Spinal Accessory Dysfunction Following Neck Dissection with Harmonic Scalpel V/S Electrocautery – A Single Centre Experience

Aims:This study is an effort towards comparing the efficacy of the Harmonic Focus and Electrosurgical technique with regard to nerve injury especially spinal accessory nerve and its morbidity postoperatively after neck dissection.Sample:Ninety patients of oral carcinoma who required neck dissection were included in the study.Study Design:This is a prospective study.Place and Duration of Study:Bhagwan Mahaveer Cancer Hospital & Research Centre, Jaipur, Rajasthan, India for a period of 17 months from November 2016 to March 2018.Methodology:Patients’ post-operative recovery was studied prospectively by using parameters pertaining to shoulder function and shoulder pain.Results:There were significant differences in the pain and abduction deformity at various time periods after surgery. However differences in the quality of life did not show significant difference at the end of 3 months. For up to one month pain scores were lower for Harmonic Focus and shoulder function was better through 3 months.Conclusion:Though the technique of neck dissection (harmonic v/s electro cautery) has significant impact on shoulder dysfunction, despite that in postoperative period shoulder function measured by way of shoulder pain and shoulder abduction recover almost fully during follow-up period without causing significant morbidity and with minimal effect on quality of life. There are few recommendations we would like to suggest that if incorporated, they might significantly affect the outcome and better results.

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.

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.

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.

Neuromuscular Ultrasound of Cranial Nerves

Ultrasound of cranial nerves is a novel subdomain of neuromuscular ultrasound (NMUS) which may provide additional value in the assessment of cranial nerves in different neuromuscular disorders. Whilst NMUS of peripheral nerves has been studied, NMUS of cranial nerves is considered in its initial stage of research, thus, there is a need to summarize the research results achieved to date. Detailed scanning protocols, which assist in mastery of the techniques, are briefly mentioned in the few reference textbooks available in the field. This review article focuses on ultrasound scanning techniques of the 4 accessible cranial nerves: optic, facial, vagus and spinal accessory nerves. The relevant literatures and potential future applications are discussed.

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.

Bilateral variation in the Origin of Sternocleidomastoid muscle.

Morphological variations of sternocleidomastoid are not uncommon. During our routine dissection, in the department of anatomy PIMS Jalandhar, we encountered a rare case of presence of third head of sternocleidomastoid, bilaterally. This anomalous head is arising from clavicle lateral to the clavicular head of sternocleidomastoid muscle. This report not only adds to the knowledge of anatomists but will hold good to surgeons, anaesthetists and radiologists as well.

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.

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.

An Immunohistochemical Tracing on the Central Neural Pathways of the Spinal Accessory Nerve using Pseudorabies Virus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVE: The transsynaptic transfer of neurotropic viruses is an effective tool for tracing chains of connected neurons because the replication of virus in the recipient neurons after transfer amplifies the "tracer signal". The purpose of study was to identify the location of spinal nucleus of the accessory nerve and the central neural pathways using Bartha strain of Pseudorabies virus (PRV-Ba), as a transsynaptic tracer. MATERIALS AND METHODS: PRV-Ba was injected into the sternocleidomastoid muscle of a rat, and the localization of PRV-Ba in the rat spinal cord and CNS was identified with light microscopic immunohistochemistry using primary antibodies against the PRV-Ba. RESULTS: Sequential tracing of retrogradely labeled cells was done. The shapes of positive immunoreactive cells were mostly ovoid or polygonal, and were shown in the spinal nucleus of the accessory nerve, nucleus ambiguus, paraventricular nucleus, and the primary motor area of cerebral cortex. CONCLUSIONS: These results showed the location of spinal accessory nucleus and the central neural pathways of spinal accessory nerve using PRV-Ba.

Innervation of the Trapezius Muscle by the Intraoperative Motor Nerve Conduction Study

OBJECTIVE: The purpose of study was to demonstrate the presence of motor input from the spinal accessory and the branches of the upper cervical plexus. METHOD: Twenty-four patients were studied during modified radical neck dissection. The entire length of the spinal accessory nerve, the contributions from the upper cervical plexus and some cervical plexus branches to run to the trapezius independently were preserved in each of these patients. Compound muscle action potentials were measured to each part of the trapezius muscle on stimulation of the spinal accessory, C2, C3, and C4 nerves. RESULTS: Spinal motor nerve evoked responses were obtained from all 24 patients in the upper, middle, and lower trapezius. C2 contributions were seen in 2 out of 24 patients, but were in no patient supplying all three parts of the muscle. C3 contributions were seen in 11 out of 24 patients, but C3 nerve supplied all three parts of the muscle in 8. C4 contributions were seen in 20 out of 24 patients, supplying all three parts of the muscle in 16. CONCLUSION: This study demonstrated that the spinal accessory nerve provided the most important and consistent motor input to the trapezius muscle. Although C2, C3, and C4 provided motor input to the trapezius muscle, they were not consistently present and if present, did not consistently innervate all three parts of the trapezius. Compared with other studies, it was interesting to note that C4 gave more consistent motor input to the trapezius than other cervical branches.

