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Preserving the spinal accessory nerve during radical neck dissection eliminates shoulder disability and does not compromise the incidence of neck recurrence in properly selected cases. The literature and standard textbooks only superficially refer to the method dissecting this nerve. We describe our technique of preserving the spinal accessory nerve during radical neck dissection.
OBJECTIVE: This study assessed patient outcome following surgical reconstruction of the accessory nerve after an iatrogenic injury. STUDY DESIGN: A retrospective chart review of 8 patients was performed. RESULTS: There were 3 men and 5 women in the study, and the mean time between injury and nerve graft/repair surgery was 5 months. Four injuries were sustained during a lymph node biopsy. Electromyography revealed a complete accessory nerve injury in all cases. In 6 cases, a nerve graft was required (mean length, 3.6 cm), and in 2 cases, a direct nerve repair was possible. The trapezius muscle was successfully reinnervated in all cases. In total, full shoulder abduction was achieved in 6 cases; in the remaining 2 cases, the patients achieved shoulder abduction to 90 degrees. CONCLUSION: Functional deficit after accessory nerve injury is significant. Nerve graft/repair reconstruction reliably yields a satisfactory result, providing good scapular rotation and thus good shoulder function.
UNLABELLED: The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.
From January 1981 through December 1985, 9 patients underwent radical neck dissection with sacrifice of the spinal accessory nerve for removal of metastatic cancer to cervical nodes followed by reconstruction of the spinal accessory nerve utilizing a cable graft from the greater auricular nerve. Shoulder function on the operated side was assessed postoperatively using a subjective questionnaire, objective strength testing, and EMG recordings. The group that had cable grafts of the spinal accessory nerve were compared to a group who had modified radical neck dissection with preservation of the spinal accessory nerve, and to a third group that had classical radical neck dissection with sacrifice of the spinal accessory nerve and no cable graft reconstruction. The group with cable grafts scored in a position intermediate between the modified neck dissection group and the classical radical neck dissection group on subjective and objective testing. Most of the patients with cable grafts demonstrated voluntary motor potentials in the trapezius muscle on postoperative EMG testing. Cable grafting of the spinal accessory nerve sacrificed during radical neck dissection results in improved shoulder function in the postoperative period. Indications and contraindications for the use of this rehabilitative procedure are presented.
We report on the surgical results of spinal accessory nerve injuries between 1992-2003. We operated on 10 patients (9 female, and 1 male) who had injuries of the spinal accessory nerve. All injuries were iatrogenic. The mean age of patients was 39.2 years (range, 20-57 years). The average interval between date of injury and surgery was 7 months (range, 4-12 months). All patients had stiffness and pain in the shoulder girdle. The average active abduction of the shoulder joint was 79.5 degrees (range, 60-100 degrees ) before surgery. End-to-end repairs were performed in 7 cases, and graft repairs were indicated in 3 cases. The mean follow-up period was 18.4 months (range, 8-36 months). The average active abduction of the shoulder joint was 171 degrees (range, 140-180 degrees ) at time of final follow-up.
Studying the ultrastructure of simple sensory corpuscles in the glabrous skin in the hedgehog snout the authors followed the accessory nerve fibres in the examined corpuscles. The accessory nerve fibres were divided into four groups: a) The accessory nerve fibres containing accumulated mitochondria in the inner core. Here the fibres were situated among the peripheral lamellae of the inner core with which they are occasionally joined though desmosomes. b) The accessory nerve fibre in the inner core containing more light vesicles but lacking completely mitochondria. c) The accessory nerve fibre rich in mitochondria between the inner core and the capsule. d) The bundle of nerve fibres among the capsular lamellae. This bundle included a fibre rich in mitochondria, the other fibres contained mitochondria sporadically. There were nor vesicles at all. The authors are of the view that the fibres of groups a), c), and d) are sensory fibres including the fibres in group d) containing sporadic mitochondria. For the time being it is not quite clear wheather the accessory fibre in the inner core is independent from the very beginning or whether it is a branch of the central axon. The nature of the fibre of group b) rich in vesicles is not quite clear. With respect to the fact that the material was fixed in glutaraldehyde the findings will have to be completed by further material fixed in potassium permanganate or by enzymatic examination. Further examinations will also be inevitable to determine a possible functon of accessory fibres in the sensory terminal.
