Spinal accessory nerve palsy: associated signs and symptoms

Chronic shoulder pain due to spinal accessory nerve palsies present opportunities for improved care integration

Aim: Chronic shoulder pain due to iatrogenic spinal accessory nerve (SAN) injury continues to be under-recognized, resulting in delayed time-to-diagnosis and poorer outcomes. Solutions are needed to improve the management of this condition, which can be challenging as care needs to be coordinated across pain management, neurophysiology, rehabilitation and reconstructive surgery.Cases: We present a series of six patients with shoulder pain refractory to conservative pain treatments to highlight how SAN injuries continued to be missed and treatment delayed, even at advanced care centers. The time to diagnosis of SAN palsy took an average of 21 months and treatment was inconsistent for all patients.Discussion: None of the six cases had initial suspicion of SAN palsy and only one patient received targeted SAN injury care. SAN treatment should be started as early as possible so that patients can be referred for prompt surgical evaluation if they fail conservative management. Integrated care pathways may be a solution for formalizing multidisciplinary team involvement and improving SAN injury outcomes.Conclusion: Systemic processes, such as integrated care pathways, are needed to optimize early recognition and targeted treatment of SAN injury and may be beneficial for other underdiagnosed and undertreated neuropathic pain conditions.

Weightlifting Induced Spinal Accessory Nerve Palsy and Winged Scapula: A Case Report

Winged scapula is a rare musculoskeletal condition with numerous etiologies including spinal accessory nerve (SAN) palsy. Sport activities are rarely implicated with few scattered case reports. We report a case of an 18-year-old bodybuilder who suffered SAN palsy secondary to weightlifting exercises. Physical examination revealed winged scapula with painful mobility of the shoulder. A scapular magnetic resonance imaging scan and electromyography of the trapezius muscle were performed and confirmed the diagnosis of SAN palsy. Through this case, we review the literature of common and rare causes of SAN palsy and outline accepted treatment options.

Paraspinal Muscle Morphology in Proximal Cervical Spondylotic Amyotrophy

STUDY DESIGN AND OBJECTIVE

This is a retrospective analysis of prospectively collected single-center observational data. The aim is to evaluate atrophy and fatty degeneration rates of cervical spinal muscles in proximal cervical spondylotic amyotrophy (PCSA).

OVERVIEW OF LITERATURE

Proximal cervical spondylotic amyotrophy affects muscles in the upper extremities. In cases that lack improvement with conservative treatment, surgery is recommended. However, preoperative factors associated with poor outcomes remain unclear. We hypothesized that assessing fatty degeneration of the cervical spinal muscles and examining its relationship with functional impairment would help predict postoperative improvement in neurological function.

METHODS

This study included 18 patients who underwent PCSA surgery. We performed selective laminoplasty and foraminotomy. Preoperative paraspinal muscle cross-sectional area and fatty degeneration were quantified and correlated with neurological function.

RESULTS

Neurological improvement based on manual muscle testing was observed in 12/18 patients, comparing preoperative, perioperative, and over 12-month postoperative statuses. On the affected side, at the C4/5 level, fatty degeneration was more significant in the trapezius, whereas at the C5/6 level, fatty degeneration was more significant in the splenius capitis and trapezius. The fatty degeneration of the C4/5 and C5/6 trapezius was significantly correlated with preoperative muscle strength and postoperative muscle strength improvement.

CONCLUSIONS

The degree of fat infiltration of the muscle correlated with pre- and postoperative muscle strength at the lesion level. Thus, our results suggest a relationship between cervical muscle morphology and the clinical manifestations of PCSA. The marked increase in trapezius fatty infiltration at the C4/5 and C5/6 levels may be a valuable indicator to predict poor improvements in postoperative muscle strength.

A case report of ansa cervicalis to spinal accessory transposition graft: a new surgical technique to prevent shoulder dysfunction

Introduction and importance

The spinal accessory nerve is at risk when performing neck dissections for head and neck cancers. Injury to this nerve can result in shoulder syndrome, which can be challenging to manage. Various nerve repair or grafting methods are available to prevent this condition. A safe, simple, and cost-effective option is the ansa cervicalis to spinal accessory transposition graft.

Case presentation

A 60-year-old Afro-Trinidadian female presented to the Outpatient clinic for evaluation of a scalp lesion and a large neck mass for a duration of one year. Preoperative tissue biopsies confirmed she had squamous cell cancer with metastatic spread to the cervical nodes. The patient underwent surgical excision of the scalp lesion and left neck dissection with the sacrifice of the sternocleidomastoid and the left spinal accessory nerve due to tumour involvement. During the procedure, the ansa cervicalis was successfully joined to the distal remainder of the spinal accessory nerve. After the surgery, the patient fully recovered and achieved a good quality of life during the 24-month follow-up.

