Analysis of fatty degeneration of the trapezius muscle after use of accessory nerve / Análise da degeneração gordurosa do músculo trapézio após uso do nervo acessório

ABSTRACT Objective: To investigate, through magnetic resonance imaging, the occurrence of fatty degeneration of the trapezius in adult patients undergoing nerve transfer procedure, using the spinal accessory nerve. Methods: A total of 13 patients meeting the criteria of unilateral brachial plexus injury and more than one year of postoperative care after nerve transfer surgery underwent an MRI scan of the trapezius. A T1-weighted 3D sequence was used, with the IDEAL technique using 8.0 mm cut thickness, 8.0 mm cut spacing, TR of 100 ms, TE of 3.45 ms, flip angle of 10 degrees, 20 cuts, on the sagittal plane. The images of the upper, transverse and lower parts of the trapezius muscle were then classified according to the degree of fatty degeneration, compared with the contralateral side, using the Goutallier score. Results: For the upper trapezius there was a change of the degeneration state in 23% (p = 0.083), for the transverse section there was a change in 84.6% (p = 0.003), for the lower one there was a change in 92.3% (p = 0.002). Conclusion: The upper trapezius did not undergo significant degeneration after transfer. The lower and transverse trapezius suffered fatty degeneration in most patients, indicating severe functional impairment. Level of Evidence IV, Case series.

RESUMO Objetivo: Através de imagens de ressonância magnética, investigar a ocorrência de degeneração gordurosa no músculo trapézio em pacientes adultos submetidos a procedimento de transferência de nervo envolvendo o nervo espinal acessório. Métodos: 13 pacientes com lesão do plexo braquial unilateral e mais de um ano de cirurgia de transferência de nervo utilizando o nervo espinal acessório foram submetidos a exame de ressonância magnética do músculo trapézio. Foi obtida uma sequência 3D ponderada em T1, com a técnica IDEAL, espessura de corte de 8,0 mm, espaçamento entre os cortes de 8,0 mm, TR de 100 ms, TE de 3,45 ms, flip angle de 10 graus e 20 cortes, no plano sagital. As imagens das porções superior, transversa e inferior do músculo trapézio foram classificadas de acordo com o grau de degeneração gordurosa e comparadas com o lado contralateral, utilizando o score de Goutallier. Resultados: Para o trapézio superior houve mudança no estado de degeneração em 23% (p = 0,083), para o trapézio transverso houve mudança em 84,6% (p = 0,003), e para o trapézio inferior houve mudança em 92,3% (p = 0,002). Conclusão: O trapézio superior não sofreu degeneração significativa após transferência. Os trapézios inferiores e médios sofreram degeneração gordurosa na maioria dos pacientes, indicando comprometimento funcional severo. Nível de Evidência IV, Série de casos .

Anatomical study of jugular foramen in the neck / Estudo anatômico do forame jugular no pescoço

Abstract Introduction The anatomical complexity of the jugular foramen makes surgical procedures in this region delicate and difficult. Due to the advances in surgical techniques, approaches to the jugular foramen became more frequent, requiring improvement of the knowledge of this region anatomy. Objective To study the anatomy of the jugular foramen, internal jugular vein and glossopharyngeal, vagus and accessory nerves, and to identify the anatomical relationships among these structures in the jugular foramen region and lateral-pharyngeal space. Methods A total of 60 sides of 30 non-embalmed cadavers were examined few hours after death. The diameters of the jugular foramen and its anatomical relationships were analyzed. Results The diameters of the jugular foramen and internal jugular vein were greater on the right side in most studied specimens. The inferior petrosal sinus ended in the internal jugular vein up to 40 mm below the jugular foramen; in 5% of cases. The glossopharyngeal nerve exhibited an intimate anatomical relationship with the styloglossus muscle after exiting the skull, and the vagal nerve had a similar relationship with the hypoglossal nerve. The accessory nerve passed around the internal jugular vein via its anterior wall in 71.7% of cadavers. Conclusion Anatomical variations were found in the dimensions of the jugular foramen and the internal jugular vein, which were larger in size on the right side of most studied bodies; variations also occurred in the trajectory and anatomical relationships of the nerves. The petrosal sinus can join the internal jugular vein below the foramen.