Radical neck dissection was the golden standard of treatment for cervical nodes in head and neck tumors. From the seventies, the preservation of the spinal accessory nerve has become increasingly popular in order to improve the functional result of the neck dissections. The aim of this study was to assess the degree of functional disability associated with each type of neck dissection and the value of anatomical references for dissection of the spinal accessory nerve. One hundred twenty seven patients were evaluated 1 month and 1 year after radical, functional or supraomohyoid neck dissection with a questionnaire and a physical examination. Anatomical measurements of the spinal accessory nerve were performed in 20 patients. We found considerable or severe shoulder dysfunction in 7%, 34% and 51% respectively of patients in whom supraomohyoid, functional and radical neck dissections were performed. Furthermore 49% of patients having undergone a radical neck dissection had little or no symptoms. Sacrifice of the spinal accessory nerve in radical neck dissection may lead to shoulder dysfunction. A functional disability may also be associated, although in a less extent, with any neck dissection in which the spinal accessory nerve is dissected and placed in traction. There is a large variation in the degree of functional disability and pain in patients with similar neck dissections. The course of the spinal accessory nerve in the neck makes it particularly vulnerable to injury during the dissection near the sternocleidomastoid muscle and in the posterior cervical triangle.
Microsurgical decompression of the accessory nerve was conducted in 10 patients with spasmodic torticollis (tonic and tonic-clonic forms). Compression of the roots of the accessory nerve of the posterior inferior cerebellar and the vertebral arteries was discovered. Decompression was accomplished by division of the arachnoid adhesions, anastomosis with sensory roots of C1 and C2, and placing a layer of muscular tissue between the nerve and the vessel. The results of treatment of spasmodic torticollis are analysed and the efficacy of neurovascular decompression is emphasized.
Although iatrogenic injury to the spinal accessory nerve in the posterior cervical triangle is a well-described phenomenon, diagnosis can prove difficult and is often incorrect or delayed. We describe a series of six men and three women (mean age 40 years; range, 20 to 52 years) with iatrogenic spinal accessory nerve injuries. Injuries resulted from lymph node biopsies in the posterior cervical triangle in eight patients and posterior foss surgery in one. Eight patients lost the ability to abduct their arm but could still shrug their shoulder, a pattern that resulted in an incorrect initial diagnosis in five patients. The average delay from injury to referral was 8 months. Seven patients underwent nerve exploration an average of 9.7 months after injury. Five had transected nerves that could be repaired; three of these patients required a nerve graft. Pain was greatly relieved in the five patients who had severe pain before surgery, and weakened shoulder abduction improved in four of six patients. Nerve exploration should be considered when the patient's clinical exam does not improve within 3 months of injury. Nerve repair frequently reduces pain and improves shoulder abduction, even 12 months after injury.
The accessory nerve was stimulated at the posterior triangle of the neck and responses were evoked simultaneously from the upper, middle and lower part of the trapezius muscle. Sixteen patients were investigated, 10 with trapezius palsy following surgical procedures at the posterior cervical triangle, three with a history suggestive of neuralgic amyotrophy and three of unknown origin. On the unaffected side the latency increases 0.16 ms per 10 mm increase in conduction distance corresponding to a conduction velocity of 63 m/s. Evidence is presented that the upper, middle and lower part of the trapezius muscle receive innervation from the accessory nerve. Follow-up of patients showed spontaneous nerve regeneration after complete axonal degeneration. These findings suggest that surgical intervention should be delayed to allow for spontaneous reinnervation. Clinical recovery was incomplete in cases of iatrogenic origin.
