Patient outcome after surgical management of an accessory nerve injury

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.

Surgical treatment of trapezius palsy: A systematic review

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.

Trapezius Palsy Resulting from Accessory Nerve Injury after Cervical Lymph Node Biopsy Dramatically Improved with Conservative Treatment

Background

Iatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during cervical lymph node biopsy. Many operative treatments for SAN injury in the posterior cervical triangle have been reported, but there are no guidelines regarding the choice between operative and nonoperative treatments. Because it is believed that the nerve seldom spontaneously regenerates, some articles suggest surgical intervention within 3 months from the nerve injury to achieve good postoperative results. However, we experienced a case of spontaneous accessory nerve recovery more than 3 months after accessory nerve injury. It is necessary to carefully exclude similar patients from unnecessary surgery.

Case

A 41-year-old woman underwent cervical lymph node biopsy at an otolaryngology clinic. She experienced pain across her neck and weakness of the shoulder in abduction just after the biopsy. Three months after the biopsy, her symptoms persisted and she was referred to our hospital for surgical treatment. On careful examination, we detected signs of accessory nerve regeneration. Consequently, we prescribed physical therapy and a rehabilitation program, including active and passive range-of-motion exercises of the shoulder and muscle strengthening exercises. Six months after the injury, there was a dramatic improvement of the trapezius muscle function and the patient became pain free.

Discussion

When the biopsy incision is more than one finger's breadth away from the normal course of the SAN, and when Tinel-like signs advance along the trapezius muscle over time, spontaneous SAN recovery can be anticipated.

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.

Scapular winging: anatomical review, diagnosis, and treatments

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery.

Iatrogenic injury to the accessory nerve

We describe two patients with uncommon causes of iatrogenic injuries and review the anatomy, presentation, possibilities of repair, and results. The incidence of such nerve injuries during lymph node biopsies is 3%-10%, but the diagnosis is often delayed. Symptoms are shoulder pain and inability to abduct the arm beyond the horizontal plane. Surgical repair may improve function and pain and should be performed early, preferably within six months, but prevention of nerve injury is most important.

Patient-reported outcome after peripheral nerve injury

PURPOSE

This study evaluated patient-reported outcome and the factors associated with disability after an upper extremity nerve injury. We hypothesized that patients at least 6 months after injury would report considerable disability and that pain would be the strongest predictor of the Disabilities of the Arm, Shoulder, and Hand (DASH) score.

METHODS

After research ethics board approval, the medical charts of patients with these inclusion criteria were reviewed: adults; presenting to a nerve surgeon; 6 months or greater after nerve injury. Patients completed the DASH questionnaire and the Short Form-36 (SF-36) as a routine part of the initial evaluation. These data were reviewed retrospectively to determine predictors of the DASH score.

RESULTS

There were 84 patients (mean age, 39 years; SD, 14 years) with brachial plexus (n=27) and peripheral nerve (n=57) injuries. The mean time after injury was 38 months (SD, 47). For all SF-36 domains, the mean values of the nerve-injured patients were significantly lower than the normative data, indicating a lower health status. The mean DASH score was 52 (SD, 22) of 100. Significantly more disability was associated with more SF-36 bodily pain and with brachial plexus injuries. In the final regression model, SF-36 bodily pain, age, and nerve injured were significant predictors of the DASH score. SF-36 bodily pain accounted for 35% of the variance.

CONCLUSIONS

Substantial long-term disability (high DASH scores) was found in patients after nerve injury that was predicted by higher pain, older age, and brachial plexus injury. Further investigation of this pain and the associated factors may provide the opportunity for improved health-related quality of life.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Same Modality nerve Reconstruction for Accessory nerve Injuries

The standard repair of a nerve gap under tension is to use a sensory autograft, such as the medial antebrachial cutaneous or the sural nerve. The practice of using sensory grafts to repair motor nerve defects is challenged by the discovery of preferential motor reinnervation and modality specific nerve regeneration. In this article, two clinical cases are presented where accessory nerve injuries are repaired with either a motor nerve transfer (a branch of C7) or a motor autograft (obturator nerve), and excellent functional results are reported. These cases provide a stimulus to consider the use of motor nerve grafts or transfers in the repair of motor nerve deficits.