Resumo Introdução A complexidade anatômica do forame jugular torna a realização de procedimentos cirúrgicos nessa região delicada e difícil. Devido aos avanços obtidos nas técnicas cirúrgicas, as abordagens do forame jugular têm sido feitas com maior frequência, o que requer uma melhoria correspondente no conhecimento de sua anatomia. Objetivo Estudar a anatomia do forame jugular, da veia jugular interna e dos nervos glossofaríngeo, vago e acessório, assim como as relações anatômicas entre estas estruturas na região do forame jugular e no espaço parafaríngeo. Método Foram examinados 60 lados de 30 cadáveres frescos algumas horas após a morte. Os diâmetros e suas relações anatômicas foram analisados. Resultados Os diâmetros do forame jugular e da veia jugular interna foram maiores no lado direito na maioria dos espécimes estudados. O seio petroso inferior terminava na veia jugular interna até 40 mm abaixo do forame jugular, em 5% dos casos. O nervo glossofaríngeo exibiu uma relação íntima anatômica com o músculo estiloglosso após a sua saída do crânio e o nervo vago exibiu uma relação semelhante com o nervo hipoglosso. O nervo acessório passou em torno da veia jugular interna via sua parede anterior em 71,7% dos cadáveres. Conclusão Foram encontradas variações anatômicas nas dimensões do forame jugular e da veia jugular interna, que apresentaram tamanhos maiores à direita na maioria dos espécimes estudados; variações também ocorreram na trajetória e nas relações anatômicas dos nervos. O seio petroso pode se unir à veia jugular interna abaixo do forame.

Spinal Accessory Neuropathy Secondary to Diffuse Large B-Cell Lymphoma

Spinal accessory neuropathy (SAN) is commonly caused by an iatrogenic procedure, and that caused by tumors is very rare. We present a case of a 49-year-old man suffering from weakness in the right trapezius and sternocleidomastoid muscle. An electrophysiology study confirmed proximal SAN. Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) revealed a diffuse large B-cell lymphoma compressing the right spinal accessory nerve. Ultrasonography showed definite atrophy on the trapezius and sternocleidomastoid muscles. In addition, post-chemotherapy FDG-PET/CT showed increased FDG uptake in the right upper trapezius, suggestive of denervation. This is the first report of SAN caused by direct compression by a diffuse large B-cell lymphoma, comprehensively assessed by an electrophysiology study, ultrasonography, and FDG-PET/CT.

Level V Clearance in Neck Dissection for Papillary Thyroid Carcinoma: A Need for Homogeneous Studies

Abstract Introduction Papillary thyroid carcinoma has a very high rate of lateral neck node metastases, and there is almost unanimity concerning the fact that some sort of formal neck dissection must be performed to address the clinical neck disease in these cases. Although there is an agreement that levels II to IV need to be cleared in these patients, the clearance of level V is debatable. Objectives We herein have tried to analyze various papers that have documented a structured approach to neck dissection in these patients. Moreover, we have also tried to consider this issue through various aspects, like spinal accessory nerve injury and the impact of neck recurrence on survival. Data Synthesis The PubMed, Medline, Google Scholar, Surveillance, Epidemiology, and End Results (SEER), and Ovid databases were searched for studies written in English that focused on lateral neck dissection (levels II-IV or II-V) for papillary thyroid carcinoma. Case reports with 10 patients or less were excluded. Conclusions The current evidence is equivocal whether to clear level V or not, and the studies published on this issue are very heterogeneous. Level II-IV versus level II-V selective neck dissections in node-positive papillary thyroid carcinoma patients is far from categorical, with pros and cons for both approaches. Hence, we feel that there is a need for more robust homogeneous data in order to provide an answer to this question.

Assessment of the results of accessory to suprascapular nerve transfer / Avaliação dos resultados da transferência do nervo acessório para o supraescapular

ABSTRACT Objective: Nerve transfers are an alternative in the reconstruction of traumatic brachial plexus injuries. In this study, we report the results of branchial plexus reconstruction using accessory to suprascapular nerve transfer. Methods: Thirty-three patients with traumatic brachial plexus injuries underwent surgical reconstruction with accessory to suprascapular nerve transfers. The patients were divided into groups in which surgery was performed either within 6 months after the injury or more than 6 months after the injury. Results were assessed using the Constant score. Results: There was no significant difference between the groups with respect to the Constant score. Conclusion: Accessory to suprascapular nerve transfer was not an efficient method for recovering active ROM or strength in the shoulder. However, it effectively improved pain control and shoulder stability. Level of evidence II, Retrospective Study.