We report a patient with neurinoma of the spinal accessory nerve, who complained of intermittent occipital headaches, nausea, vomiting, blurred vision and unsteady gait. Neurological examination revealed papilledema, bilateral horizontal nystagmus and right cerebellar signs. Computed tomography revealed mild hydrocephalus, a low-attenuated lesion with a faint capsule after enhancement and partial compression of the 4th ventricle in the right posterior fossa. Vertebral angiography revealed no definite tumor vessels or stains. Under the impression of a posterior fossa tumor, a suboccipital craniectomy with a C1 and C2 laminectomy was performed. A 4 x 4 x 2.5 cm3 dumbbell tumor arising from the left spinal accessory nerve at the C2 level was found 4 x 4 x 2.5 cm3. The tumor extended upward through the foramen magnum with upward displacement of both tonsils to the right jugular foramen with slight adhesion to the right IX, X and XI cranial nerves. The left spinal accessory nerve was severed from the pedicle at the C2 level, and the tumor was totally removed. Diagnosis was made during the operation. The pathological examination showed neurinoma with cystic degeneration. During the following year, atrophy of the left sternocleidomastoid and trapezius muscles were noticed. Up to the time of this writing, there had been no clinical recurrence.
Preservation of the spinal accessory nerve in radical or modified neck dissection is oncologically accepted in order to avoid the sequelae of the so called "shoulder syndrome". In 23 patients, on whom 29 neck dissections had been performed, the functional results were evaluated on an average 2.6 years postoperatively. 19 patients were radiated post surgery. Clinical and electromyographic examination revealed paresis of 62% of the preserved accessory nerves. Nevertheless, only 48% of the patients suffered from the shoulder syndrome, the remaining were able to innervate or compensate for the resulting deficit. Postoperative functional exercises are mandatory to prevent the shoulder syndrome and to make the preservation technique a worthwhile concept.
Injury to the spinal accessory nerve is most commonly iatrogenic, but can be related to cervical trauma or resection of tumor. Of the two most recent publications related to injury of the spinal accessory nerve, one describes transfer of the levator scapulae muscle to restore shoulder function, while the other reports on the results of six surgical repairs, three of which used a sural nerve graft to reconstruct a short neural defect. The present report describes the results obtained in two patients when an iatrogenic injury to the XIth nerve was reconstructed at 3 months after the loss of shoulder function. Denervation of the XIth nerve was confirmed by a first EMG at 6 weeks, and a second one at 12 weeks. At surgery, each XIth nerve was found to have an in-continuity neuroma, most probably related to electrocoagulation. Intraoperative electrical stimulation did not pass the region of nerve injury. In the first patient, the XIth nerve was reconstructed with an autograft from the greater auricular nerve. In the second patient, the XIth nerve was reconstructed with a bioabsorbable conduit, the Neurotube. The patient with the Neurotube reconstruction reached M5 trapezius function by 3 months after surgery, and had no nerve graft donor-site morbidity, while the patient with the autograft reached M4 function by 6 months after reconstruction, and has persistent numbness of the ear lobe. This is the first reported case of a cranial motor nerve being reconstructed with a bioabsorbable conduit.
Iatrogenic lesions of the spinal accessory nerve were explored and repaired in 10 patients. Symptoms included pain, trapezius muscle atrophy, restricted active abduction and drop shoulder; as they developed after cervical lymph node biopsy, diagnosis was usually easy. Depending on the operative findings, microsurgical repair involved suture, neurolysis or grafts. Clinical and electromyographic results are available from 7 patients followed up for 14 months on average: complete recovery was observed in 3 cases and satisfactory but incomplete recovery in 3; there was one failure. Since these lesions often have severe sequelae, exploration and repair are advocated.
