Academic literature on the topic 'Accessory nerve shoulder dysfunction'

The spinal accessory nerve provides motor innervation to the sternocleidomastoid and trapezius muscle. It is an extremely important structure to be preserved during neck dissection to avoid sequalae related to shoulder dysfunctions. The incidence of shoulder dysfunction and morbidity can be attributed to varied anatomy and branching pattern of the nerve or the contribution by the cervical plexus to the motor innervations of the trapezius muscle. Hence it is important to have knowledge of the varied anatomy and branching pattern of the spinal accessory nerve to avoid the possible shoulder morbidity and dysfunction following neck dissections. Lanisnik B etal’s study showed that there are three recognizable branching patterns of the spinal accessory nerve for innervation of the trapezius muscle. In type 1, the SAN enters the Sternocleidomastoid muscle and a single trapezius muscle branch exits from the posterior border of the SCM after receiving communications from the cervical nerves, especially C2 and C3. In type 2, the motor branch for trapezius muscle separates from the main trunk at level II, before the nerve enters the sternocleido-mastoid muscle. In the type 3 pattern, CN XI enters the SCM in the same way as described in type 1, and the motor branch for the trapezius muscle exits from the SCM muscle behind its posterior border; however, it does not immediately travel to level V and the trapezius muscle, but instead takes a more medial course and mixes with the cervical nerves, predominantly C2 and C3. In this case report, we will discuss an unusual branching pattern of spinal accessory nerve similar to the type 3 variant as explained by Lanisnik that we have encountered during a modified radical neck dissection, in a case of Squamous cell carcinoma of right buccal mucosa.

Preserving the spinal accessory nerve (SAN) is an important step in the modern-day neck dissection to avoid postoperative functional morbidity in patients. This goal can become technically difficult, especially, when rare anatomical variations are encountered. We present a case of dual SAN in a patient undergoing selective neck dissection for oral squamous cell carcinoma. Both SANs were preserved and patient had no shoulder dysfunction postoperatively. We take this opportunity to emphasise that meticulous dissection is the only proven way to preserve the nerve. And that surgeons should be aware of this anatomical variation. SAN should be subjected to minimal traction during neck dissection to avoid tension neuropraxia and long-term shoulder dysfunction.

Iatrogenic injury to the spinal accessory nerve is one of the most common causes of trapezius muscle palsy. Dysfunction of this muscle can be a painful and disabling condition because scapular winging may impose traction on the soft tissues of the shoulder region, including the suprascapular nerve. There are few reports regarding therapeutic options for an intracranial injury of the accessory nerve. However, the surgical release of the suprascapular nerve at the level of the scapular notch is a promising alternative approach for treatment of shoulder pain in these cases. The author reports on 3 patients presenting with signs and symptoms of unilateral accessory nerve injury following resection of posterior fossa tumors. A posterior approach was used to release the suprascapular nerve at the level of the scapular notch, transecting the superior transverse scapular ligament. All patients experienced relief of their shoulder and scapular pain following the decompressive surgery. In 1 patient the primary dorsal branch of the C-2 nerve root was transferred to the extracranial segment of the accessory nerve, and in the other 2 patients a tendon transfer (the Eden–Lange procedure) was used. Results from this report show that surgical release of the suprascapular nerve is an effective treatment for shoulder and periscapular pain in patients who have sustained an unrepairable injury to the accessory nerve.

AbstractObjective:To investigate evidence that intra-operative nerve monitoring of the spinal accessory nerve affects the prevalence of post-operative shoulder morbidity and predicts functional outcome.Methods:A search of the Medline, Scopus and Cochrane databases from 1995 to October 2012 was undertaken, using the search terms ‘monitoring, intra-operative’ and ‘accessory nerve’. Articles were included if they pertained to intra-operative accessory nerve monitoring undertaken during neck dissection surgery and included a functional shoulder outcome measure. Further relevant articles were obtained by screening the reference lists of retrieved articles.Results:Only three articles met the inclusion criteria of the review. Two of these included studies suggesting that intra-operative nerve monitoring shows greater specificity than sensitivity in predicting post-operative shoulder dysfunction. Only one study, with a small sample size, assessed intra-operative nerve monitoring in neck dissection patients.Conclusion:It is unclear whether intra-operative nerve monitoring is a useful tool for reducing the prevalence of accessory nerve injury and predicting post-operative functional shoulder outcome in patients undergoing neck dissection. Larger, randomised studies are required to determine whether such monitoring is a valuable surgical adjunct.