Clinical discussion

This is the first reported case of using the ansa cervicalis to reinnervate the trapezius muscle through the spinal accessory nerve. This procedure aims to prevent pain, muscle wasting, and adhesive capsulitis. A quality-of-life questionnaire and adequate range of motion proved the success of this procedure, demonstrating that this option provides practical, functional, and aesthetic benefits for patients.

Conclusion

The ansa cervicalis to spinal accessory transposition nerve graft is a valuable option for reinnervation. This case report highlights the effectiveness of this single-stage procedure in preventing shoulder syndrome.

Spinal accessory nerve anatomy in the posterior cervical triangle: A systematic review with meta-analysis

This study aimed to investigate the anatomy of the spinal accessory nerve (SAN) in the posterior cervical triangle, especially in relation to adjacent anatomical landmarks, along with a systematic review of the current literature with a meta-analysis of the data. Overall, 22 cadaveric and three prospective intraoperative studies, with a total of 1346 heminecks, were included in the analysis. The major landmarks relevant to the entry of the SAN at the posterior border of the SCM muscle (PBSCM) were found to be the mastoid apex, the great auricular point (GAP), the nerve point (NP), and the point where the PBSCM meets the upper border of the clavicle. The SAN was reported to enter the posterior cervical triangle above GAP in 100% of cases and above NP in most cases (97.5%). The mean length of the SAN along its course from the entry point to its exit point from the posterior triangle of the neck was 4.07 ± 1.13 cm. The SAN mainly gave off 1 or 2 branches (32.5% and 31%, respectively) and received either no branches or one branch in most cases (58% and 23%, respectively) from the cervical plexus during its course in the posterior cervical triangle. The major landmarks relevant to the entry of the SAN at the anterior border of the TPZ muscle (ABTPZ) were found to be the point where the ABTPZ meets the upper border of the clavicle and the midpoint of the clavicle, along with the mastoid apex, the acromion, and the transverse distance of the SAN exit point to the PBSCM. The results of the present meta-analysis will be helpful to surgeons operating in the posterior cervical triangle, aiding the avoidance of the iatrogenic injury of the SAN.

Does Age Affect the Rate of Spinal Nerve Injury after Selective Neck Dissection? Age as a Prognostic Factor of Spinal Nerve Injury after Selective Neck Dissection

OBJECTIVE

The objective of this study is to investigate whether age is a significant risk factor for spinal nerve injury following selective neck dissection (SND) in patients with head and neck cancer.

METHODS

A retrospective cohort study was conducted on patients who had undergone SND for head and neck cancer at a tertiary hospital between 2020 and 2022. The primary outcome was the incidence of spinal nerve injury after SND. The secondary outcomes included the types and severity of spinal nerve injury and the impact of age on these outcomes.

RESULTS

A total of 78 patients were included in the study and subdivided into two groups. Two shoulder-specific questionnaires (the Shoulder Pain and Disability Index (SPADI) and the Shoulder Disability Questionnaire (SDQ)) were administered to assess shoulder morbidity postoperatively. Twelve patients showed shoulder impairment following surgery. We divided the sample into two age-based groups; the older group showed a higher rate of SAN injury and the younger group showed a lower rate of improvement over time.

CONCLUSION

This study suggests that age is a significant risk factor for spinal nerve injury following SND in patients with head and neck cancer. Older patients are more likely to experience spinal nerve injury after SND than younger patients. The findings of this study may help in the development of strategies to prevent spinal nerve injury in older patients undergoing SND for head and neck cancer.

Feasibility and safety of Heavy Lifting Strength Training in Head and Neck Cancer survivors post-surgical neck dissection (the LIFTING trial)

BACKGROUND

Light-to-moderate intensity strength training (LMST) improves muscular strength, physical functioning, and some side effects in head and neck cancer survivors (HNCS). Heavy lifting strength training (HLST) may further improve these outcomes; however, it has not been studied in HNCS. The primary aim of the LIFTING trial was to examine the feasibility and safety of a HLST program in HNCS ≥1-year post-surgical neck dissection.

METHODS

In this single-arm feasibility study, HNCS were asked to complete a twice weekly, 12-week, supervised HLST program, gradually progressing to lifting heavy loads of 80-90% of 1 repetition maximum (1RM) for barbell squat, bench press, and deadlift. The feasibility outcomes included recruitment rate, 1RM completion rate, program adherence, barriers, and motivation. The preliminary efficacy outcomes included changes in upper and lower body strength.

RESULTS

Nine HNCS were recruited over an 8-month period during the COVID-19 pandemic. All 9 (100%) completed the 1RM tests and successfully progressed to heavy loads at approximately 5 weeks. The median attendance was 95.8% (range 71-100%), and few barriers were reported. Weight lifted increased for squat/leg press (median change: +34kg; 95% CI +25 to +47), bench press (median change: +6kg; 95% CI +2 to +10), and deadlift (median change: +12kg; 95% CI +7 to +24). No adverse events were reported and participants were motivated to continue HLST after the study.

