulnerable, since it is superficial and covered only by skin and subcutaneous fascia. Therefore, extreme caution should be taken with any surgical procedures in the posterior triangle. Traction injury of the spinal accessory nerve in the posterior triangle cannot be ignored.
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Affiliation(s)
- Like Lu
- Department of Orthopedic Surgery, Medical College of Ohio, Toledo, 43614-5807, USA
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17
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Affiliation(s)
- P Porter
- Dorset County Hospital, Dorchester, United Kingdom
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18
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Alonso JL, Reis RG. [Neuropathies of the spinal accessory nerve secondary to cervical surgery: clinical and electrophysiological study of 7 cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 2000; 58:704-12. [PMID: 10973113 DOI: 10.1590/s0004-282x2000000400017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
After innervating the sternocleidomastoid muscle, the spinal accessory nerve emerges and down crosses the posterior cervical triangle to innervate the trapezius. At the posterior triangle, the nerve is closely related to local lymph nodes and may be injured by their enlargement or surgical removal. Injury to this nerve is uncommom. Most cases are iatrogenically due to surgical procedures in the posterior cervical triangle, often following lymph nodes biopsies or benign turmors approaches. We present seven cases of post-surgical related spinal accessory nerve injury and discuss its clinical and electrophysiologycal profiles. The major motor signs were shoulder drop and paresis to raise arm. Pain and sensory complaints were almost universal and most probably due to concomitant injury of cervical plexus cutaneous branches, which are in direct relation to the spinal accessory nerve in the posterior cervical triangle. Lesion type is usually axonotmesis, but varied degrees of compression by cicatricial spurs are observed in some patients. Surgical approach and nerve repair must be considered for pacients with delayed recovery.
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Affiliation(s)
- J L Alonso
- Seção de Eletrodiagnóstico, Serviço de Neurologia, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira
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Abstract
Injury to the spinal accessory nerve can lead to dysfunction of the trapezius. The trapezius is a major scapular stabilizer and is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating, and retracting the scapula. The superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury. Iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Dysfunction of the trapezius can be a painful and disabling condition. The shoulder droops as the scapula is translated laterally and rotated downward. Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. If diagnosed within 1 year of the injury, microsurgical reconstruction of the nerve should be considered. Conservative treatment of chronic trapezius paralysis is appropriate for older patients who are sendentary. Active and healthy patients in whom 1 year of conservative treatment has failed are candidates for surgical reconstruction. Studies have shown the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.
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20
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Affiliation(s)
- P P Mariani
- Orthopaedic Clinic University La Sapienza, Rome, Italy
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Bodack MP, Tunkel RS, Marini SG, Nagler W. Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report. J Pain Symptom Manage 1998; 15:321-8. [PMID: 9654838 DOI: 10.1016/s0885-3924(98)00008-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal accessory nerve injury is most commonly reported following surgery in and around the posterior cervical triangle. Pain, impaired ability to raise the ipsilateral shoulder, and scapular winging on abduction of the arm are the most frequently noted clinical manifestations. We report the case of a collegiate swimmer who developed left-sided neck and shoulder pain secondary to a spinal accessory nerve palsy (SANP) after a "whiplash injury," which we believe to be the first such reported case in the English language literature. We review the clinical manifestations, diagnostic pitfalls, and therapeutic approaches to SANP. A high index of suspicion for SANP following whiplash-type injury will ensure its earlier detection and treatment and improve the chances of a better functional outcome.
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Affiliation(s)
- M P Bodack
- Department of Rehabilitation Medicine, New York Hospital-Cornell Medical Center 10021, USA
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22
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Bigliani LU, Compito CA, Duralde XA, Wolfe IN. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. J Bone Joint Surg Am 1996; 78:1534-40. [PMID: 8876581 DOI: 10.2106/00004623-199610000-00011] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Twenty-two patients who had paralysis of the trapezius muscle secondary to injury of the spinal accessory nerve had transfer of the levator scapulae and rhomboid major and minor muscles. In each patient, function of the trapezius had failed to improve with either physical therapy or an operative attempt at neurolysis or reconstruction of the spinal accessory nerve. The etiology of the injury was biopsy of a cervical node in thirteen patients, trauma in seven, and radical dissection in the neck in two. All patients had pain, visible deformity, and dysfunction of the shoulder girdle. Physical examination revealed asymmetry of the neckline, drooping of the shoulder girdle with lateral displacement of the scapula, and weakness of active elevation. Fourteen patients had had an incorrect clinical diagnosis, and twelve patients had had an inaccurate or incomplete electromyographic examination. A long thoracic nerve palsy developed in three patients. At an average of seven and a half years (range, two to fourteen years), the result of the operative procedure, as determined with the American Shoulder and Elbow Surgeons Shoulder Evaluation Form, was excellent for thirteen patients, satisfactory for six, and unsatisfactory for three. All but three patients had adequate relief of pain and demonstrable functional improvement.
