The necessity of IIb dissection in T1-T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial.

BACKGROUND: There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, "shoulder syndrome" appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1-2N0M0 oral squamous cell carcinoma (OSCC). METHODS: We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression-free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant-Murley scale to measure shoulder function. DISCUSSION: Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1-T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800019128 . Registered on 26 October 2018.

Unsafe workout: a weak and painful shoulder in a professional volleyball player.

A 29-year-old professional volleyball player started complaining of a dull ache in the right lateral base of the neck. This pain arose during a preseasonal athletic training intense session. After 3 days, he presented deficiency of right scapula adduction, limitation of scapula elevation, right shoulder weakness and local mild pain. He had asymmetrical neckline with drooping of the affected shoulder, lateral displacement and minimal winging of the right scapula. After 1 week, hypothrophy of superior trapezius appeared. An electromyography of right upper limb showed a denervation in the upper, middle and lower components of the right trapezius muscle, due to axonotmesis of spinal accessory nerve (SAN). A subsequent MRI was consistent with muscular suffering caused by early denervation. This case shows idiopathic SAN palsy, likely secondary to an inappropriate use of a weight-lifting machine, where the athlete recovered after an adequate rest and rehabilitation period.

Anatomy, Etiology, and Management of Scapular Winging.

Scapular winging is a painful and debilitating condition. The composite scapular motion of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. The most common causes reported in the literature for scapular winging are dysfunction of the serratus anterior from long thoracic nerve injury causing medial winging or dysfunction of the trapezius from spinal accessory nerve injury causing lateral winging. Most reviews and teaching focus on these etiologies. However, acute traumatic tears of the serratus anterior, trapezius, and rhomboids off of the scapula are important and under-recognized causes of scapular winging and dysfunction. This article will review the relevant anatomy, etiology, clinical evaluation, diagnostic testing, and treatment of scapular winging. It will also discuss the differences in diagnosis and management between scapular winging arising from neurogenic causes and traumatic muscular detachment.

Ultrasound in the management of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area.

INTRODUCTION: The purpose of this study was to evaluate the application of ultrasound in the management of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area. METHODS: In this retrospective study, we compared ultrasonographic results with intraoperative findings in patients with iatrogenic spinal accessory nerve palsy during the time period from 2014 to 2018 at our hospital. RESULTS: Eleven patients were included. Ultrasound detected nerve transections in 9 patients and continuities in 2 patients. The ultrasonographic results were consistent with the intraoperative findings. Furthermore, ultrasound was able to accurately reveal lesion location in 8 of 9 patients with nerve transections. DISCUSSION: Ultrasound provides direct images about nerve lesions contributing to the diagnosis of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area and also reveals lesion location, assisting in formulating suitable surgical plans preoperatively. We recommend that ultrasound be integrated into the preoperative evaluation. Muscle Nerve 59:64-69, 2019.

Comparison of hospital based and home based exercise on quality of life, and neck and shoulder function in patients with spinal accessary nerve injury after head and neck cancer surgery.

OBJECTIVES: The purpose of this study was to compare the effects of hospital-based and home-based exercise programs on quality of life (QOL) and neck and shoulder function of patients who underwent head and neck cancer (HNC) surgery. METHODS: This clinical trial included 40 patients with neck and shoulder dysfunction after HNC. The exercise program included range of motion (ROM) exercises, massage, stretching, and strengthening exercises. Twenty patients who were assigned to the hospital-based exercise group performed physical therapy for 40 min three times a week for four weeks, and the remaining 20 patients were assigned to the home-based group. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck Questionnaire (EORTC QLQ-H&N), the Neck and Shoulder Disability Index (NDI), ROM, and numeric rating scale (NRS) were assessed before and after the exercise program. The program consisted of a 10-minute ROM to the neck and shoulder, a 10-minute massage, and 15 min of progressive resistance exercises, followed by a five-minute stretching exercise. RESULTS: There were statistically significant differences in the changes of neck and shoulder disability index (p < .05). Additionally, there were significant differences in neck extension and rotation ROM and NRS in the hospital-based group compared with the home-based group (p < .05). QOL was not significantly different between the two groups. CONCLUSIONS: Home-based exercise was effective for improving QOL, shoulder function, and pain relief. Hospital-based exercise had better effects on physical function of the neck and shoulder and reduced pain.

Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury.

OBJECTIVE Spinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients. METHODS Six fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN. RESULTS The mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patient's denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment. CONCLUSIONS NFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.

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.

Expanding what is known of the anatomy of the spinal accessory nerve.

The spinal accessory nerve (SAN) is classically considered a motor nerve innervating the sternocleidomastoid and trapezius muscles. Its anatomical relevance derives from the high prevalence of lesions following head and neck surgeries. As expected, trapezius weakness and atrophy are the most common findings; however, it is also commonly accompanied by pain and other sensory deficits that have no clear explanation, suggesting other functions. We have recently seen two patients presenting with an unrecognized sign, that is, subclavicular/pectoral asymmetry secondary to the SAN lesion. Retrospectively, we reviewed other patients with similar findings in our case series and in the literature. We discuss the anatomical connections of the SAN with the superficial cervical plexus and propose an explanation for this finding. Of the 41 patients in our series, we identified this sign in all who had preoperative photographs. New insights on the anatomy and connections of the SAN may account for the diversity of symptoms and signs presented following an operative intervention as well as the variability of its severity.

Measurement of the trapezius muscle volume: A new assessment strategy of shoulder dysfunction after neck dissection for the treatment of head and neck cancers.