ABSTRACT Aims To assess preoperative and postoperative shoulder function by electromyography (EMG) in spinal accessory nerve (SAN) sparing neck dissections in head and neck cancers. Materials and methods A prospective study was done on 50 patients (51 shoulders) with histopathologically proven head and neck cancers with N0 or N1 neck who underwent nerve sparing neck dissections. Patients were assessed preoperatively and postoperatively at 3 weeks and 3 months by needle EMG and muscle strength tests of upper trapezius. Results and interpretation: At 3 weeks postoperatively, 11 shoulders (39.3%) in FND group and four shoulders (33.3%) in modified radical neck dissection (MRND) group showed severely abnormal EMG, while in supraomohyoid neck dissection (SOHND) group only two (18.2%) shoulders showed severely abnormal EMG. All patients who underwent nerve sparing neck dissections showed improvement in at least one category on the second electromyogram at 3 months. This could be attributed to neuropraxia or transient devascularization of the accessory nerve. In our study, 11 patients in FND group showed severely abnormal EMG finding, but they did not have as great a degree of shoulder dysfunction as would be expected. This could be due to factors like preoperative condition of other synergistic shoulder girdle muscles, postoperative exercises, etc. Conclusion SAN injuries are common in all types of nerve sparing neck dissections requiring aggressive physiotherapy for an improved shoulder function. To conclude, in patients in whom it is oncologically sound, nerve sparing neck dissections offers significant benefit in terms of shoulder function. How to cite this article Mohiyuddin A, Raj S, Merchant S, Oomen, Kottaram PJ. Electromyographic Assessment of Accessory Nerve Function Following Nerve Sparing Neck Dissection. Int J Head and Neck Surg 2013;4(1):19-23.

In order to clarify the functional prognosis of accessory nerve injury after nerve repair and non-surgical treatment, 27 of our cases with accessory nerve injury were studied. 20 cases were followed up for more than 8 months. In ten cases treated conservatively, the dull feeling and hypaesthesia did not improve. However, pain and dysfunction of the shoulder improved in half of these cases. In ten cases treated surgically, nerve suture was performed in two cases, nerve graft in five cases and neurolysis in three cases. In the surgically treated group, subjective complaints disappeared in all cases, but hypaesthesia or contracture of the shoulder persisted in three cases. Surgical treatment of the accessory nerve is recommended in fresh cases with complete paralysis and in cases in which there is no sign of nerve recovery within one year after the original injury.

AbstractSpinal 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.

Objective To evaluate through electromyography (EMG) the injury to the 11th cranial nerve following neck dissection. Methods Prospective study with 60 patients submitted to neck dissection as part of treatment of head and neck tumors. All the cases underwent physiotherapic evaluation of shoulder dysfunction. Nerve integrity was evaluated pre- and postoperatively through surface EMG registering the electric activity of descendent fibers of trapezius muscle during maximal isometric voluntary contraction. The patients were grouped according the type of neck dissection, presence of shoulder pain, impairment during abduction movement, and hypotrophy or atrophy of trapezius muscle. Results The action potential had mean and standard deviation of 61,7±31,6mcV in preoperative evaluation and 15,6±12,4mcV in postoperative evaluation (p<0.001). According to the neck dissection extension, there were mean values of 18,8±14,2mcV after dissection includiog level IIb and 18,8±14,2 mcV after dissection including levels IIb and V (p<0.002). Conclusions Surface EMG is a sensitive and painless for 11th cranial nerve disfunction evaluation. In all cases, the superior fibers of trapezius muscle were affected with presence of pain and impairment abduction movement of the arm. The results suggest the benefit of trapezius muscle EMG to confirm the diagnosis and early physiotherapic intervention in neuropathies of the 11th cranial nerve.

Background Shoulder pain and dysfunction can occur following neck dissection surgery for cancer. These conditions often are due to accessory nerve injury. Such an injury leads to trapezius muscle weakness, which, in turn, alters scapular biomechanics. Objective The aim of this study was to assess which strengthening exercises incur the highest dynamic activity of affected trapezius and accessory scapular muscles in patients with accessory nerve dysfunction compared with their unaffected side. Design A comparative design was utilized for this study. Methods The study was conducted in a physical therapy department. Ten participants who had undergone neck dissection surgery for cancer and whose operated side demonstrated clinical signs of accessory nerve injury were recruited. Surface electromyographic activity of the upper trapezius, middle trapezius, rhomboid major, and serratus anterior muscles on the affected side was compared dynamically with that of the unaffected side during 7 scapular strengthening exercises. Results Electromyographic activity of the upper and middle trapezius muscles of the affected side was lower than that of the unaffected side. The neck dissection side affected by surgery demonstrated higher levels of upper and middle trapezius muscle activity during exercises involving overhead movement. The rhomboid and serratus anterior muscles of the affected side demonstrated higher levels of activity compared with the unaffected side. Limitations Exercises were repeated 3 times on one occasion. Muscle activation under conditions of increased exercise dosage should be inferred with caution. Conclusions Overhead exercises are associated with higher levels of trapezius muscle activity in patients with accessory nerve injury following neck dissection surgery. However, pain and correct scapular form must be carefully monitored in this patient group during exercises. Rhomboid and serratus anterior accessory muscles may have a compensatory role, and this role should be considered during rehabilitation.