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Affiliation(s)
- L U Bigliani
- Shoulder Service, New York Orthopaedic Hospital, Columbia-Presbyterian Medical Center, New York City 10032, USA
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23
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Pelliccioni G, Scarpino O, Guidi M. Magnetic stimulation of the spinal accessory nerve: normative data and clinical utility in an isolated stretch-induced palsy. J Neurol Sci 1995; 132:84-8. [PMID: 8523037 DOI: 10.1016/0022-510x(95)00126-m] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We report the clinical and electrophysiological findings of isolated stretch-induced accessory nerve palsy obtained by using conventional technique compared to magnetic stimulation at the base of the skull. The same methods of magnetic stimulation were applied in 10 healthy volunteers, to determine normal limits of amplitude and latency of the motor responses. The clinical features of the isolated spinal accessory nerve palsy are weakness of the sternocleidomastoid muscle and of the three portions of trapezius muscle. Most commonly reported etiologies include surgical manipulation and excision in the posterior triangle of the neck. Less frequently the cause is represented by radiation procedures, shoulder traction, penetrating, blunt or stretch injuries; this last etiology is extremely rare. The use of conventional electrophysiological methods to evaluate injuries of the nerves leaving the base of the skull is limited by the difficulty in obtaining an adequate electrical surface stimulation necessitating the use of needle electrodes. Moreover, conventional electrical stimulation often causes significant discomfort to the patient. The magnetic coli stimulation at the base of the skull is a new alternative painless technique that permits to elicit motor responses, by stimulating deeply situated nerves and, in particular, the accessory nerve, resulting as a useful electrodiagnostic tool.
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Affiliation(s)
- G Pelliccioni
- Neurology Unit, Geriatric Hospital, Italian National Research Centres on Aging (I.N.R.C.A.), Ancona, Italy
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24
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Knowledge-based expert systems. Clin Neurophysiol 1995. [DOI: 10.1016/b978-0-7506-1183-1.50021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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25
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Magoni M, Scipione V, Anzola GP. Isolated accessory nerve palsy of unusual cause. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1994; 15:241-3. [PMID: 7960678 DOI: 10.1007/bf02342454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We report the case of a 23 year old male patient who presented for an isolated left accessory nerve palsy which had appeared one year before. Neuroradiological investigations showed that the causative pathology was a giant saccular aneurysm of the intracranial left vertebral artery. Three months after diagnosis, signs of bulbar palsy rapidly developed. An emergency intra-arterial embolization was then attempted, which led to complete recovery except for the accessory nerve palsy which remained unchanged. We conclude that, in cases of apparently isolated accessory nerve palsy, neuroradiological investigations should include the posterior fossa.
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Affiliation(s)
- M Magoni
- Clinica Neurologica, Università di Brescia
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26
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Blackwell KE, Landman MD, Calcaterra TC. Spinal accessory nerve palsy: an unusual complication of rhytidectomy. Head Neck 1994; 16:181-5. [PMID: 8021139 DOI: 10.1002/hed.2880160213] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Rhytidectomy is a safe and effective procedure for rejuvenation of the aging face. Reported complication rates vary between 2.5% and 28%, and with proper management, longterm sequelae are unusual. Injury to the spinal accessory nerve is a rare but potentially debilitating complication of rhytidectomy. Afflicted patients present with dull, constant pain in the shoulder region which can be serve in nature. In addition, there is weakness of shoulder abduction and cosmetic deformity related to trapezius atrophy. Measures for conservative management include analgesics and physical therapy to strengthen the shoulder girdle. Nerve exploration is indicated for cases with documented denervation that do not respond to conservative treatment. A review of the English literature identified two previous case reports of spinal accessory nerve injury sustained during rhytidectomy. In this report, we present two additional cases and review current concepts regarding diagnosis, management, and prevention of this unusual complication of rhytidectomy.