OBJECTIVE: The major complication of neck dissection and surgery at the posterior triangle of the neck is severe disability of the shoulder or "shoulder syndrome", which results from spinal accessory nerve injury. Surgical landmarks of the nerve in this area were studied. METHODS: Fifty-six fresh Thai cadavers (112 necks) were dissected to identify the anatomical relationship of the spinal accessory nerve and its commonly used landmarks. RESULTS: The spinal accessory nerve was found within 3.6 cm (mean, 1.43 cm) above Erb's point. The distance between the spinal accessory nerve entering the trapezius muscle and the clavicle was between 2.6 cm and 6.9 cm (mean, 4.5 cm). CONCLUSION: Our data were different from those described in the literature. Reconsideration of these two important landmarks can help to minimize iatrogenic injury of the spinal accessory nerve.
Injury to the accessory nerve is the most frequent complication of surgical procedures in the posterior triangle of the neck. The symptoms produced by paralysis of the trapezius are disabling. The components of this disability are pain, limitation of abduction, and drooping of the affected shoulder. A detailed knowledge of the course of the nerve and its anatomic relations are essential in avoiding injury. Useful anatomic landmarks are the proximal internal jugular vein in the anterior triangle and Erb's point in the posterior triangle. Prevention of accessory nerve injury is the best management. The indications for lymph node biopsies in the neck should be sound. The use of a general anesthetic without paralysis is recommended if an excisional biopsy is necessary. Adequate exposure is essential. Whether the nerve needs to be identified in all cases has to be individualized and requires careful judgment. A divided or injured nerve is best managed with primary repair within 3 months of injury.
OBJECTIVE: To determine how the spinal accessory nerve and the trapezius branches of the cervical plexus contribute to the innervation of each of the 3 parts of the trapezius muscle. Special emphasis was placed on the nerve supply of the clinically most important descending part of the muscle. DESIGN: Anatomical analysis of the distribution of the cervical plexus and spinal accessory nerve branches in the human trapezius muscle. MATERIALS: Twenty-two trapezius muscles from 11 perfusion-fixed human cadavers ranging in age from 66 to 92 years (mean, 81.7 years). INTERVENTIONS: The specimens were dissected free and macerated, decalcified, and stained according to Sihler's technique for about 6 weeks. The translucent, stained muscles were then backlit, and the findings were documented photographically and by schematic drawings. RESULTS: In all 22 muscles, the innervation of each of the 3 parts of the trapezius muscle was seen. In all muscles investigated, the nerve supply to the descending part of the muscle consisted of a single fine branch of the spinal accessory nerve, whereas the transverse and ascending parts were innervated by both the spinal accessory nerve and the trapezius branches of the cervical plexus. CONCLUSION: Our results, especially those involving the descending part of the trapezius muscle, may help to minimize the rate of unexpected trapezius muscle paresis after surgery of the neck.
We reviewed the results of repair of the spinal accessory nerve in seven patients seen between September 1994 and January 1996. The nerve had been injured during biopsy of a cervical lymph node in six patients and during removal of a bullet in one. The average interval between the time of the injury and the repair of the nerve was eight months (range, three to fourteen months). An end-to-end repair of the nerve was performed in six patients, and a neurolysis was done in one. The average duration of follow-up was thirty-two months (range, twenty-four to thirty-nine months). Postoperatively, all seven patients had relief of pain and stiffness in the shoulder girdle. Manual muscle-testing revealed normal strength of the trapezius, which was comparable with that on the unaffected side. Four patients regained normal function of the shoulder. Three patients reported a stretching sensation or discomfort in the neck, periscapular discomfort, and fatigue of the extremity when lifting heavy objects or performing overhead activities. However, these residual symptoms were mild and tolerable and thus were different in nature from the preoperative pain and stiffness. Iatrogenic injury of the spinal accessory nerve should be suspected if a patient has pain or stiffness in the shoulder girdle and a history of a recent operation on the neck. The nerve should be explored if spontaneous recovery does not occur.