Spinal accessory (11th) nerve palsy following carotid endarterectomy

Cadaver investigation of the usefulness of the transstyloid diaphragm approach for high-position plaque carotid endarterectomy

OBJECTIVES

Patients sometimes present with high cervical internal carotid artery (ICA) stenosis. This study demonstrates the usefulness of the transstyloid approach to expose the distal ICA by dissection of the styloid diaphragm covering the distal cervical ICA for carotid endarterectomy (CEA). In particular, the possible exposure length achieved by this approach was investigated using cadaveric heads.

METHODS

The procedure of the transstyloid diaphragm approach was confirmed in 10 cadaveric heads (20 sides). After the carotid triangle was opened, both the posterior belly of the digastric muscle (PBDM) and the stylohyoid muscle could be divided. Then, the carotid sheath was dissected, and the glossopharyngeal nerve was identified crossing over the distal ICA. The revealed length of the ICA was measured with or without dissection of both the PBDM and the stylohyoid muscle. The specimens were dissected under the surgical microscope.

RESULTS

The transstyloid diaphragm approach was achieved successfully in all specimens. The revealed lengths of the ICA with and without dissection of the styloid diaphragm were 53.7 ± 5.9 mm and 38.8 ± 2.9 mm (mean ± standard deviation), respectively. Therefore, the revealed length of the distal ICA was 14.9 ± 4.5 mm greater using the transstyloid diaphragm approach compared to the regular CEA approach.

CONCLUSIONS

More of the ICA can be revealed by dissection of both the PBDM and the stylohyoid muscle. The transstyloid diaphragm approach might be helpful to reveal the distal ICA in cases of high cervical ICA stenosis.

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.

Meta-analysis of retrojugular versus antejugular approach for carotid endarterectomy

INTRODUCTION

The retrojugular approach for carotid endarterectomy (CEA) has been reported to have the advantages of shorter operative time and ease of dissection, especially in high carotid lesions. Controversial opinion exists with regard to its safety and benefits over the conventional antejugular approach.

METHODS

A systematic review of electronic information sources was conducted to identify studies comparing outcomes of CEA performed with the retrojugular and antejugular approach. Synthesis of summary statistics was undertaken and fixed or random effects models were applied to combine outcome data.

FINDINGS

A total of 6 studies reporting on a total of 740 CEAs (retrojugular approach: 333 patients; antejugular approach: 407 patients) entered our meta-analysis models. The retrojugular approach was found to be associated with a higher incidence of laryngeal nerve damage (odds ratio [OR]: 3.21, 95% confidence interval [CI]: 1.46-7.07). No significant differences in the incidence of hypoglossal or accessory nerve damage were identified between the retrojugular and antejugular approach groups (OR: 1.09 and 11.51, 95% CI: 0.31-3.80 and 0.59-225.43). Cranial nerve damage persisting during the follow-up period was similar between the groups (OR: 2.96, 95% CI: 0.79-11.13). Perioperative stroke and mortality rates did not differ in patients treated with the retrojugular or antejugular approach (OR: 1.26 and 1.28, 95% CI: 0.31-5.21 and 0.25-6.50).

CONCLUSIONS

Currently, there is no conclusive evidence to favour one approach over the other. Proof from a well designed randomised trial would help determine the role and benefits of the retrojugular approach in CEA.

Specific scapular kinematic patterns to differentiate two forms of dynamic scapular winging

BACKGROUND

Dynamic scapular winging (DSW) is a rare and misdiagnosed disorder causing considerable disability due to reduced scapular stability and abnormal motion. Two common causes are long thoracic nerve lesions resulting in serratus anterior muscle palsy and spinal accessory nerve lesions resulting in trapezius muscle palsy. The aim of this study was to analyse 3D scapular kinematic patterns in patients with DSW due to long thoracic (LTNL) or spinal accessory nerve lesions (SANL).

METHODS

3D scapular kinematics were assessed using a non invasive method involving an electromagnetic device during arm elevation in the frontal and sagittal planes in 9 patients (4 with SANL and 5 with LTNL) with unilateral DSW confirmed by electrical evidence. Within subject affected-unaffected differences were measured and compared between pathological groups (Mann-Whitney).

FINDINGS

Differences between affected and unaffected shoulders were significantly greater for scapular posterior tilt (at rest and 30° for sagittal arm elevation, at rest, 30° and 60° for frontal arm elevation) in the LTNL compared to the SANL group. Differences between affected and unaffected shoulders were significantly greater for scapular protraction (at rest and 60° of sagittal arm elevation, at rest, 30° and 60° of frontal arm elevation) and scapular lateral rotation at 60° for frontal arm elevation in the SANL compared to the LTNL group.

INTERPRETATIONS

These kinematic findings show two different scapular patterns that are specific to the neurological lesion. Moreover our kinematic data relate to specific clinical signs and the functional roles of the muscles involved.

Impairment of upper trapezius branch of the spinal accessory nerve during bypass grafting: a stretch injury?

Internal jugular vein catheterization has been implicated in spinal accessory nerve (SAN) injuries after coronary artery bypass grafting (CABG). Stretch injury due to prolonged positioning during CABG has also been proposed as another mechanism of injury. Herein we describe a male patient with left shoulder pain and abduction difficulty following CABG, who displayed electromyographic abnormalities confined to the left upper trapezius muscle. Internal jugular vein catheterization had not been performed during surgery. Although unusual, the possibility of upper trapezius muscular branch paralysis should be considered in patients with shoulder pain or weakness after CABG.

Cranial nerve injuries and the retrojugular approach in carotid endarterectomy

INTRODUCTION

This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches.

PATIENTS AND METHODS

Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test.

RESULTS

Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches.

CONCLUSIONS

The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.

Isolated spinal accessory nerve palsy after coronary artery bypass: an unusual complication

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.

Spontaneous unilateral accessory nerve palsy: a case report and review of the literature

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.

Clinical evaluation of the shoulder

Shoulder pain is an exceptionally common problem in physiatric practice. Evaluation and management of patients with shoulder dysfunction can challenge even the most experienced practitioner. The complexity and inherent instability of the shoulder lead to functional overload of various bony and soft tissues within the joint complex and adjacent structures.Additionally, shoulder pain may be the initial manifestation of a potentially serious condition. Consequently, a detailed and systematic approach to the evaluation of a patient with shoulder pain is crucial in establishing a complete and accurate diagnosis. A skillfully performed history and physical examination allows identification of specific tissue pain generators and biomechanical dysfunction throughout the kinetic chain. Only after these elements have been defined clearly can an appropriate rehabilitation program be de-signed. A thorough clinical assessment also can aid in the detection of serious diseases that masquerade as shoulder pain. An effective clinical evaluation enhances the quality and cost-effectiveness of care and facilitates a successful outcome in most cases.

Cranial and cervical nerve injuries after repeat carotid endarterectomy

BACKGROUND AND PURPOSE

The incidence of cranial and/or cervical nerve injuries after primary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical outcome of these injuries after repeat CEA has not been thoroughly analyzed in the English-language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA.

PATIENTS AND METHODS

This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clinical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glossopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with postoperative cranial nerve injuries were followed up for a long time to assess their recovery.

RESULTS

Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves [2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed within 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryngeal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries.

CONCLUSIONS

Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability.

Magnetic stimulation of the spinal accessory nerve: normative data and clinical utility in an isolated stretch-induced palsy

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.