CONCLUSIONS

HLST appears feasible and safe for HNCS and may result in meaningful improvements in muscular strength. Future research should consider additional recruitment strategies and compare HLST to LMST in this understudied survivor population.

TRIAL REGISTRATION

NCT04554667.

Neck and Shoulder Morbidity in Patients with Oral Cancer and Clinically Negative Node Neck Status: A Comparison between the Elective Neck Dissection and Sentinel Lymph Node Biopsy Strategies

The choice for the most optimal strategy for patients with a cT_1-2N₀ carcinoma of the oral cavity, sentinel lymph node biopsy (SLNB) or elective neck dissection (END), is still open for debate in many head and neck cancer (HNC) treatment centers. One of the possible benefits of the less invasive SLNB could be reduced neck and shoulder morbidity. Recent studies have shown a benefit in favor of SLNB the first year after intervention, but the long-term consequences and differences in neck morbidity remain unclear. This cross-sectional study aimed to research differences in neck and shoulder morbidity and Health-Related Quality of Life (HR-QoL) in patients with a cT_1-2N₀ carcinoma of the oral cavity, treated with either END or SLNB. Neck and shoulder morbidity and HR-QOL were measured with patient-reported questionnaires (SDQ, SPADI, NDI, NDII, EORTC-QLQ-C30, EORTC-QLQ-HN35) and active range of motion (AROM) measurements. In total 18 patients with END and 20 patients with SLNB were included. We found no differences between END and SLNB for long-term neck morbidity, shoulder morbidity, and HR-QOL. The significant differences found in the rotation of the neck are small and not clinically relevant.

Decreased muscle strength and scapular muscle endurance associated with shoulder function after neck dissection

BACKGROUND

Shoulder disability is a common problem following neck dissection. Even if nerve structures are preserved, this may occur after the surgery.

OBJECTIVE

The primary aim was to research changes in rotator cuff and scapular muscles strength, and scapular muscle endurance after neck dissection in patients with head and neck cancer. The secondary aim was to investigate the relationship between these changes and postoperative shoulder function.

METHODS

This cross-sectional and prospective follow-up study included 14 patients who underwent neck dissection (9 unilateral and 5 bilateral). Evaluations were performed preoperatively and at 3 months postoperatively. Muscle strength measurements, including trapezius, serratus anterior, and rotator cuff muscles, were obtained using a handheld dynamometer. The scapular muscle endurance test was used for muscle endurance assessment. Postoperative shoulder function was evaluated using Constant-Murley shoulder score.

RESULTS

A decrease in muscle strength and the scapular muscle endurance test was found at 3 months postoperatively, except for the subscapularis muscle strength (p< 0.05). There were moderate to strong correlations between Constant-Murley shoulder score and percentage changes in muscle strength and the scapular muscle endurance test, except for the upper trapezius muscle strength (p< 0.05).

CONCLUSIONS

Muscle strength and scapular muscle endurance may reduce following neck dissection. These reductions are associated with postoperative shoulder function. Thus, muscle strength and endurance training may be beneficial for early postoperative rehabilitation in patients with head and neck cancer.

A randomized controlled trial of scapular exercises with electromyography biofeedback in oral cancer patients with accessory nerve dysfunction

PURPOSE

This study aims to investigate the effects of electromyography (EMG) biofeedback on scapular positions and muscle activities during scapular-focused exercises in oral cancer patients with accessory nerve dysfunction.

METHODS

Twenty-four participants were randomly allocated to the motor-control with biofeedback group (N = 12) or the motor-control group (N = 12) immediately after neck dissection. Each group performed scapular-focused exercises with conscious control of scapular orientation for 3 months. EMG biofeedback of upper trapezius (UT), middle trapezius (MT), and lower trapezius (LT) was provided in the motor-control with biofeedback group. Scapular symmetry measured by modified lateral scapular slide test; shoulder pain; active range of motion (AROM) of shoulder abduction; upper extremity function; maximal isometric muscle strength of UT, MT, and LT; and muscle activities during arm elevation/lowering in the scapular plane were evaluated at baseline and the end of the intervention.

RESULTS

After the 3-month intervention, only the motor-control with biofeedback group showed improving scapular symmetry. Although both groups did not show significant improvement in shoulder pain, increased AROM of shoulder abduction and muscle strength of the UT and MT were observed in both groups. In addition, only the motor-control with biofeedback group had improved LT muscle strength, upper extremity function, and reduced UT and MT muscle activations during arm elevation/lowering.

CONCLUSIONS

Early interventions for scapular control training significantly improved shoulder mobility and trapezius muscle strength. Furthermore, by adding EMG biofeedback to motor-control training, oral cancer patients demonstrated greater effectiveness in stabilizing scapular position, muscle efficiency, and upper extremity function than motor-control training alone.