RESUMO Objetivo: A transferência de nervos é uma alternativa na reconstrução das lesões traumáticas do plexo braquial. Neste estudo, relatamos os resultados da reconstrução do plexo braquial com a transferência do nervo acessório para o nervo supraescapular. Métodos: Trinta e três pacientes com lesões traumáticas do plexo braquial foram submetidos à reconstrução cirúrgica com transferência do nervo acessório para o nervo supraescapular. Os pacientes foram divididos em grupos em que a cirurgia foi realizada dentro de 6 meses a partir da lesão ou mais de 6 meses depois da lesão. Os resultados foram avaliados com o escore Constant. Resultados: Não houve diferença significante entre os grupos com relação ao escore Constant. Conclusão: A transferência do nervo acessório para o nervo supraescapular não foi um método eficiente para recuperar a ADM ativa ou a força no ombro. No entanto, foi eficiente para melhorar o controle da dor e a estabilização do ombro. Nível de evidência II, Estudo Retrospectivo.

Parálisis del XI par craneal secundaria a enfisema subcutáneo por uso de pieza de mano de alta velocidad en cirugía de terceros molares / Paralysis of the XI cranial nerve following subcutaneous emphysema by use of high speed handpiece in third molar surgery

Introducción: La cirugía de los terceros molares es el procedimiento quirúrgico más frecuentemente realizado por los cirujanos orales y maxilofaciales, que a pesar de contar con una vasta experiencia y entrenamiento en el área quirúrgica pueden presentarse complicaciones transoperatorias y postoperatorias. Cuando éste es realizado por un cirujano dentista de práctica general las complicaciones pueden aumentar. Presentación de caso clínico: Se trata de un paciente de 25 años de edad sometido a extracción quirúrgica de terceros molares por un dentista de práctica general, el cual realiza procedimiento quirúrgico con uso de pieza de mano de alta velocidad. Tres días posteriores al evento quirúrgico el paciente acude al Departamento de Cirugía Oral y Maxilofacial del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado por presentar edema, infl amación y crepitación en región bucal, maseterina y submandibular derecha, así como limitación a la apertura bucal de 25 mm. En tomografía computarizada contrastada se obs erva desviación de la vía aérea hacia el lado izquierdo. Se decide manejó del proceso infeccioso y de enfi sema subcutáneo con farmacoterapia y drenaje del mismo. Una vez remitido el enfi sema subcutáneo, en la cuarta semana de evolución el paciente refi ere limitación a la abducción del hombro derecho, observándose atrofi a del músculo trapecio y esternocleidomastoideo ipsilateral, correspondiente a lesión del XI par craneal. Discusión: La lesión del nervio accesorio (XI par craneal) ocasiona parálisis del músculo trapecio, principal estabilizador de la escápula que contribuye en los movimientos de fl exión, rotación y abducción del hombro. El trayecto del XI par craneal es superfi cial en el triángulo posterior del cuello presentando susceptibilidad a ser lesionado de manera iatrogénica, en este caso la utilización de pieza de mano de alta velocidad durante la extracción quirúrgica de los terceros molares generó enfi sema subcutáneo que condicionó la posible compresión del nervio accesorio, lesionando al mismo (AU)

