Accessory spinal nerve damage during a cervical lymph node biopsy: case report.

The lesion of the accessory spinal nerve is often of iatrogenic origin. We report the case of an injury after a right jugulocarotid lymph node biopsy. A 30-year-old patient was referred for the treatment of right cervical lymphadenopathy suspected of tuberculosis. After the intervention and confirmation of tuberculosis diagnosis, the patient presented a functional impotence of the right shoulder and swarming of the right hand. The clinical examination found an active limitation of the shoulder, and a wasting of the upper bundle of the right trapezius muscle and the sternocleidomastoid. The EMG showed axonotmesis of the accessory spinal nerve and the MRI an amyotrophy of the trapezius with denervation edema. A simple rehabilitation has been scheduled. Damage of the accessory spinal nerve most often occurs after local surgery. EMG is essential for diagnosis. Rehabilitation is the first therapeutic option. Surgery can be considered if it fails. The surgeons must consider the protection of the accessory spinal nerve in case of cervical lymph node surgery.

Spinal accessory nerve injury: A potentially missed cause of a painful, droopy shoulder.

BACKGROUND: Spinal accessory nerve (SAN) injury can be an overlooked cause of scapular winging and shoulder dysfunction. The most common etiology is iatrogenic injury following surgical procedures at the posterior triangle of the neck. We present three cases of isolated injury to the SAN following trauma. OBJECTIVE: To improve detection of SAN injuries through highlighting the clinical presentation, diagnosis and treatment via three cases in which the injuries were initially missed. METHODS: Clinical case series and narrative review. RESULTS: Three (3) patients were evaluated by history, physical exam and electrodiagnostic study (EMG). Clinical symptoms included, a painful, droopy shoulder and difficulties with overhead activities. Clinical signs included the observation of scapular winging, and focal atrophy of the trapezius and in some cases the sternocleidomastoid (SCM). Novel clinical signs such as the active elevation lag sign and triangle sign were also helpful clinically to highlight the SAN as the site of pathology. EMG revealed denervation and reduced motor unit recruitment in the trapezius and SCM. CONCLUSIONS: Early detection of SAN injuries can be improved through appropriate clinical suspicion, a detailed history and careful physical exam. EMG testing can help guide prognosis, direct conservative and surgical treatment, and reduce patient morbidity.

Electrophysiologic analysis of injury to cranial nerve XI during neck dissection.

BACKGROUND: Despite preservation of the accessory nerve, a considerable number of patients report partial nerve damage after modified radical neck dissection (MRND) and selective neck dissection. METHODS: Accessory nerve branches for the trapezius muscle were stimulated during neck dissection, and the M wave amplitude was measured during distinct surgical phases. RESULTS: The accessory nerve was mapped in 20 patients. The M wave recordings indicated that major nerve damage occurred during dissection at levels IIa and IIb in the most proximal segment of the nerve. The M waves evoked from this nerve segment decreased significantly during surgery (analysis of variance; p = .001). CONCLUSION: The most significant intraoperative injury to the accessory nerve during neck dissection occurs at anatomic nerve levels IIa and IIb. © 2015 Wiley Periodicals, Inc. Head Neck 38: E372-E376, 2016.

Complete Spinal Accessory Nerve Palsy From Carrying Climbing Gear.

We report an unusual case of spinal accessory nerve palsy sustained while transporting climbing gear. Spinal accessory nerve injury is commonly a result of iatrogenic surgical trauma during lymph node excision. This particular nerve is less frequently injured by blunt trauma. The case reported here results from compression of the spinal accessory nerve for a sustained period-that is, carrying a load over the shoulder using a single nylon rope for 2.5 hours. This highlights the importance of using proper load-carrying equipment to distribute weight over a greater surface area to avoid nerve compression in the posterior triangle of the neck. The signs and symptoms of spinal accessory nerve palsy and its etiology are discussed. This report is particularly relevant to individuals involved in mountaineering and rock climbing but can be extended to anyone carrying a load with a strap over one shoulder and across the body.

[Injury to the spinal accessory nerve during lymph node biopsy: expert witnesses and evidence-based procedures]. / Verletzung des Nervus accessorius im Rahmen von Lymphknotenexstirpationen - Begutachtung und evidenzbasierte operative Techniken.