TRIAL REGISTRATION

Institutional Review Board: This study was approved by the Chang Gung Medical Foundation Institutional Review Board (Approval No: 201901788A3. Approval Date: 2 January, 2020).

CLINICAL TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (ClinicalTrials.gov ID: NCT04476004. Initial released Date: 16 July, 2020).

Transfer of the anterior C3 levator scapulae motor nerve branch for spinal accessory nerve injury: illustrative case

BACKGROUND

Injury to the spinal accessory nerve (Acc) results in loss of motor function of the trapezius muscle and leads to severe shoulder problems. A vast number of surgical strategies have been proposed to reinnervate (suture, grafting, and nerve transfers) or compensate (tendon and muscle transfers) the lost function of the trapezius muscle.

OBSERVATIONS

The authors report a successful case of Acc reconstruction 5 months after the injury with the anterior C3 levator scapulae motor nerve branch transfer in omotrapezoid triangle of the neck.

LESSONS

The advantages of the proposed technique over preexisting nerve transfers were discussed. We believe that this technique can be considered as an alternative to already existing techniques for proximal injuries to Acc.

Incobotulinum toxin A with a one-year long-lasting effect for trapezius contouring and superior efficacy for the treatment of trapezius myalgia

Context:

Based on various Botulinum toxin A products, reports of the lower efficacy of Incobotulinum toxin A compared with Onabotulinum toxin A for muscle contouring were observed. In addition, complications of trapezius myalgia and shoulder contouring treatment from malpractice have been reported.

Aims:

The study aimed at comparing the efficacy between Incobotulinum toxin A and Onabotulinum toxin A; research was conducted on a safe treatment technique for trapezius hypertrophy and trapezius myalgia.

Materials and Methods:

A split-shoulder, double-blind, randomized controlled trial was performed. Twenty volunteers with trapezius hypertrophy and trapezius myalgia were randomly injected with 30 units of Incobotulinum toxin A and Onabotulinum toxin A in each trapezius muscle guided by ultrasound.

Results:

The trapezius thickness among those receiving treatment with Onabotulinum toxin A and Incobotulinum toxin A on day 60 was 7.35 ± 1.11 and 7.33 ± 1.21 mm, respectively, which did not portray a significant difference (P = 0.991). Compared with the muscle size from day 60 to one year, the size of the trapezius muscle that had been treated by Onabotulinum toxin type A regained a significantly larger size compared with that treated by Incobotulinum toxin A (P = 0.027). On comparing the size of the trapezius muscle treated by Incobotulinum toxin A between one year and day 0, it was observed that the trapezius thickness at one year had significantly decreased (P < 0.001). On comparing the pain score from day 60 to day 0, it was observed that the pain scores of trapezius myalgia treated by Onabotulinum toxin A and Incobotulinum toxin A significantly differed (P = 0.003).

Conclusions:

Incobotulinum toxin A had the same efficacy but a longer lasting effect for the trapezius size contouring and a higher efficacy for trapezius myalgia treatment compared with Onabotulinum toxin A.

Effects of Conscious Control of Scapular Orientation in Oral Cancer Survivors With Scapular Dyskinesis: A Randomized Controlled Trial

OBJECTIVES

Spinal accessory nerve dysfunction is one of the complications of neck dissection in patients with oral cancer. This study aimed to explore the effects of long-term scapular-focused exercises and conscious control of scapular orientation on scapular movement and quality of life (QoL).

METHODS

This study was a randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Thirty-six patients with oral cancer were randomly allocated to the motor-control group (scapular-focused exercise + conscious control of scapular orientation) or the regular-exercise group (scapular-focused exercises only). Both groups received conventional physical therapy after neck dissection for 3 months. Shoulder pain intensity, active range of motion (AROM) of shoulder abduction, scapular muscle strength and activity under maximal voluntary isometric contraction (MVIC), scapular muscle activity when performing scapular movements, and QoL were measured at baseline, 1 month after the start of the intervention, and the end of the intervention.

RESULTS

Both groups showed significant improvement in all outcomes except shoulder pain intensity. After the 3-month intervention, the motor-control group had more significant improvement in AROM of shoulder abduction with a 19° difference (95% CI: 10-29, P < .001), muscle strength of upper trapezius with an 11 N difference (95% CI: 2-20; P = .021), and QoL than the regular-exercise group. When performing shoulder horizontal adduction and flexion, the relative value (%MVIC) of serratus anterior was smaller in the motor-control group with a 106%MVIC difference (95% CI: 7-205, P = .037).

CONCLUSIONS

Scapular-focused exercises have promising effects on spinal accessory nerve dysfunction. Combining scapular-focused exercises with conscious control of scapular orientation has more remarkable benefits on AROM of shoulder abduction, UT muscle strength, and muscle activation pattern than the scapular-focused exercises alone. Conscious control of scapular orientation should be considered to integrate into scapular-focused exercises in patients with oral cancer and scapular dyskinesis.Trial registry name and URL, and registration number: ClinicalTrials.gov (URL: https://clinicaltrials.gov; Approval No: NCT03545100).