Introduction: The third molar surgery is the most frequent surgical procedure performed by oral and maxillofacial surgeons, who despite their vast experience and training in the surgical area can present transoperatory and postoperative complications. When the oral surgery is done by a general practice dentist the complications can be increased. Case presentation: A 25-year-old male patient undergoing third molar surgery by a general practice dentist who performs a surgical procedure using a high-speed handpiece. Three days after the surgical procedure patient comes to the Department of Oral and Maxillofacial Surgery Institute for Social Security and Services for State Workers by present edema, swelling and crepitus in buccal space, masseteric and right submandibular region and limitation of mouth opening of 25 mm. Contrast computed tomography shows airway deviation to the left side. We decided to manage the infectious process and subcutaneous emphysema with antibiotic therapy and drainage. After subcutaneous emphysema was in remission, in the fourth week of evolution, the patient reported limitation of abduction of the right shoulder, with atrophy of the trapezius muscle and ipsilateral sternocleidomastoid, corresponding to a lesion of the XI cranial nerve. Discussion: Accessory nerve injury (XI cranial nerve) causes palsy of the trapezius muscle, the major stabilizer of the scapula that contributes to the fl exion, rotation and abduction movements of the shoulder. The trajectory of the XI cranial nerve is superfi cial in the posterior triangle of the neck presenting susceptibility to iatrogenic injury, in this case, the use of high-speed handpiece during the surgical extraction of the third molars, caused subcutaneous emphysema that conditioned the possible compression of the spinal nerve (AU)

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.

Dissection and observation of a large unnamed nerve in the posterior cervical triangle / 南方医科大学学报

<p><b>OBJECTIVE</b>To characterize the anatomical features of a large unnamed nerve in the posterior cervical triangle and clarify its relationship with the lesser occipital nerve.</p><p><b>METHODS</b>We dissected 31 adult formalin-fixed cadaver head and neck specimens (62 sides). The lateral cervical region, the anterior cervical region, the sternocleidomastoid region, and the occipital region were dissected to define the anatomical features of the unnamed nerve.</p><p><b>RESULTS</b>This unnamed nerve was identified in the posterior cervical triangle in 96.8% of the specimens. The main trunk of the nerve had a diameter of about 3 mm with a length of around 10 cm. The nerve arose from the anterior branch of the second cervical nerve (C2, C2-3), entered the posterior cervical triangle at 1-3 cm above the accessory nerve, and continued to ascend along or in parallel with the posterior border of the sternocleidomastoid muscle. It passed between the attachments of the sternocleidomastoid and the trapezius to the occiput and divided into 3-5 branches, which innervated the skin area between the lesser and greater occipital nerves.</p><p><b>CONCLUSIONS</b>We identified a large unnamed nerve in the posterior cervical triangle, for which we coined the name "long occipital nerve" based on its unique anatomical features. The discovery of this nerve can be important for local surgery and for diagnosis and treatment of related diseases.</p>

High-resolution Imaging of Neural Anatomy and Pathology of the Neck

The neck has intricately connected neural structures, including cervical and brachial plexi, the sympathetic system, lower cranial nerves, and their branches. Except for brachial plexus, there has been little research regarding the normal imaging appearance or corresponding pathologies of neural structures in the neck. The development in imaging techniques with better spatial resolution and signal-to-noise ratio has made it possible to see many tiny nerves to predict complications related to image-guided procedures and to better assess treatment response, especially in the management of oncology patients. The purposes of this review is to present imaging-based anatomy of major nerves in the neck and explain their relevant clinical significance according to representative pathologies of regarded nerves in the neck.

An anatomic study of the branch from cervical plexus into the accessory nerve / 中华显微外科杂志

Objective To identify whether the branches of cervical nerve roots joined into the accessory nerve trunk or not.Methods In 10 adult cadavers (7 males and 3 females, including 20 laterals of brachial plexus nerves), we observe source of cervical plexus branches to the accessory nerve anatomically.In 10 clinical cases of males with brachial plexus nerve injures, in the supraclavicular approach of brachial plexus exploration, the part of the supraclavicular cutaneous nerve for histological specimen were cut off;in the posterior approach, electrical stimulation of the trunk and branches of cervical plexus were performed to observed istaltrapezius muscle contraction.After accessory nerve transfer, the residual terminal accessory nerve and branch of cervical plexus were taked for histological specimens;and observed and judged of each nerve sample by acetylcholinesterase (AchE) immunohistochemical staining.Results In 10 of 20 lateral cases, cervical plexus communicating branches were derived from the fourth cervical nerve root.The intraoperative electrical stimulation of the accessory nerve trunk, 10 cases of distal trapezius muscle were significantly shrink;electrical stimulation of the cervical plexus branch, 2 cases after stimulation of the mild distal trapezius contraction, the remaining 8 cases without trapezius muscle contraction.10 cases of supraclavicular nerve staining for AchE were negative, 10 cases of accessory nerve terminal branches of AchE staining were mixed,10 cases of branch AchE cervical plexus to the accessory nerve staining were negative.Conclusion The branches of the fourth cervical nerve root constantly joins into the accessory nerve, participating in the trapezius muscle inner vation, the fibers of the branches are sensorial fibers.