Higher Doctorate - Doctor of Medicine (MD)
Prologue: Surgery can be defined as the art and science of the operative management of human injury, deformity or disease. It historically has been, and continues to be, achieved by either manual or instrumental means. Recently it has borne witness to the introduction of minimally invasive and robotic technologies. Surgical procedures have been variously described since the era of the ancient great river civilizations, circa 7000 BC. Historically, Practitioners of surgery have been identified throughout classical antiquity, medieval times, the Renaissance and the age of Enlightenment. They were typified by an eclectic mix of philosopher nobleman, knowledgeable clergymen, Barbers and Battlefield surgeons. They all provided detailed analyses of their surgical techniques and operative outcomes, which have in the main been methodically preserved for posterity. Despite the introduction by medieval universities of defined curricula in medicine, science and the arts, there remained a distinct separation in the respective developments of the disciplines of medicine (physic) and surgery. Within the latter, Guilds of Barbers and Surgeons were initially established and subsequently paved the way for a more formalized training of surgeons. This in turn led to the development of gazetted Colleges of Surgeons. Head and neck surgery has progressively developed as an anatomically defined regional surgical specialty. Tumors of the head and neck are treated by a variety of surgical disciplines. In addition, radiation and medical oncologists also provide primary and or adjuvant management of selected pathology. Surgeons practicing within the head and neck include the otolaryngologist, maxillofacial surgeon, general surgeon and plastic surgeon. They each come from a different and unique surgical background. This is particularly evident in their individual approaches to the management of head and neck pathology. However, regardless of their respective backgrounds, the “contemporary head and neck surgeon” is required to achieve independent, competent and proficient surgical practice. These demands remain rooted in the successful completion of a “surgical apprenticeship”. Significantly, the Halstedian theory of “see one, do one and teach one”, which to a greater extent shaped twentieth century surgical training, has been strengthened in the twenty first century by the inclusion of the trilogy of curriculum, core competency and critical analysis. Critical analysis can be defined as the systematic appraisal of research methodology. In the broadest sense, it is based on the scientific evaluation of (health related) clinical care. In contemporary surgical practice, critical analysis embodies activities like audit (the evaluation that pre-defined standards have been met), quality assurance, and clinical and biomedical research. Ultimately, it aims to contribute to the establishment, maintenance and promotion of an ongoing scientific body of knowledge in defined areas of specialty (surgical) practice. This scientific body of knowledge is considered by resources such as Medline and Pubmed, which index journals and catalogue their articles. Purpose: All medical treatments aim to save or prolong life, to relieve symptoms, to provide care or to improve health related quality of life. The aim of this research was to undertake a critical analysis of selected aspects of the biopsycho-social outcomes that resulted from the surgical management of a cohort of patients who were diagnosed with a head and neck cancer. The surgery and its outcomes were a direct result of the author’s fulfilment of curriculum and core competencies, which underpin competent and proficient practice. A treatment catalogue of a substantial patient cohort who had developed a head and neck cancer was established and maintained by the author. Patients considered for inclusion in the various studies were initially assessed by a Head and Neck Multi-disciplinary Team. The patients were subsequently admitted under the care of the author to a tertiary referral hospital and underwent surgical management of their cancer according to the recommendations of the MDT assessment. The advanced study was based on the systematic critical analysis of aspects of the quality of care provided by the author. Results: Publications that resulted from the study were based on clinical audit investigation, metaanalysis, technical innovation and unique case reports supported by literature review/discussion. The thesis that was subsequently developed consisted of an extended discourse on the history of surgery and in particular, head and neck surgery, combined with a compendium of original research works which had been published in peer reviewed journals. Conclusion: Maxillofacial surgery is a bona fide surgical specialty. It has evolved to manage a range of diseases, deformities and defects that afflict the mouth, jaws, face – head and neck. In keeping with the trials and tribulations of my surgical forebears, this body of scientific works consists of a series of peer reviewed papers and monographs that have been published in relevant specialty journals. It is my contention that the research has provided an original and substantial contribution to the literature. In particular, it expands the existing body of knowledge in the field of head and neck surgery. In conclusion, the author considers that he has fulfilled an appropriate curriculum, addressed core competencies and applied critical analysis to his resultant surgical outcomes in the discipline of head and neck surgery.