The Modified Eden-Lange Tendon Transfer for Lateral Scapular Winging Secondary to Spinal Accessory Nerve Injury

Trapezius paralysis following injury to the spinal accessory nerve can be a debilitating complication resulting from lymph node biopsy, radical neck dissection, or penetrating trauma in the region of the posterior cervical triangle. Disruption of the delicate muscular balance in the shoulder girdle may result in lateral scapular winging, ipsilateral upper extremity radiculopathy, and limited shoulder function and range of motion. Spontaneous recovery with nonoperative management is possible in some patients, and restoration of function after reparative neural procedures has been observed in patients undergoing timely repair. However, extended delays from the time of injury to surgery are common and may necessitate various muscle transfers to reestablish the complex biomechanics and balance of the shoulder girdle. We describe a modification to the classic Eden-Lange procedure with lateral transfer of the levator scapulae and rhomboid minor to the scapula spine and rhomboid major transfer with a small wafer of bone to the scapula body for chronic lateral winging of the scapula following injury to the spinal accessory nerve as the result of a cervical lymph node biopsy.

Shoulder pain and scapular dyskinesis associated with lower trapezius dysplasia - A case report

BACKGROUND

Scapular dyskinesis (SD) has been associated with shoulder soft-tissue tightness as well scapular muscle strength and/or activation deficits. Inadequate development of the trapezius muscle (trapezius dysplasia) is a relatively rare condition inconsistently associated with shoulder dysfunction.

CASE DESCRIPTION

a 24-year old male complaining of left scapular area pain associated with SD and scapular muscle weakness was noted to present with a smaller ipsilateral lower trapezius (LT). Further inquiry including electromyography, rehabilitative ultrasound imaging (RUSI) and magnetic resonance imaging ruled out nerve palsy and demonstrated a hypoplastic left LT. This led to a greater emphasis on serratus anterior (SA) training along with the addition of neuromuscular electrical stimulation of the LT.

OUTCOMES

Following 12 sessions over a 5-month period the patient reported no pain or functional deficits, and was able to resume all recreational activities. The patient's subjective shoulder value increased from 55% to 80%, and LT strength was markedly improved.

DISCUSSION

Scapular muscle dysplasia may represent a less recognized cause of SD. A more thorough inspection of scapular muscle shape and orientation, possibly augmented by RUSI may be indicated in patients presenting with SD. Neuromuscular electrical stimulation is a potentially useful modality for addressing scapular muscle activation and strength deficits and future research into its efficacy under these circumstances may be warranted.

Improving screening for physical impairments and access to early physiotherapy after neck dissection surgery: a translational controlled trial

PURPOSE

Lack of routine screening for a range of physical impairments that can result after neck dissection (ND) may hinder physiotherapy referral and treatment. The purpose of this study was to implement an intervention that targeted both physiotherapists and surgeons to increase their post-operative physical screening of ND patients and in turn improve physiotherapy referral rates.

METHODS

The authors undertook a translational controlled pilot study, conducted over a 12-month period that utilised three tertiary hospital sites. The target groups were physiotherapists at one intervention site and surgeons at the other intervention site, with the third hospital acting as a control site and receiving usual care. The intervention included a physiotherapy brochure and a clinical pathway for screening, to promote early identification and prompt referral of patients with a physical impairment. The primary outcome variables were screening and referral rates between sites at the study end-point.

RESULTS

Logistic regression analyses were conducted on n = 174 to assess differences in screening and referral rates between sites. Patients at the intervention site that targeted physiotherapists had four times the odds of being screened for shoulder dysfunction compared to the control site (p = 0.0002), and three times the odds of being referred to physiotherapy (0.0039). There were no statistically significant differences in the odds of patients being screened for shoulder dysfunction or referred to physiotherapy at the intervention site that targeted surgeons.

CONCLUSION

The translational intervention undertaken by physiotherapists resulted in significantly greater screening and referral rates of post-operative ND patients for physiotherapy.

Optimal Trapezius Electrophysiological Recording Site

BACKGROUND

Various active recording electrode positions for the trapezius motor nerve conduction study have been suggested.

OBJECTIVE

To determine the optimal recording site of the trapezius muscles in a spinal accessory nerve conduction study.

DESIGN

Retrospective descriptive study.

SETTING

Department of physical medicine and rehabilitation in a tertiary clinic center.

PARTICIPANTS

Thirty-four patients between 33 and 82 years of age with preoperative head and neck cancer (68 upper and middle trapezius muscles).

INTERVENTIONS

Analysis of compound muscle action potentials (CMAPs) of upper and middle trapezius.

MAIN OUTCOME MEASUREMENTS

CMAP latency and amplitudes were obtained at five and four recording points with constant intervals on the horizontal line of the upper and middle trapezius, respectively.