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Affiliation(s)
- K E Blackwell
- Department of Surgery, UCLA School of Medicine 90024-1624
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27
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Abstract
Eighty-three consecutive patients with extracranial accessory nerve injury seen over a 12-year period are reviewed. The most common etiology was iatrogenic injury to the nerve at the time of previous surgery. Such operations were usually minor in nature and often related to lymph node or benign tumor removal. Examination usually distinguished winging due to trapezius weakness from that of serratus anterior palsy. Trapezius weakness was seen in all cases. Sternocleidomastoid weakness was unusual. Patients with accessory palsy were evaluated by both clinical and electromyographic studies. Patients who exhibited no clinical or electrical evidence of regeneration were operated on (44 cases). Based on intraoperative nerve action potential studies, 8 lesions in continuity had neurolysis alone. Resection with repair either by end-to-end suture or by grafts was necessary in 31 cases. One case had suture removed from nerve, two had nerve placed into target muscle, and two had more proximal neurotization. Function was usually improved in both operative and nonoperative patients. Related anatomy is discussed.
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Affiliation(s)
- T R Donner
- Department of Neurosurgery, Louisiana State University Medical Center School of Medicine, New Orleans
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28
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29
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Monaco ML, Pasqua PGD, Tonali P. Conduction studies along the accessory, long thoracic, dorsal scapular, and thoracodorsal nerves. Acta Neurol Scand 1992. [DOI: 10.1111/j.1600-0404.1992.tb05046.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Abstract
In a series of 23 patients, the commonest cause of accessory nerve palsy was surgical trauma at the time of lymph node biopsy. The less common causes were penetrating or blunt trauma and a few were of spontaneous onset. There was involvement of adjacent motor sensory nerves in about half of the patients. The prognosis was better following blunt trauma, stretch injuries and after a spontaneous onset. The anatomical relationships of the accessory nerve and aspects of the clinical picture and management are discussed.
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Affiliation(s)
- H Berry
- Division of Neurology, St. Michael's Hospital, University of Toronto, Ontario, Canada
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31
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32
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Pierre PA, Laterre CE, Van den Bergh PY. Neuralgic amyotrophy with involvement of cranial nerves IX, X, XI and XII. Muscle Nerve 1990; 13:704-7. [PMID: 2385255 DOI: 10.1002/mus.880130807] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We report a patient who presented with involvement of multiple cranial nerves associated with otherwise typical neuralgic amyotrophy. This syndrome of unknown etiology is not limited to the brachial plexus. Simultaneous involvement of cranial nerves IX, X, XI, and XII is a unique presentation. The electrophysiological data indicate the presence of a multifocal neuropathy.
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Affiliation(s)
- P A Pierre
- Department of Neurology, University of Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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33
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34
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Abstract
Although sharp and blunt injury to the spinal accessory nerve has been well-documented, stretch or traction-type injury has not been reported previously. Such a case, treated successfully with nerve grafting, is described.
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Affiliation(s)
- A L Dellon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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35
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36
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Abstract
A nerve conduction method is demonstrated for cranial nerve XII, the hypoglossal nerve. Submandibular surface stimulation is performed while recording over the anterior surface of the tongue. There were 30 normal adult subjects and 60 hypoglossal nerves studied. Evoked response parameters are reported as follows: mean latency 2.2 +/- 0.4 msec, mean amplitude 3.8 +/- 1.6 mV (baseline to peak, best of 5 responses). This nerve conduction method is reliable and should expand the electrophysiological assessment of XII cranial nerve motor function.