XI cranial nerve cervical schwannoma - case report / Schwannoma do nervo acessório cervical- relato de caso

Cisternal spinal accessory schwannoma are still a rare condition without neurofibromatosis with only 32 cases reported so far. We describe a cisternal accessory schwannoma presented in a 36-year-old woman with posterior cervical pain and cervical mieolopaty, defined by grade IV tetraparesia. A suboccipital craniectomy with C1 posterior arch resection was performed. During microsurgical dissection together with electrophysiological monitoring and nerve stimulation tumor was identified as having the spinal accessory root as its origins. Carefully intraneural dissection was then performed with complete lesion removal, histopatological examination confirmed the hypothesis of schwannoma. The patient was free from pain and improved her neurological status with no accessory nerve palsy. Complete surgical resection is indicated for such lesions and can be achieved with good outcome.

O schwannoma do ramo espinhal do nervo acessório em sua porção cisternal, quando não associado à neurofibromatose, é uma condição rara, com apenas 32 relatos de caso na literatura. O diagnóstico diferencial da lesão deve ser atentado, principalmente no que diz respeito à preservação da função motora do nervo acessório. Este é um relato de caso de uma paciente do sexo feminino de 36 anos com queixa de cervicalgia associada à mielopatia cervical compressiva secundária à lesão expansiva intradural, extramedular, estendendo-se do forame magno até a porção superior da lâmina de C2. A paciente foi submetida a uma craniectomia de fossa posterior e ressecção do arco posterior de C1. Durante exploração cirúrgica, auxiliada por monitoração eletrofisiológica e estimulação neural, foi identificado que a lesão tinha origem no ramo espinhal do nervo acessório direito. Foi então ressecada de forma completa com preservação dos fascículos íntegros do nervo de origem. O exame anatomopatológico confirmou a hipótese de schwannoma. A paciente evoluiu sem dor e com melhora do quadro neurológico, sendo preservada a função do nervo acessório. O schwannoma do ramo espinhal do nervo acessório é uma condição rara. A ressecção cirúrgica total é o tratamento de escolha para esses pacientes e pode ser alcançada sem lesões neurológicas significativas secundárias ao ato cirúrgico.

Multiple Cervical Schwannomas Mimicking Metastatic Lymph Nodes from Papillary Thyroid Cancer / 대한갑상선학회지

We report a case of multiple cervical schwannomas mimicking cervical nodal metastasis in a 45-year-old female patient with papillary thyroid carcinoma. Ultrasonography revealed a hypoechoic lesion with irregular contour in the left isthmus of the thyroid gland. A contrast-enhanced CT of the neck showed two well-circumscribed, cystic masses in the left cervical level II. The preoperative results of ultrasonography guided fine needle aspiration biopsy from both thyroid and lateral neck masses were papillary thyroid cancer and atypical cell, respectively. Considering clinical and imaging results, the lateral neck masses were suspected to be metastatic cervical lymphadenopathy. During surgery, however, we identified that two lateral neck masses were originated from spinal accessory nerve and cervical plexus. The pathologic examination confirmed that lateral neck masses were typical schwannomas. Before surgery, it is important to make every efforts to discriminate metastatic lymphadenopathy from the cystic neck mass in patients with papillary carcinoma.

Intracisternal Cranial Root Accessory Nerve Schwannoma Associated with Recurrent Laryngeal Neuropathy

Intracisternal accessory nerve schwannomas are very rare; only 18 cases have been reported in the literature. In the majority of cases, the tumor origin was the spinal root of the accessory nerve and the tumors usually presented with symptoms and signs of intracranial hypertension, cerebellar ataxia, and myelopathy. Here, we report a unique case of an intracisternal schwannoma arising from the cranial root of the accessory nerve in a 58-year-old woman. The patient presented with the atypical symptom of hoarseness associated with recurrent laryngeal neuropathy which is noted by needle electromyography, and mild hypesthesia on the left side of her body. The tumor was completely removed with sacrifice of the originating nerve rootlet, but no additional neurological deficits. In this report, we describe the anatomical basis for the patient's unusual clinical symptoms and discuss the feasibility and safety of sacrificing the cranial rootlet of the accessory nerve in an effort to achieve total tumor resection. To our knowledge, this is the first case of schwannoma originating from the cranial root of the accessory nerve that has been associated with the symptoms of recurrent laryngeal neuropathy.

