Unusual insidious spinal accessory nerve palsy: a case report

Regional anesthesia for scapulothoracic fixation surgery: Anatomic review and case series

Scapulothoracic fixation surgery is a surgical intervention used for symptom relief in patients who suffer from scapular dysfunction. To date, there are few reports on the use of regional anesthesia for pain control in patients undergoing this procedure. The nerve supply of the scapula and surrounding tissues is complex and arises from both cervical and thoracic nerve roots. We suggest the use of a combined technique for perioperative pain control in patients undergoing scapulothoracic surgery. After a review of the relevant anatomy, we present four cases using combined regional techniques for postoperative pain control. The techniques utilized include thoracic paravertebral blocks with shoulder blockade, resulting in satisfactory pain control.

Isolated Spinal Accessory Nerve Palsy from Volleyball Injury

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.

Complex Scapular Winging following Total Shoulder Arthroplasty in a Patient with Ehlers-Danlos Syndrome

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.

Expanding what is known of the anatomy of the spinal accessory nerve

The spinal accessory nerve (SAN) is classically considered a motor nerve innervating the sternocleidomastoid and trapezius muscles. Its anatomical relevance derives from the high prevalence of lesions following head and neck surgeries. As expected, trapezius weakness and atrophy are the most common findings; however, it is also commonly accompanied by pain and other sensory deficits that have no clear explanation, suggesting other functions. We have recently seen two patients presenting with an unrecognized sign, that is, subclavicular/pectoral asymmetry secondary to the SAN lesion. Retrospectively, we reviewed other patients with similar findings in our case series and in the literature. We discuss the anatomical connections of the SAN with the superficial cervical plexus and propose an explanation for this finding. Of the 41 patients in our series, we identified this sign in all who had preoperative photographs. New insights on the anatomy and connections of the SAN may account for the diversity of symptoms and signs presented following an operative intervention as well as the variability of its severity.