© 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Rehabilitation following motor nerve transfers

Cortical mapping and relearning are key factors in optimizing patient outcome following motor nerve transfers. To maximize function following nerve transfers, the rehabilitation program must include motor reeducation to initiate recruitment of the weak reinnervated muscles and to establish new motor patterns and cortical mapping. Patient education and a home program are essential to obtain the optimal functional result.

Iatrogenic spinal accessory nerve injury in children

Injury to the spinal accessory nerve in the posterior triangle of the neck results in trapezius paralysis and shoulder dysfunction. The most common etiology is iatrogenic and has been reported extensively in adults. We report 3 cases of spinal accessory nerve injury recognized postoperatively in children and discuss the microsurgical treatment, results, and simple strategies to avoid this complication.

Refinements in the technique for repair of the accessory nerve

Trapezius muscle palsy after accessory nerve injury leads to periscapular pain and shoulder motion deficit. The results of accessory nerve repair generally are good, but surgery is difficult. The difficulty consists of finding the nerve stumps that are embedded in fat and scar tissue from previous surgeries or injuries. Five patients with accessory nerve lesions had surgery and grafting of the accessory nerve. We dissected the proximal stump of the accessory nerve within the fibers of the sternocleidomastoid muscle and in the vicinity of the greater auricular nerve. To achieve dissection of the distal nerve stump, the deep cervical fascia was detached from the trapezius muscle 3 cm cephalad to the clavicle. The detached fascia and the trapezius muscle were flipped similar to book pages. The motor branches entering the trapezius muscle were visualized and followed toward the accessory nerve. A sural nerve graft with a mean length of 6.6 cm was used for grafting. Uncomplicated identification of the nerve stumps was possible in all patients. After accessory nerve grafting, pain and motion consistently improved in all patients. The technique proposed here ensures reliable and rapid identification of the divided stumps of the accessory nerve.

Clinical signs of accessory nerve palsy

BACKGROUND

Injury to the spinal accessory nerve causes paralysis of the trapezius muscle, which is a painful and disabling condition. Many injuries are iatrogenic. Diagnosis is often made after a long delay, suggesting that current clinical signs are inadequate.

METHODS

Accessory nerve palsy is known to be a cause of winging of the scapula. Observation of six patients with accessory nerve palsy has shown that winging of the scapula is most prominent when the patient actively externally rotates the shoulder against resistance.

RESULTS

This is in contrast to the other causes of winging of the scapula including long thoracic nerve palsy and muscular dystrophy, where the scapula is most prominent on flexion or abduction of the shoulder.

CONCLUSION

We propose that the resisted active external rotation test should be regarded as the key clinical sign for accessory nerve palsy.

Reconstruction of accessory nerve defects with sternocleidomastoid muscle—great auricular nerve flap

We introduced a new method for reconstruction of accessory nerve defects by using the sternocleidomastoid muscle (SCM)-great auricular nerve flap. Thirty-four patients receiving traditional radical neck dissection were divided into two groups: the accessory nerve not-reconstructed group (Group A, N = 19) and the accessory nerve reconstructed group (Group B, n = 15). The surgical procedure of the reconstruction is described in detail. Postoperative shoulder functions were compared between the two groups. We found that Group B experienced much better shoulder function recovery than Group A. Both groups had good wound healing. It is concluded that reconstruction of accessory nerve defects with SCM-great auricular nerve flap is simple, effective and complication-free and worthwhile.

Treatment of a Proximal Accessory Nerve Injury with Nerve Transfer

OBJECTIVE AND HYPOTHESIS

This study presents a case report of a patient who sustained an iatrogenic proximal accessory nerve injury that was treated with a medial pectoral to accessory nerve transfer.

STUDY DESIGN

Case study.

MATERIALS AND METHODS

Chart of one patient who was treated with a medial pectoral to accessory nerve transfer was reviewed.

RESULTS

Five months after excision of a branchial cyst that resulted in a very proximal injury to the accessory nerve, this patient underwent a medial pectoral to accessory nerve transfer. At final follow-up, 3 years after surgery, the patient had full abduction overhead with some residual shoulder/scapular discomfort and mild scapular winging.

CONCLUSION

The medial pectoral to accessory nerve transfer provides a viable surgical option with good reinnervation of the trapezius muscle in patients with a proximal accessory nerve injury where standard nerve repair or graft techniques are not feasible.