Malignant Nerve Sheath Tumor of the Spinal Accessory Nerve: A Unique Presentation of a Rare Tumor

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNSTs), sarcomas originating from tissues of mesenchymal origin, are rare in patients without a history of neurofibromatosis. CASE REPORT: We report a case of an MPNST of the spinal accessory nerve, unassociated with neurofibromatosis, which metastasized to the brain. The tumor, originating in the intrasternomastoid segment of the spinal accessory nerve, was removed. Two years later, the patient presented with focal neurological deficits. Radiographic findings revealed a well-defined 2.2x2.2x2.2 cm, homogeneously enhancing mass in the left parieto-occipital region of the brain surrounded by significant vasogenic edema and mass effect, culminating in a 1-cm midline shift to the right. The mass was surgically removed. The patient had nearly complete recovery of vision, speech, and memory. CONCLUSIONS: To our knowledge, this is the first documented case of an MPNST arising from an extracranial segment of the spinal accessory nerve and metastasizing to the brain.

Abordagem posterior para transferência nervosa do nervo acessório para o nervo supraescapular / Posterior approach to accessory nerve transfer to supraescapular nerve

Objetivo: Os autores realizaram uma avaliação comparativa entre a abordagem anterior e posterior do nervo acessório para transferência nervosa para o nervo supraescapular. Método: Foram estudados pacientes submetidos à neurotização do nervo supraescapular utilizando como doador o nervo acessório, no período de janeiro de 2007 a janeiro de 2010. Os registros cirúrgicos foram avaliados para analisar as vantagens e desvantagens das duas formas de abordagem desses nervos na cirurgia. Foram avaliados os marcos anatômicos utilizados para a localização dos nervos durante a cirurgia e as dificuldades ocorridas nas duas formas de abordagem. Resultados: Foram estudados ao todo 29 pacientes, sendo que 22 deles foram abordados pela via anterior e sete por via posterior. A localização do nervo supraclavicular foi considerada mais fácil pela via posterior, enquanto a localização do nervo acessório foi feita mais rapidamente pela via anterior. Em nenhuma das cirurgias foi necessária a interposição de enxerto nervoso. Não ocorreram complicações cirúrgicas nas duas técnicas. Conclusão: A análise comparativa das duas abordagens cirúrgicas demonstra que a anatomia desses dois nervos é importante fator na dificuldade técnica apresentada na cirurgia. Novos estudos devem analisar se há uma melhora dos resultados funcionais com a abordagem pela via posterior.

Objective: The authors conducted a comparative evaluation between the previous approach and later transfer accessory nerve to nerve nervous supraescapular. Method: Patients undergoing the nerve supraescapular transfer to the accessory nerve, in the period January 2007 to January 2010 were studied. Surgical records were evaluated to analyze the advantages and disadvantages of the two ways to approach these nerves in surgery. The anatomical landmarks used for localization of nerves during surgery were evaluated and the difficulties that occurred in the two forms of approaches. Results: Were studied in all 29 patients, with 22 of these were addressed through anterior and 7 through posterior. The location of supraclavicular nerve was considered easier through posterior approach, while the localization of accessory nerve was made more quickly through anterior. In none of the surgeries were required the interposition graft nervous. Non-surgical complications occurred in two techniques. Conclusion: A comparative analysis of two forms of surgical approach demonstrates that knowledge of the anatomy of these two nerves is important factor in technical difficulty presented in surgery. New long-term studies should examine whether there is an improvement of the functional results with the approach through posterior.

