Extracranial Spinal Accessory Nerve Injury

Abstract

Eighty-three consecutive patients with extracranial accessory nerve injury seen over a 12-year period are reviewed. The most common etiology was iatrogenic injury to the nerve at the time of previous surgery. Such operations were usually minor in nature and often related to lymph node or benign tumor removal. Examination usually distinguished winging due to trapezius weakness from that of serratus anterior palsy. Trapezius weakness was seen in all cases. Sternocleidomastoid weakness was unusual. Patients with accessory palsy were evaluated by both clinical and electromyographic studies. Patients who exhibited no clinical or electrical evidence of regeneration were operated on (44 cases). Based on intraoperative nerve action potential studies, 8 lesions in continuity had neurolysis alone. Resection with repair either by end-to-end suture or by grafts was necessary in 31 cases. One case had suture removed from nerve, two had nerve placed into target muscle, and two had more proximal neurotization. Function was usually improved in both operative and nonoperative patients. Related anatomy is discussed.

Accessory nerve monitoring and stimulation during neck surgery

“…In cases of iatrogenic XIth nerve injury, many studies have found that surgical repair gives generally good results: Williams et al 3 repaired 39 accessory nerves by either grafting or neurolysis and found 32 of these patients had improved symptoms of shoulder pain and weakness. Donner et al 1 repaired 31 nerves, most showing similar postoperative improvement. Weisberger 13 performed cable grafting of 20 nerves post-neck dissection, and found that resulting shoulder strength, function, and electromyography results were intermediate when compared to patients without XIth nerve injury and those with XIth nerve injury which was not repaired.…”

Refinements in the Technique for Repair of the Accessory Nerve

“…[3][4][5][6][7][8][9][10][11] This probably is because in the earlier reports the injuries predominantly occurred as a result of lymph node biopsy procedures (a punctate lesion). [3][4][5][6][7][8][9][10][11] All of our patients had surgery after extended palsy, and this long interval between injury and repair probably accounts for progressive retraction and scarring of the nerve stumps with a resultant wider gap between the nerve ends. Experimentally, we showed that the length of the nerve graft interferes with the recovery of mixed nerves.…”

“…2 Several investigators 3-12 have described series of patients with traumatic transection of the accessory nerve who have been explored and had the division repaired with good functional results. All of these surgeons, [3][4][5][6][7][8][9][10][11][12] however, characterized the surgery as difficult. Often a mixture of scar, blood vessels, lymph nodes, and adipose tissue occupies the region between the posterior border of the sternocleidomastoid muscle and the anterior border of the trapezius muscle, rendering identification of the nerve stumps laborious.…”

Treatment of scapular winging with modified Eden-Lange procedure in patient with pre-existing glenohumeral instability

“…Conservative treatment and physical therapy for spinal accessory nerve injuries have been shown to be unsuccessful because of the inability to adequately strengthen adjacent muscle groups to compensate for the trapezius palsy. 3,4,6,10,12,15,18,19 Therefore, the modified Eden-Lange procedure was chosen as the surgical treatment for our patient's lateral scapular winging. This procedure allowed him to achieve good results in terms of pain relief, strength, and stability after a routine physical therapy program (Table I).…”