Disorders affecting the lower cranial nerves – V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus), XI (accessory) and XII (hypoglossal) – are discussed in the first part of this chapter. The clinical neuroanatomy of each nerve is described in detail, as are disorders – often in the form of lesions – for each nerve.Trigeminal nerve function may be affected by supranuclear, nuclear, or peripheral lesions. Because of the wide anatomical distribution of the components of the trigeminal nerve, complete interruption of both the motor and sensory parts is rarely observed in practice. However, partial involvement of the trigeminal nerve, particularly the sensory component, is relatively common, the main symptoms being numbness and pain. Reactivation of herpes zoster in the trigeminal nerve (shingles) can cause pain and a rash. Trigeminal neuralgia and sensory neuropathy are also discussed.Other disorders of the lower cranial nerves include Bell’s palsy, hemifacial spasm and glossopharyngeal neuralgia. Cavernous sinus, Tolosa–Hunt syndrome, jugular foramen syndrome and polyneuritis cranialis are caused by the involvement of more than one lower cranial nerve.Difficulty in swallowing, or dysphagia, is a common neurological problem and the most important consequences include aspiration and malnutrition (Wiles 1991). The process of swallowing is a complex neuromuscular activity, which allows the safe transport of material from the mouth to the stomach for digestion, without compromising the airway. It involves the synergistic action of at least 32 pairs of muscles and depends on the integrity of sensory and motor pathways of several cranial nerves; V, VII, IX, X, and XII. In neurological practice dysphagia is most often seen in association with other, obvious, neurological problems. Apart from in oculopharyngeal muscular dystrophy, it is relatively rare as a sole presenting symptom although occasionally this is seen in motor neurone disease, myasthenia gravis, and inclusion body myositis. Conversely, in general medical practice, there are many mechanical or structural disorders which may have dysphagia as the presenting feature. In some of the disorders, notably motor neurone disease, both upper and lower motor neurone dysfunction may contribute to the dysphagia. Once dysphagia has been identified as a real or potential problem, the patient should undergo expert evaluation by a clinician and a speech therapist, prior to any attempt at feeding. Videofluoroscopy may be required. If there is any doubt it is best to achieve adequate nutrition through the use of a fine-bore nasogastric tube and to periodically reassess swallowing. Anticholinergic drugs may be helpful to reduce problems with excess saliva and drooling that occur in patients with neurological dysphagia, and a portable suction apparatus may be helpful. Difficulty in clearing secretions from the throat may be helped by the administration of a mucolytic agent such as carbocisteine or provision of a cough assist device.

Disorders affecting the scapula can lead to significant limitations in arm movement and pain. Scapular winging is a rare, painful, and debilitating condition that leads to limited functional abilities of the upper limb. This condition can be caused by multiple etiologies, most commonly lesions to the long thoracic nerve (serratus anterior weakness) and spinal accessory nerve (trapezius weakness). Other less common types may be caused by lesions affecting the dorsal scapular nerve. These neurological lesions produce characteristic and distinct types of scapular winging or dyskinesis. This chapter reviews the various types of scapular winging and discusses their evaluation, diagnosis, and management options.

Restoration of external rotation of the shoulder in adults with partial brachial plexus palsies is challenging. While nerve grafts are possible, nerve transfers are currently the most use method for satisfactory restoration of function. Numerous nerve transfers have been described, although the transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. The suprascapular nerve and the nerve to the teres minor muscle are the two preferred targets to restore external rotation of the shoulder. There are numerous nerve donors, but their use obviously depends on the initial injury. The most common donors are the spinal accessory nerve, the rhomboid nerve, branches of the radial nerve, the C7 root fascicle or the ulnar nerve. The choice for the transfer depends on the available nerves and first of all on chosen approach, whether it be cervical or scapular. It also depends on the other associated reconstruction procedures, grafts, or nerve transfers for the recovery of other functions, specifically, elevation of the shoulder and flexion of the elbow. The objective of this chapter is to present the main nerve transfers and to propose a therapeutic strategy.