INTRODUCTION: Injury to the spinal accessory nerve during lymph node biopsy in the lateral cervical triangle is a dreaded complication. It is disproportionately frequently the basis for medico-legal debates even though an evidence base is lacking. The scientific clarification of meaningful and mandatory measures during the procedure is essential. MATERIALS AND METHODS: A legal database query from 1970 to 2011 was carried out using related keywords. Judgements were examined for expert witnesses, and a literature search regarding expert witnesses was done. The arguments found were verified with respect to evidence. RESULTS: From 1970 to 2011, 18 verdicts were found with 11 claims upheld and seven rejected. Expert witnesses regularly asked for clear preparation of the nerve as well as the requirement of specialist standards, and often used the prima facie argument to show surgeon errors. In contrast, analyses of the literature showed a significant risk of injury during nerve preparation. The need for specialist standards remains, however, with significantly lower demands upon the expertise of the surgeon as described by expert witnesses. DISCUSSION: There was a lack of scientific evidence for special manoeuvers during surgical procedures in the lateral cervical triangle. This prompted experts to ask for scientifically unproved manoeuvers during the procedure. "Eminence-based" expert witnesses with a teaching aptitude still have considerable influence on judicial decisions but are an unnecessary burden regarding the provision of medical treatment.

Vernet's syndrome after carotid endarterectomy.

Unilateral paresis of cranial nerves IX to XI is defined as Vernet's syndrome. We retrospectively assessed cranial nerve symptoms from the clinical records of 143 carotid endarterectomy patients. A flexible nasolaryngoscope was used to examine vocal fold movements in 73 patients. If vocal fold paresis (VFP) was confirmed, the patient also underwent magnifying laryngoscopy (for correct diagnosis of injury to the glossopharyngeal and vagus nerves). It was found from clinical records that 8 patients (6%) were confirmed to have cranial nerve symptoms corresponding to Vernet's syndrome; 7 patients (9 %) had VFP on nasolaryngoscopy. In 2 patients, magnifying laryngoscopy confirmed ipsilateral VFP, pharyngeal paresis, pharyngeal wall hypesthesia, and ipsilateral pharyngeal wall swelling. These 2 patients also had symptoms of injury to the accessory nerve. Damage to cranial nerves IX to XI probably occurred in the parapharyngeal space, based on the existence of posterior pharyngeal wall edema or swelling after carotid endarterectomy.

Neck-shoulder pain and weakness: an uncommon presentation.

Neck and shoulder pain is a very common complaint in Western society that most often does not include motor compromise. Although peripheral nerve injuries are not as common, they should not be misdiagnosed. This case report describes the subjective assessment and physical examination of a patient with neck-shoulder pain and disabilities following a cervicofacial lift surgery. The patient was referred to physiotherapy treatment for what was diagnosed as a multi-level cervical disorder. Physical examination by the physiotherapist revealed diagnostic signs of accessory and suprascapular nerve injury as the cause of the shoulder impairment. Physiotherapy treatment included electrical motor stimulation and a comprehensive strengthening program, which resulted in full recovery. The purpose of this case study is to differentiate this presentation from commonly seen neck and shoulder pain by exploring the diagnostic factors for accessory and suprascapular nerve injury, based on the available evidence. The presented case report aims to raise the awareness of clinicians about the potential risk of peripheral nerve injury following cervicofacial lift, a common and elective surgical procedure.

Electrophysiological testing of spinal accessory nerve in suspected cases of nerve transection.

INTRODUCTION: In this study we sought to determine whether standard electrophysiological testing of the spinal accessory nerve (SAN) accurately identifies patients who would benefit from surgical repair. METHODS: Sixteen consecutive patients sent for surgical evaluation of unilateral SAN injury were studied clinically and electrophysiologically. RESULTS: All patients demonstrated a low-amplitude SAN compound muscle action potential (CMAP) that required a higher stimulus intensity to obtain it than on the unaffected side. Upper trapezius needle electromyography showed dense fibrillation potentials in 16 of 16 nerves, with voluntary motor unit potentials (MUPs) in 5 of 16. Intraoperatively, 12 of 16 nerves were transected; 4 of 16 had neuromas across which there was no nerve action potential. Patients underwent direct repair (6 of 16) or interpositional nerve grafting (10 of 16). Fourteen of 15 patients seen postoperatively had improvement in pain, muscle bulk, and range of motion. CONCLUSIONS: Surgical exploration of the SAN is warranted in patients with clinical signs of severe injury, even when electrophysiological testing shows low-amplitude CMAPs and/or residual MUPs.