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Affiliation(s)
- M D Redmond
- Physical Medicine and Rehabilitation Service, Walter Reed Army Medical Center, Washington, DC 20307-5001
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37
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Fialka V, Vinzenz K. Investigations into shoulder function after radical neck dissection. J Craniomaxillofac Surg 1988; 16:143-7. [PMID: 3164320 DOI: 10.1016/s1010-5182(88)80036-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In order to determine shoulder function after radical neck dissection, and to evaluate the outcome of postoperative physical treatment, 43 patients were investigated 10 days up to 1 month after this procedure. Shoulder function was judged by means of (a) clinical investigation of the shoulder girdle and by (b) electromyographic testing of the trapezius muscle. Our results demonstrated a correlation between the extent of atrophy and clinical parameters such as abduction and lateral displacement of the scapula. Electromyography revealed damage present mainly in the descending part of the trapezius, while in the majority of patients the ascending part was only slightly damaged or normal. Electromyography proved a valuable tool for the determination of the clinical state after neck dissection. There was also evidence supporting the efficacy of physical therapy in case of irreversible shoulder disability.
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Affiliation(s)
- V Fialka
- Institute of Physical Medicine, University of Vienna, Austria
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38
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Logigian EL, McInnes JM, Berger AR, Busis NA, Lehrich JR, Shahani BT. Stretch-induced spinal accessory nerve palsy. Muscle Nerve 1988; 11:146-50. [PMID: 3343990 DOI: 10.1002/mus.880110210] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Left spinal accessory nerve palsy occurred in a young man when he quickly turned his head to the right while his shoulders were pulled down by heavy hand-held objects. Electrophysiologic studies demonstrated partial axonotmesis of the spinal accessory nerve branches innervating the sternocleidomastoid and upper and middle trapezius and complete axonotmesis of spinal accessory branches to the lower trapezius. There was a separate, although functionally minor, cervical plexus innervation of the lower trapezius.
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Affiliation(s)
- E L Logigian
- Clinical Neurophysiology Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston
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39
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40
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41
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Abstract
Two patients who had an accessory nerve palsy following carotid endarterectomy are presented. Both patients had high carotid bifurcations necessitating unusually high retraction and dissection. The ipsilateral accessory nerve was injured in the anterior cervical triangle in both cases. It is believed that vigorous lateral retraction of the superior aspect of the sternocleidomastoid muscle led to a stretch injury of the nerve. The symptoms completely resolved in both patients within 6 months.
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42
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Petrera JE, Trojaborg W. Conduction studies along the accessory nerve and follow-up of patients with trapezius palsy. J Neurol Neurosurg Psychiatry 1984; 47:630-6. [PMID: 6736997 PMCID: PMC1027862 DOI: 10.1136/jnnp.47.6.630] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The accessory nerve was stimulated at the posterior triangle of the neck and responses were evoked simultaneously from the upper, middle and lower part of the trapezius muscle. Sixteen patients were investigated, 10 with trapezius palsy following surgical procedures at the posterior cervical triangle, three with a history suggestive of neuralgic amyotrophy and three of unknown origin. On the unaffected side the latency increases 0.16 ms per 10 mm increase in conduction distance corresponding to a conduction velocity of 63 m/s. Evidence is presented that the upper, middle and lower part of the trapezius muscle receive innervation from the accessory nerve. Follow-up of patients showed spontaneous nerve regeneration after complete axonal degeneration. These findings suggest that surgical intervention should be delayed to allow for spontaneous reinnervation. Clinical recovery was incomplete in cases of iatrogenic origin.
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43
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Lo Monaco M, Di Pasqua PG, Tonali P. Conduction studies along the accessory, long thoracic, dorsal scapular, and thoracodorsal nerves. Acta Neurol Scand 1983; 68:171-6. [PMID: 6650128 DOI: 10.1111/j.1600-0404.1983.tb05344.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Latencies to the trapezius (upper and lower portion), serratus anterior, latissimus dorsi and rhomboid muscles were evaluated in 66 subjects. There was a significant relation between latencies and conduction distances to the rhomboid, to the trapezius and to the serraturs anterior muscles but not to the latissimus dorsi muscle, probably due to differences in the organization of the endplate regions in the muscles in question.
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44
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Doriguzzi C, Palmucci L, Troni W. Isolated accessory nerve palsy. Case report. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1982; 3:135-8. [PMID: 7118525 DOI: 10.1007/bf02043946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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45
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Abstract
A young man was bitten by his girl friend at the anterior border of the left trapezius muscle. Weakness of the trapezius resulted and a longstanding ache in the shoulder developed. Clinically and neurophysiologically, an axonotmesis type crush injury of the accessory nerve was verified.
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