Applied anatomy for transfer of the spinal accessory nerve to the suprascapular nerve / 中华显微外科杂志

Objective Anatomical study of trapezius muscle innervations in order to find the best point for transfer of the spinal accessory nerve to the suprascapular nerve. Methods Observation of right and left trapezius muscle innervations in ten cadavers. Study the course and branches of accessory nerve with-in the trapezius muscle.Reseetion and cross-sectional biopsy of accessory and supraseapular nerves at different levels. Counting and comparing the number of nerve fibers at different levels in both nerves. Results The accessory nerve enters trapezius muscle within the deep fascia and run posterior just 2-3era above the clavicle. At the level of the midpoint of the spine of the scapula 3-4cm above and anterior, it unites with the cervical branch of the cervical plexus, then crosses medial to the spine of the scapula with straight course down to the lower trapezius. The number of nerve fibers in cross section at point A (just entering the muscle) was 1245± 46, in point B (just before union with cervical branch) was 830 ± 36 and in point C (posterior approach in-the anatomy is constant; Operation is simple and does not affect the upper trapezius muscle innervations. Also it gives us a full use of the cervical branch and shortens the nerve regeneration.

Anatomia cirúrgica do nervo acessório espinhal: comoevitar lesões em procedimentos cirúrgicos no trígonocervical posterior / Surgical anatomy of the spinal accessory nerve: how to avoid injuries to the posterior cervical triangle during surgical procedures

Introdução: A síndrome resultante da lesão iatrogênica do nervo acessório espinhal (NAE) secaracteriza por dor, paralisia e escápula alada, estando relacionada a morbidade considerável. Opresente estudo investiga o grau de variação na ramificação e no curso do NAE no trígono cervicalposterior (TCP). Método: A região cervical de oito cadáveres foi dissecada bilateralmente paraexpor o NAE. A ramificação e as variações no curso do NAE no TCP foram registradas. Medidasrelacionadas a estruturas anatômicas do Músculo Esternocleidomastóideo (MEC) e do MúsculoTrapézio (MTZ) foram analisadas. Resultados: As 16 dissecções demonstraram padrão de ramificaçãodo NAE como: nenhum ramo em 25%, um ramo em 37,5% e dois ramos em 37,5%dos casos. Considerável variação foi observada na anatomia regional do NAE no TCP. Medidasrevelaram que o NAE tem relação relativamente constante com o nervo auricular magno (NAM)e esta é uma importante referência anatômica para identificação do NAE no TCP. Conclusões:O NAM é uma referência anatômica útil para a identificação do NAE no TCP. Essa abordagemsugere uma possibilidade para diminuição de lesão iatrogênica do NAE, frequentemente relacionadaà manipulação cervical de estruturas anatômicas adjacentes sem exposição direta do nervo.

Background: The resulting syndrome from iatrogenic injury to the spinal accessory nerve (SAN)is characterized by pain, paralysis and winging of the scapula are often the source of considerablemorbidity. This study analyses the degree of ramification and variations of the SAN at the posteriortriangle (PT). Method: The necks of 8 adult cadavers were dissected bilaterally to expose the SAN.The ramifications and variations of the SAN at the PT were recorded. Measurements related toanatomical landmarks of the Sternocleidomastoid Muscle (SM) and the Trapezius Muscle (TM)were analyzed. Results: The sixteen dissections performed showed the ramification pattern ofthe SAN as: no ramus in 25%, one ramus in 37.5% and 2 ramus in 37.5% of cases. Considerablevariation was seen in regional anatomy of the SAN at the PT. Measurements revealed that the SANhas a relatively constant relationship with the great auricular nerve (GAN) and this is a importantlandmark for the identification of the SAN at the PT. Conclusions: The GAN is a useful landmarkfor identification of the SAN at the PT. This approach suggests a possibility to decrease theincidence of iatrogenic injury of the SAN, that is frequently related to dissection of surroundinganatomical structures and reduced direct exposure of the nerve.