RESULTS

The maximum CMAP amplitude of the upper trapezius was (mean ± SD) 8.5 ± 1.4 mV with the recording at the midpoint between the C7 spinous process and the lateral margin of the acromion. The maximum CMAP amplitude of the middle trapezius was 4.2 ± 1.4 mV, recorded on the horizontal line at the junction of the middle and lateral thirds between the root of the scapular spine and the vertebral spinous process.

CONCLUSION

The optimal recording site in motor nerve conduction study of the trapezius is the midpoint between the C7 spinous process and the acromion for the upper trapezius, and the junction of middle and lateral thirds of the line between the root of scapular spine and the vertebral spine for the middle trapezius.

Unsafe workout: a weak and painful shoulder in a professional volleyball player

A 29-year-old professional volleyball player started complaining of a dull ache in the right lateral base of the neck. This pain arose during a preseasonal athletic training intense session. After 3 days, he presented deficiency of right scapula adduction, limitation of scapula elevation, right shoulder weakness and local mild pain. He had asymmetrical neckline with drooping of the affected shoulder, lateral displacement and minimal winging of the right scapula. After 1 week, hypothrophy of superior trapezius appeared. An electromyography of right upper limb showed a denervation in the upper, middle and lower components of the right trapezius muscle, due to axonotmesis of spinal accessory nerve (SAN). A subsequent MRI was consistent with muscular suffering caused by early denervation. This case shows idiopathic SAN palsy, likely secondary to an inappropriate use of a weight-lifting machine, where the athlete recovered after an adequate rest and rehabilitation period.

Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes

Targeted ultrasound of the median, ulnar, and radial nerves is a well-established technique for suspected upper extremity peripheral neuropathy. However, sonographic imaging of the brachial plexus and smaller peripheral nerve branches is more technically difficult and the anatomy is less familiar to many radiologists. As imaging techniques improve, many clinicians refer patients for imaging of previously less-familiar structures. In addition, some patients may present with injuries that could involve local neurovascular structures. Finally, patients presenting with isolated peripheral neuropathies may be referred for perineural injections with local anesthetic for diagnostic purposes, or steroid for therapeutic reasons. This requires sonologists to have a firm understanding of the courses of these nerves and the surrounding anatomic landmarks that can be used to accurately identify and characterize them. We discuss clinical syndromes referable to specific peripheral nerve branches in the upper extremity, the relevant anatomy, and sonographic technique.

Spinal Accessory Nerve Injury Induced by Manipulation Therapy: A Case Report

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.

Neuromuscular complications in cancer

Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.

Patient outcome after surgical management of the spinal accessory nerve injury: A long-term follow-up study

Objectives:

A lesion in the spinal accessory nerve is typically iatrogenic: related to lymph node biopsy or excision. This injury may cause paralysis of the trapezius muscle and thus result in a characteristic group of symptoms and signs, including depression and winging of the scapula, drooped shoulder, reduced shoulder abduction, and pain. The elements evaluated in this long-term follow-up study include range of shoulder motion, pain, patients’ satisfaction, delay of surgery, surgical procedure, occupational status, functional outcome, and other clinical findings.

Methods:

We reviewed the medical records of a consecutive 37 patients (11 men and 26 women) having surgery to correct spinal accessory nerve injury. Neurolysis was the procedure in 24 cases, direct nerve repair for 9 patients, and nerve grafting for 4. Time elapsed between the injury and the surgical operation ranged from 2 to 120 months. The patients were interviewed and clinically examined after an average of 10.2 years postoperatively.

Results:

The mean active range of movement of the shoulder improved at abduction 44° (43%) in neurolysis, 59° (71%) in direct nerve repair, and 30° (22%) in nerve-grafting patients. No or only slight atrophy of the trapezius muscle was observable in 75%, 44%, and 50%, and no or controllable pain was observable in 63%, 56%, and 50%. Restriction of shoulder abduction preceded deterioration of shoulder flexion. Patients’ overall dissatisfaction with the state of their upper extremity was associated with pain, lower strength in shoulder movements, and occupational problems.

Conclusion:

We recommend avoiding unnecessary delay in the exploration of the spinal accessory nerve, if a neural lesion is suspected.

Neck muscle atrophy and soft-tissue fibrosis after neck dissection and postoperative radiotherapy for oral cancer

Late complications of head and neck cancer survivors include neck muscle atrophy and soft-tissue fibrosis. We present an autopsy case of neck muscle atrophy and soft-tissue fibrosis (sternocleidomastoid, omohyoid, digastric, sternohyoid, sternothyroid, and platysma muscles) within the radiation field after modified radical neck dissection type I and postoperative radiotherapy for floor of mouth cancer. A 70-year-old man underwent primary tumor resection of the left floor of mouth, left marginal mandibulectomy, left modified radical neck dissection type I, and reconstruction with a radial forearm free flap. The patient received adjuvant radiotherapy. The dose to the primary tumor bed and involved neck nodes was 63 Gy in 35 fractions over 7 weeks. Areas of subclinical disease (left lower neck) received 50 Gy in 25 fractions over 5 weeks. Adjuvant chemotherapy was not administered.

