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.

Electrophysiologic evidence of spinal accessory neuropathy in patients with cervical myofascial pain syndrome.

OBJECTIVE: To evaluate whether or not spinal accessory neuropathy exists in patients with cervical myofascial pain syndrome (MFPS). DESIGN: Prospective study. SETTING: A neurophysiologic laboratory in a university hospital. PARTICIPANTS: Patients with cervical MFPS (n=25) and healthy controls (n=20). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We performed nerve conduction studies (NCSs) in bilateral spinal accessory nerves, and electromyography and stimulated single-fiber electromyography in the trapezius muscles of all patients and controls. Parameters including nerve conduction velocities (NCVs), amplitudes and areas of compound muscle action potentials (CMAPs), and mean consecutive differences (MCDs) in single-fiber electromyography were measured, analyzed, and compared with the disease durations of the patients. RESULTS: Spinal accessory NCSs showed normative NCVs but with prominently reduced CMAP amplitude in the patients with cervical MFPS, which is recognized as an axonal neuropathy of the spinal accessory nerves. Electromyography showed prominent evidence of denervation and reinnervation patterns in 48% of the MFPS patients. The abnormal MCDs in single-fiber electromyography indicated a synaptic delay of motor endplates in the motor units, and may signify evolving instability of neuromuscular transmission in the spinal accessory nerves innervating trapezius muscles of the patients. CONCLUSIONS: This study demonstrates electrophysiologic evidence of neuroaxonal degeneration and neuromuscular transmission disorder in a significant proportion of patients with cervical MFPS. We suggest that spinal accessory neuropathy may be associated with cervical MFPS.

Spinal accessory nerve cavernous malformation.

We present the first reported case of a spinal accessory nerve cavernous malformation. A 54-year-old Caucasian male presented with a several-year history of progressive, vague bilateral upper and lower extremity paresthesias and pain. MRI of the spine revealed a heterogenously enhancing mass in the dorsal aspect of the spinal canal at the level of the atlas with mild spinal cord compression. The lesion was resected and upon gross and histologic examination it was a cavernous malformation embedded within a branch of the spinal accessory nerve. Post-operatively, the patient had no complications and some improvement in his symptoms. To our knowledge, this is the first report of a patient with a spinal accessory nerve cavernous malformation, and this should be considered in the differential of lesions in the craniocervical region.

Same modality nerve reconstruction for accessory nerve injuries.

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

Laryngeal zoster with multiple cranial nerve palsies.

A young immunocompetent patient is presented with a very rare presentation of a common viral illness: herpes zoster of the left hemilarynx with sensorial and motoric neuropathy of three ipsilateral lower cranial nerves: IX, X and XI. The mucosal lesions were discovered during upper gastrointestinal endoscopy. PCR of erosional exsudate confirmed the clinical diagnosis. Antiviral therapy and corticosteroids possibly contributed to the prosperous evolution with complete healing.

[Diagnostic complexities and anatomical surprises in a case of thyroid surgery for papillary carcinoma]. / Complessità diagnostiche e sorprese anatomiche in un caso di chirurgia tiroidea per carcinoma papillare.

We present the case of a male patient who needed surgery for a large undefined submandibular schwannoma and a small contralateral thyroid carcinoma associated with cervical lymph nodes of a dubious nature. During the operative procedure all the pathological conditions were resolved, with some remarkable surprises. A non-functioning parathyroid adenoma was found and removed. A fairly unusual anatomical complication was also detected with regard to the right inferior laryngeal nerve, i.e. an anastomotic branch connecting the main trunk to the vagus nerve.

Intractable hiccup as the initial presenting feature of systemic lupus erythematosus.

An infarctus of medulla oblongata was discovered in a 44-year old man with an intractable hiccup and 10, 11th and 12th right cranial nerves palsies. Systemic lupus erythematosus (SLE) with antiphospholipid syndrome was subsequently diagnosed. Hiccup has withdrew with corticosteroid therapy and low-dose aspirin. The other cases of literature and pathophysiologic hypotheses are briefly reported.

Spinal accessory neuropathy, droopy shoulder, and thoracic outlet syndrome.

Droopy shoulder has been proposed as a cause of thoracic outlet syndrome. Two patients developed manifestations of neurovascular compression upon arm abduction, associated with unilateral droopy shoulder and trapezius muscle weakness caused by iatrogenic spinal accessory neuropathies following cervical lymph node biopsies. The first patient developed a cold, numb hand with complete axillary artery occlusion when his arm was abducted to 90 degrees. The second patient complained of paresthesias in digits 4 and 5 of the right hand, worsened by elevation of the arm, with nerve conduction findings of right lower trunk plexopathy (low ulnar and medial antebrachial cutaneous sensory nerve action potentials). Spinal accessory nerve grafting (in the first patient) coupled with shoulder strengthening physical exercises in both patients resulted in gradual improvement of symptoms in 2 years. These two cases demonstrate that unilateral droopy shoulder secondary to trapezius muscle weakness may cause compression of the thoracic outlet structures.

Physical therapy for spinal accessory nerve injury complicated by adhesive capsulitis.

BACKGROUND AND PURPOSE: The authors found no literature describing adhesive capsulitis as a consequence of spinal accessory nerve injury and no exercise program or protocol for patients with spinal accessory nerve injury. The purpose of this case report is to describe the management of a patient with adhesive capsulitis and spinal accessory nerve injury following a carotid endarterectomy. CASE DESCRIPTION: The patient was a 67-year-old woman referred for physical therapy following manipulation of the left shoulder and a diagnosis of adhesive capsulitis by her orthopedist. Spinal accessory nerve injury was identified during the initial physical therapy examination, and a program of neuromuscular electrical stimulation was initiated. OUTCOMES: The patient had almost full restoration of the involved muscle function after 5 months of physical therapy. DISCUSSION: This case report illustrates the importance of accurate diagnosis and suggests physical therapy intervention to manage adhesive capsulitis as a consequence of spinal accessory nerve injury.

Spasmodic torticollis due to neurovascular compression of the spinal accessory nerve by the anteroinferior cerebellar artery: case report.

OBJECTIVE AND IMPORTANCE: Spasmodic torticollis is a neuromuscular disorder characterized by uncontrollable clonic and intermittently tonic spasm of the neck muscles. We report a case of spasmodic torticollis attributable to neurovascular compression of the right XIth cranial nerve by the right anteroinferior cerebellar artery (AICA). CLINICAL PRESENTATION: A 72-year-old man with a 2-year history of right spasmodic torticollis underwent magnetic resonance imaging, which demonstrated compression of the right XIth cranial nerve by an abnormal descending loop of the right AICA. INTERVENTION: The patient underwent microvascular decompression surgery. During surgery, it was confirmed that an abnormal loop of the right AICA was compressing the right accessory nerve. Compression was released by the interposition of muscle between the artery and the nerve. CONCLUSION: The patient's postoperative course was uneventful, and his symptoms were fully relieved at the 2-year follow-up examination. This is the first reported case of spasmodic torticollis attributable to compression by the AICA; usually, the blood vessels involved are the vertebral artery and the posteroinferior cerebellar artery.