Study of the Shoulder Function after Neck Dissection / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Radical neck dissection (RND) has been a standard treatment for the head and neck cancer with metastasis to the cervical lymphatics. The sacrifice of the spinal accessory nerve which innervates the trapezius muscle creates a definite impairement of the shoulder function. Therefore, the modified radical neck dissection (MRND) has been introduced in order to minimize the postoperative morbidities. But, even if the spinal accessory nerve has been preserved, the impaired shoulder function has been reported in some studies. The degree of the shoulder dysfunction after RND tended to be minimal in a few patients. The purpose of this study was to evaluate the shoulder function according to the various types of the neck dissection in 39 cases of 24 patients. MATERIALS AND METHODS: The shoulder functions were evaluated using clinical examinations and the electrodiagnostic method of the trapezius muscles. The results of each test according to the types of neck dissection were compared. RESULTS: We observed a significant correlation between the clinical parameters and electrodiagnostic results. The functional results of the trapezius muscle in the group of modified radical neck dissection were better than that of the radical neck dissection. In the RND group, 80% of the cases presented incomplete denervation of the trapezius muscle, so it might provide a evidence of innervation of the other nerves to this muscle. In the MRND group, 45% of the cases presented partial denervation of the trapezius muscle, indicating that it might have been caused by damage during the operations. CONCLUSION: We found that careful manipulation of the nerve should be required in order to preserve the spinal accessory nerve. Rehabilitative therapy can also improve the shoulder function after neck dissection. Further studies including anatomic dissection and intraoperative electrophysiologic evaluation of the innervation in the trapezius muscle should be performed.

Function of Trapezius Muscle after Various Types of Neck Dissection

Radical neck dissection(RND) has been a standard treatment for the head and neck cancer with metastasis to the cervical lymphatics. The sacrifice of the spinal accessory nerve innervating trapezius muscles creates a definite deficit of the shoulder function. Therefore, the modified radical neck dissection(MRND) preserving one or more structures of the spinal accessory nerve, internal jugular vein or sternocleidomastoid muscle was introduced to minimize the postoperative morbidities. We studied the shoulder function by clinical examinations and electrodiagnosis for the various types of neck dissection in 39 cases of 24 patients and compared the results of each test according to the types of neck dissection. Correlation between the clinical parameter and electrodiagnostic results showed a statistical significancy. The functional results of trapezius muscle in the group of modified radical neck dissection were better than those of the radical neck dissection. The fact that 80% of the cases in the RND group presented incomplete denervation of the trapezius muscle, suggests the innervation of other nerves to this muscle. Forty five percents of the cases in the MRND group which presented partial denervation of the trapezius muscle, might be due to the damages during operations. To preserve the spinal accessory nerve, a careful manipulation of the nerve is required. Further studies including an anatomic dissection and intraoperative electrophysiologic evaluation of the trapezius muscle should be performed for the better rehabilitation outcomes.

Intracranial Schwannoma of the Spinal Accessory Nerve

A 28-year-old man presented with ataxic gait, left side hearing loss and vertigo, symptoms which had first appeared four months previously. MRI showed a 3X4cm mass in the left cerebellopontine angle. The tumor was totally removed via the suboccipital route; During removal, the distal part of the nerve root from which the tumor arose was stimulated and confirmed to be a spinal accessory nerve. Immediately after surgery, the patient's hearing returned and the other symptoms improved rapidly. Histologic examination showed that the tumor was a schwannoma.

Upper Cervical Ventral Rhizotomy and Selective Spinal Accessory Nerve Section for Spasmodic Torticollis

As one of the various surgical procedures for the spasmodic torticollis the author performed bilateral C1, 2, 3 ventral rhizotomy and unilateral selective spinal accessory nerve section in 4 patients with disabling torticollis, The patients consisted of 3 men and 1 woman with symptom duration of 1 to 3 years. The surgical outcome was excellent in 2, markedly improved in 1 and slightly improved in 1. Postoperative complications were shoulder weakness, transient leg weakness, voiding difficulty and mild weakness of neck movement.

Surgical Treatment of Spasmodic Torticollis by Microvascular Decompression with Selective Dorsal Cervical Phizotomy: Case Report

A case of spasmodic torticollis in a 48-year-old man cured by micovascular decompression of the spinal accessory nerve with selective dorsal cervical rhizotomy of the first and second cervical nerves. The 11th nerve was compressed by the posterior inferior cerebellar artery originating from the vertebral artery at the C1 level. After intraoperative identification of each posterior rootlets of C1 and C2 nerves exclusively related with the involved sternocleidomastoid muscle(SCM) using the monopolar electric nerve stimulator, microvascular decompression with selective dorsal cervical rhizotomy was done using the Teflon felt and electrobipolar coagulator. The patient was significantly relieved from symptoms 1 week after operation.