Surgical outcomes of 156 spinal accessory nerve injuries caused by lymph node biopsy procedures

OBJECT

Iatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during lymph node biopsy of the posterior cervical triangle (PCT). In this study, the authors review the operative techniques and surgical outcomes of 156 surgical repairs of the SAN following iatrogenic injury during lymph node biopsy procedures.

METHODS

This retrospective study examines the authors’ clinical and surgical experience with 156 patients with SAN injury between 1980 and 2012. All patients suffered iatrogenic SAN injuries during lymph node biopsy, with the vast majority (154/156, 98.7%) occurring in Zone I of the PCT. Surgery was performed on the basis of anatomical and electro-physiological findings at the time of the operation. The mean follow-up period was 24 months (range 8–44 months).

RESULTS

Of the 123 patients who underwent graft or suture repair, 107 patients (87%) improved to Grade 3 functionality or higher using the Louisiana State University Health Science Center (LSUHSC) grading system. Neurolysis was performed in 29 patients (19%) when the nerve was found in continuity with recordable nerve action potential (NAP) across the lesion. More than 95% of patients treated by neurolysis with positive NAP recordings recovered to LSUHSC Grade 3 or higher. Forty-one patients (26%) underwent end-to-end repair, while 82 patients (53%) underwent graft repair, and Grade 3 or higher recovery was assessed for 90% and 85% of these patients, respectively. The average graft length used was 3.81 cm. Neurotization was performed in 4 patients, 2 of whom recovered to Grade 2 and 3, respectively.

CONCLUSIONS

SAN injuries present challenges for surgical exploration and repair because of the nerve’s size and location in the PCT. However, through proper and timely intervention, patients with diminished or absent function achieved favorable functional outcomes. Surgeons performing lymph node biopsy procedures in Zone I of the PCT should be aware of the potential risk of injury to the SAN.

Effect of scapular dyskinesis on supraspinatus repair healing in a rat model

BACKGROUND

Rotator cuff tears are common conditions that often require surgical repair to improve function and to relieve pain. Unfortunately, repair failure remains a common problem after rotator cuff repair surgery. Several factors may contribute to repair failure, including age, tear size, and time from injury. However, the mechanical mechanisms resulting in repair failure are not well understood, making clinical management difficult. Specifically, altered scapular motion (termed scapular dyskinesis) may be one important and modifiable factor contributing to the risk of repair failure. Therefore, the objective of this study was to determine the effect of scapular dyskinesis on supraspinatus tendon healing after repair.

METHODS

A rat model of scapular dyskinesis was used. Seventy adult male Sprague-Dawley rats (400-450 g) were randomized into 2 groups: nerve transection of the accessory and long thoracic nerves (SD) or sham nerve transection (Sham control). After this procedure, all rats underwent unilateral detachment and repair of the supraspinatus tendon. All rats were sacrificed at 2, 4, and 8 weeks after surgery. Shoulder function, passive joint mechanics, and tendon properties (mechanical, histologic, organizational, and compositional) were evaluated.

RESULTS

Scapular dyskinesis alters joint function and may lead to compromised supraspinatus tendon properties. Specifically, diminished mechanical properties, altered histology, and decreased tendon organization were observed for some parameters.

CONCLUSION

This study identifies scapular dyskinesis as one underlying mechanism leading to compromise of supraspinatus healing after repair. Identifying modifiable factors that lead to compromised tendon healing will help improve clinical outcomes after repair.

Shoulder function following reconstruction with the supraclavicular artery island flap

OBJECTIVES/HYPOTHESIS

The supraclavicular artery island flap (SCAIF) is a pedicled fasciocutaneous flap used for head and neck reconstruction. In recent years, its use has significantly increased as a result of several advantageous characteristics, including pliability, an excellent color and texture match, ability to reconstruct a variety of skin and aerodigestive tract defects, and short harvest times. Clinical experience suggests that donor site complications are relatively infrequent and typically self-limiting, and there have been no documented cases of prolonged or permanent shoulder dysfunction. However, formal studies have not been performed to assess this outcome. The goal of this study was to evaluate the effects of SCAIF flap harvest on postoperative shoulder strength and flexibility.

STUDY DESIGN

Prospective cohort pilot study.

METHODS

Data was gathered prospectively during routine follow-up and surveillance. The Penn Shoulder Score and Constant Shoulder Scale were used to measure subjective and objective outcomes. Physical therapists performed testing for strength and flexibility.