BACKGROUND: The purpose of this study was to determine the actual degree of shoulder muscle change and its relation to symptoms after neck dissection for head and neck cancers. METHODS: Forty-two patients who underwent unilateral neck dissection were selected. Data obtained from each subject were trapezius muscle volume ratio and a Shoulder Disability Questionnaire (SDQ) score. Patients who had undergone neck dissection with spinal accessory nerve (SAN) preservation were compared with those who had received radical neck dissection. The preservation group was further separated into subgroups by the extent of neck dissection. RESULTS: Trapezius muscle volume ratio was higher and SDQ score was significantly lower in the SAN preservation group compared to the radical neck dissection group. However, the SAN preservation subgroups did not differ from each other. In addition, a good correlation between the muscle volume ratio and SDQ score was observed. CONCLUSION: With trapezius muscle volume ratio, clinicians may be able to diagnose shoulder dysfunction after neck dissection. Further research on the subject is warranted. This suggests a novel strategy for assessing the degree of shoulder dysfunction.

Maximizing shoulder function after accessory nerve injury and neck dissection surgery: A multicenter randomized controlled trial.

BACKGROUND: Shoulder pain and dysfunction after neck dissection may result from injury to the accessory nerve. The effect of early physical therapy in the form of intensive scapular strengthening exercises is unknown. METHODS: A total of 59 neck dissection participants were prospectively recruited for this study. Participants were randomly assigned to either the intervention group (n = 32), consisting of progressive scapular strengthening exercises for 12 weeks, or the control group (n = 29). Blinded assessment occurred at baseline, and at 3, 6, and 12 months. RESULTS: Three-month data were collected on 52 participants/53 shoulders. Per-protocol analysis demonstrated that the intervention group had statistically significantly higher active shoulder abduction at 3 months compared to the control group (+26.6°; 95% confidence interval [CI] 7.28-45.95; p = .007). CONCLUSION: The intervention is a favorable treatment for maximizing shoulder abduction in the short term. The effect of the intervention compared to usual care is uncertain in the longer term.

Anatomic study of the intercostal nerve transfer to the suprascapular nerve and a case report.

The purpose of this study was to investigate the anatomical basis of intercostal nerve transfer to the suprascapular nerve and provide a case report. Thoracic walls of 30 embalmed human cadavers were used to investigate the anatomical feasibility for neurotization of the suprascapular nerve with intercostal nerves in brachial plexus root avulsions. We found that the 3rd and 4th intercostal nerves could be transferred to the suprascapular nerve without a nerve graft. Based on the anatomical study, the 3rd and 4th intercostal nerves were transferred to the suprascapular nerve via the deltopectoral approach in a 42-year-old man who had had C5-7 root avulsions and partial injury of C8, T1 of the right brachial plexus. Thirty-two months postoperatively, the patient gained 30° of shoulder abduction and 45° of external rotation. This procedure provided us with a reliable and convenient method for shoulder function reconstruction after brachial plexus root avulsion accompanied with spinal accessory nerve injury. It can also be used when the accessory nerve is intact but needs to be preserved for better shoulder stability or possible future trapezius transfer.

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.

Neuroanalysis: a method for brain-related neuroscientific diagnosis of mental disorders.

BACKGROUND: As an Ancient Chinese proverb says "The beginning of wisdom is to call things by their right names" thus we must start calling mental disorders by the names of their underlying brain disturbances. Without knowledge of the causes of mental disorders, their cures will remain elusive. METHODS: Neuroanalysis is a literature-based re-conceptualization of mental disorders as disturbances of brain organization. Psychosis and schizophrenia can be re-conceptualized as disturbances to connectivity and hierarchical dynamics in the brain; mood disorders can be re-conceptualized as disturbances to optimization dynamics and free energy in the brain, and finally personality disorders can be re-conceptualized as disordered default-mode networks in the brain. RESULTS AND CONCLUSIONS: Knowledge and awareness of the disease algorithms of mental disorders will become critical because powerful technologies for controlling brain activity are developing and becoming available. The time will soon come when psychiatrists will be asked to define the exact 'algorithms' of disturbances in their psychiatric patients. Neuroanalysis can be a starting point for the response to that challenge.

Shoulder function after selective and superselective neck dissections: clinical and functional outcomes.

The aim of this work is to assess the clinical and functional outcome of patients who underwent different types of neck dissection, with special regards to the spinal accessory nerve, trapezius muscle and shoulder function. From February 2008 to July 2010, we evaluated 17 cases of neck dissection in patients affected by laryngeal carcinoma clinically staged N0. We performed selective neck dissection (IIA-IIBIII- IV) in 11 cases (group A) and superselective neck dissection in 6 cases (group B). All patients underwent clinical examination before surgery to evaluate shoulder function. They also underwent functional evaluation of the spinal accessory nerve through electromyography (study of muscular activity) and electroneurography (study of motor action potential). Patients were evaluated before surgery (T0), 8 days after surgery (T1) and 21 days after surgery (T2). In all cases, at the end of surgery it was possible to assess the integrity of the spinal accessory nerve. The average value of the MAP was 13.06 in group A and 10.98 in group B at T0. Eight days after surgery (T1) the value of MAP was reduced to 1.35 in group A and 6.15 in group B. Electromyography evaluation showed signs of denervation in 6 cases in group A and in 2 cases in group B. Voluntary activity was not detectable in 6 cases in group A, while it was present, even if reduced, in all cases in group B. At 21 days after surgery (T2), we found a value of MAP of 1.03 in group A and 6.43 in group B. Electromyography showed signs of denervation in 10 patients in group A and in 3 cases in group B. Voluntary activity was not detectable in 10 cases in group A, while it was present in all cases in group B. The arm abduction test was 2.5 in group A and 4.0 in group B. Neck dissection quality of life questionnaire showed a value of 24.17 in group A and a value of 25.5 in group B. Our data thus confirm that surgical manipulation of the nerve may be associated with severe impairment of nerve conduction when sublevel IIB is involved in the dissection.

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.