Estudo da disposição anatômica da veia jugular interna, nervos glossofaríngeo, vago e acessório, na abertura inferior do forame jugular / Study of the anatomical arrangement of the internal jugular vein, glossopharyngeal, vagus and accessory nerves at the lower opening of the jugular foramen

Introdução: O forame jugular é uma abertura na base do crânio, entre os ossos occipital e temporal, por onde saem do crânio a veia jugular interna, os nervos cranianos glossofaríngeo, vago e acessório e, eventualmente, o seio petroso inferior. Objetivo: Estudar a disposição dessas estruturas anatômicas na abertura inferior do forame jugular. Métodos: Foram estudados 60 espécimes não formolizados. Resultados: Baseando-se em dados de literatura, foi criada uma classificação com quatro tipos de disposições, encontrando-se em 66,7% o tipo 1, com o nervo acessório cruzando a veia jugular interna pela parede anterior; em 28,3% o tipo 2, com o nervo cruzando a veia por trás; e em 5% o tipo 3, com o seio petroso presente abaixo do forame. O tipo 4, com um canal próprio para o nervo glossofaríngeo, não foi encontrado nesse estudo.

Introduction: The jugular foramen is an opening between the occipital and the temporal bones. Through it the internal jugular vein, the glossopharyngeal nerve, the vagal nerve, and the accessory nerve emerge from the skull, as well as sometimes the inferior petrosal sinus. Objective: To investigate the anatomical disposition of those structures in the exit of the foramen. Methods: Studies of 60 sides of not formalised corpses were made. Results: It was classified in four types, 1, 2, 3, and 4. Type 1 was the most common with the XI cranial nerve crossing the front of the internal jugular vein. It incidence was 66.7%. In type 2 with accessory nerve posterior to the vein the incidence was 28.3%. In type 3 with the inferior petrosal sinus draining in the internal jugular vein below the inferior opening of the jugular foramen the incidence it was 5% of cases, and type 4, with an own canal to the IX cranial nerve, was not observed in this study.

Is the Supraspinal Accessory Lymph Node Dissection Always Necessary in Thyroid Carcinoma Patients with Lateral Neck Node Metastasis? / 대한내분비외과학회지

PURPOSE: Controversy still exists concerning the extent of neck nodedissection in thyroid carcinoma patients. A modified neck dissection is usually performed for the treatment of thyroid carcinoma patients with positive lateral neck nodes. When performing a neck dissection, removal of the nodes superior to the spinal accessory nerve (level IIB) is difficult and time consuming. This study was performed to determine whether level IIB node dissection is always necessary in therapeutic neck dissection for metastatic papillary thyroid carcinoma. METHODS: A total of 200 neck dissections were performed in 175 papillary thyroid carcinoma patients with positive lateral neck nodes between September 2005 and June 2007. The patterns of lateral neck metastasis were analyzed with respect to neck level, but the level IIB nodes were studied as separate specimens. Potential factors predicting level IIB node metastasis were also evaluated. RESULTS: The most common site of metastasis was level III, showing 95.0% (190/200), followed by level IV 66.0% (132/200), level IIA 54.0% (108/200), and level V 15.5% (31/200). Level IIB metastases were seen in 12 necks (6.0%) and seen only in the necks with positive level IIA nodes. In 11 of the 12 necks, the primary tumors were located in the upper pole of the thyroid. CONCLUSION: Level IIB node dissection is not necessary when there is no level IIA metastasis. Even when there is level IIA metastasis, level IIB node dissection is not always necessary, unlessthe primary tumors are located in the upper pole of the thyroid.

Positive Effects of Local Anesthetic Nerve Blocks for a Patient with Newly Developed Left Side Spasmodic Torticollis after Surgical Intervention of Right Side Spasmodic Torticollis: A case report / 대한통증학회지

We report here on a case of right side spasmodic torticollis (ST) that was refractory to botulinum toxin type A injection and medication.The patient finally underwent a selective ramisectomy with ipsilateral sternocleidomastoid muscle (SCM) resection, but the remaining symptoms slowly aggravated, and a contralateral left side SCM spasm began.As conservative therapy for reducing the spasmodic symptoms, accessory nerve block, upper cervical plexus block and stellate ganglion block were performed twice in a week.After 6 months, the spasmodic symptoms significantly decreased. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) decreased by more than 70%.After one year of serial intermittent local anesthetic blockade therapy, the patient became almost free from the original ST symptoms (TWSTRS = 1).Serial local anesthetic interventions for the ST patient may have a beneficial role on the pathological peripherocentral neural activity of the ST patient and can modulate motor-sensory integration in the patient.