RESULTS

Ten patients were evaluated from January to July, 2013. Subjective self-reporting of shoulder function and satisfaction was good to excellent in most patients. The majority of patients demonstrated limitations in range of motion for one or more shoulder movements. Muscle strength was preserved postoperatively.

CONCLUSION

Harvest of the SCAIF appears to have limited postoperative morbidity. Postoperative shoulder strength and function appears to be very good; however, some limitation of range of motion was observed.

LEVEL OF EVIDENCE

4

Histologic confirmation of neuronal cell bodies along the spinal accessory nerve

INTRODUCTION

Most sources conclude that the spinal accessory nerve (SAN) is a purely motor nerve. There are some reports that suggest a sensory component, although the exact nature of such sensory fibers has yet to be elucidated. With such discrepancies in the literature and with well-established pain syndromes of unknown etiology following SAN injury, the authors performed the present study to better clarify this anatomy.

MATERIALS AND METHODS

The entire accessory nerve was harvested from 10 adult cadavers. Samples were then submitted for immunohistochemical analyses.

RESULTS

Occasional microganglia cells were identified along the SAN in all specimens. These ganglia were most numerous along the intracranial segment of the SAN, but none was found along the cranial rootlets of the accessory nerve.

CONCLUSIONS

Neuronal cell bodies were identified along the course of the SAN in human cadavers. Although the function is not certain, such cells have been found in other animals to be nocioceptive in nature. Pending further study, these cells may be found to be involved in enigmatic pain syndromes thought to arise in the sternocleidomastoid and trapezius muscles.

Measurement properties of existing clinical assessment methods evaluating scapular positioning and function. A systematic review

The aims were to compile a schematic overview of clinical scapular assessment methods and critically appraise the methodological quality of the involved studies. A systematic, computer-assisted literature search using Medline, CINAHL, SportDiscus and EMBASE was performed from inception to October 2013. Reference lists in articles were also screened for publications. From 50 articles, 54 method names were identified and categorized into three groups: (1) Static positioning assessment (n = 19); (2) Semi-dynamic (n = 13); and (3) Dynamic functional assessment (n = 22). Fifteen studies were excluded for evaluation due to no/few clinimetric results, leaving 35 studies for evaluation. Graded according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN checklist), the methodological quality in the reliability and validity domains was "fair" (57%) to "poor" (43%), with only one study rated as "good". The reliability domain was most often investigated. Few of the assessment methods in the included studies that had "fair" or "good" measurement property ratings demonstrated acceptable results for both reliability and validity. We found a substantially larger number of clinical scapular assessment methods than previously reported. Using the COSMIN checklist the methodological quality of the included measurement properties in the reliability and validity domains were in general "fair" to "poor". None were examined for all three domains: (1) reliability; (2) validity; and (3) responsiveness. Observational evaluation systems and assessment of scapular upward rotation seem suitably evidence-based for clinical use. Future studies should test and improve the clinimetric properties, and especially diagnostic accuracy and responsiveness, to increase utility for clinical practice.

A comprehensive review of head and neck cancer rehabilitation: physical therapy perspectives

Rehabilitation in relation to cancer can be preventative, restorative, supportive, and palliative. It is recognized that patients may have rehabilitation needs throughout their care pathway. The role of physiotherapy in the cancer rehabilitation is less understood and particularly in the head and neck cancer (HNC) patients. This results in various residual deformities and dysfunctions for the patients with HNC. The objective of this review is to provide detailed information regarding the problems faced after the cancer treatments and rehabilitation of patients who suffered with HNC. The fact that cancer patients are facing several months of chemotherapy and/or radiotherapy and usually major surgery, as well as the direct effect of immobility due to pain, means that muscle wasting, joint stiffness, as well as de-conditioning and fatigue are inevitable. The absence of physiotherapy intervention would be detrimental to patient care and the ability of the patient/family to cope with the effects of the disease or its treatment on their functional capacity and quality of life. Following any treatment for HNC, physical therapy may play an essential role in preventing various complications and helping patients to mitigate impairments, and restoring function of the shoulder joint, neck, and face.

Use of the Guide to Physical Therapist Practice by pediatric physical therapists

PURPOSE

Physical therapists are encouraged to use the Guide to Physical Therapist Practice (Guide) in their practice. The purpose of this study was to determine whether and how pediatric physical therapists (PTs) use the Guide.

SUBJECTS AND METHODS

A nationwide electronic survey was sent to pediatric physical therapists. Four hundred seventy-five members returned the survey yielding a 9.6% response rate.

RESULTS

Respondents reported that they practice consistently with the Guide's patient/client management model but that they do not find the Guide useful. Respondents made recommendations for a future edition of the Guide.

CONCLUSIONS

Pediatric PTs value the Guide as a reference, resource, and teaching tool. When the Guide is revised, the following should be considered: pediatric content, format, and utility of the Guide; educational needs of pediatric PTs about the Guide; and how stakeholders and PTs with other specialties view and use the Guide.