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.

Safety and Efficacy of Primary Multisession Dose Fractionated Gamma Knife Radiosurgery for Jugular Paragangliomas.

BACKGROUND: While multisession dose fractionated Gamma Knife radiosurgery (DFGKS) is common, its use has never been described for jugular paragangliomas (JP), which are notoriously difficult to treat. OBJECTIVE: To define efficacy, safety, and complication profile of DFGKS in 2 or 3 consecutive sessions for the treatment of a cohort of 10 cases of JP. METHODS: Between 2012 and 2017, 10 patients with JP were treated with DFGKS in 2 or 3 sessions, because it was not safe to treat the lesion in a single session because of the large volume or proximity to organs at risk. The small to medium-sized JP are treated with 16-22 Gy radiation, but the large-volume JP were treated with 23-25 Gy radiation dose. The Leksell G frame was kept in situ during the whole procedure. The tumor volumes on pretreatment and posttreatment imaging were compared, using the Leksell Gamma Plan treatment plan software to assess tumor progression. The patients were regularly evaluated for their clinical outcome with radiologic correlation. RESULTS: The mean radiologic follow-up was 39 months (range, 12-78 months). The mean marginal dose for 3 fractions and 2 fractions was 7.64 Gy at 50% and 11.2 Gy at 50%, respectively. The mean tumor size was 29.9 cm3 (range, 9.95-47.63 cm3) at treatment and 21.9 cm3 (range, 8.83-37.5 cm3) at follow-up (suggestive of 26.7% reduction). Tumor control was achieved in all patients (100%). Of 110 potential neurologic problems (signs/symptoms) evaluated (11 in each patient), 56 (50.9%) were present preoperatively. Of them, 27 (48.2%) improved and 29 (51.8%) stabilized after treatment. There were 2 new-onset neurologic problems (of 110, 1.8%) attributable to treatment (new-onset headache and spinal accessory paresis). No patient had any permanent neurologic deterioration. CONCLUSIONS: DFGKS for large-volume JP leads to acceptable progression-free survival, tumor control rate, and symptomatic improvement. It may be preferred to surgery or fractionated radiotherapy given its better safety, efficacy, and complication profile.

Carotid artery pseudoaneurysm after orthognathic surgery causing lower cranial nerve palsies: endovascular repair.

PURPOSE: Reported complications following Le Fort osteotomies are rare but can include epistaxis from disruptions or pseudo-aneurysms of the maxillary artery or its distal branches the descending palatine and sphenopalatine arteries, aseptic necrosis of the maxilla, ophthalmic injuries including blindness, ophthalmoplegia, and keratitis sicca, and arteriovenous fistulas or false aneurysms of the carotid arteries (external and/or internal). The mechanism of injury to neurovascular structures can be the result of direct or indirect trauma, such as injuries from surgical instruments, traction injuries during manipulation of the osteotomized bone segments or during inadvertent manipulations of the head and neck, or from fractures extending to the base of the skull, orbit, or pterygopalatine fossa associated with the pterygomandibular dysjunction or maxillary downfracture. CASE REPORT: An 18 year-old male with facial bone dysplasia, apertognathia, maxillary hypoplasia and mandibular hyperplasia was treated with maxillary Le Fort I osteotomy with internal fixation and elastic intermaxillary fixation. Following surgery, the patient developed palsies of the vagus and accessory nerves manifesting as dysphagia, cough, vocal cord paralysis and trapezius muscle atrophy. Cross sectional imaging revealed a small, laterally pointing pseudoaneurysm of the high cervical internal carotid artery (ICA) at the skull base, exerting pulsatile mass effect on adjacent lower cranial nerves. The patient was treated with carotid artery stent reconstruction and pseudoaneurysm coil obliteration, and kept on dual antiplatelet therapy for two months. Partial recovery from cranial nerve palsies was observed within a year. CONCLUSION: A small, broad-based, laterally-pointing ICA pseudoaneurysm at the exit of the carotid canal without surrounding hematoma was clearly demonstrated on CTA, which visualization was difficult on MRA due to considerable metallic artifact from surgical hardware. Angiography exquisitely demonstrated the pseudoaneurysm, which was fully repaired with the combination of stenting and coil obliteration, allowing total preservation of the ICA.

Transfemoral transarterial onyx embolization of carotid body paragangliomas: technical considerations, results, and strategies for complication avoidance.

BACKGROUND: The association of carotid body paragangliomas with neurovascular structures can cause cranial nerve injury and significant intraoperative blood loss. Preoperative embolization may be performed either percutaneously or transarterially. OBJECTIVE: We reviewed our experience with transfemoral transarterial Onyx embolization. METHODS: We retrospectively reviewed a prospectively maintained database of head and neck tumors embolized between November 2007 and February 2012. Patients were assessed for number of sessions of embolization, number of pedicles embolized, fluoroscopic time, extent of tumor devascularization as assessed by postembolization angiography, and operative blood loss. RESULTS: Eleven patients (5 men, 6 women; mean age, 48.1 years) with 13 paragangliomas (5 right-sided, 9 left-sided, 2 bilateral) underwent preoperative embolization for 12 tumors. Onyx alone was used in 9 cases. In a mean of 1.2 embolization sessions (range, 1-2), an average of 2.8 pedicles (range, 1-7) was embolized. The average fluoroscopic time was 54.3 minutes. In 5 cases, the tumors were completely devascularized by using this strategy. In 5 cases, more than 90% tumor devascularization was achieved. In the remaining 2 cases, tumor devascularization was more than 50%. A partial cranial nerve XII palsy was the only postprocedural complication. The mean surgical blood loss was 191.7 mL (range, 25-600 mL). CONCLUSION: The arterial supply to carotid body tumors can be catheterized effectively through a transfemoral approach, permitting embolization of feeding pedicles. Transarterial Onyx embolization of these lesions is safe and effective, and it decreases blood loss during surgical resection.

Late-onset spinal accessory nerve palsy after traffic accident: case report.

An injury to the spinal accessory nerve is mostly reported after surgical procedures performed in the posterior triangle of the neck. In addition, it may be caused by fractures in the jugular foramina, traumas or skull base tumors. Clinically, paralysis of the trapezius muscle leads to weakness, downward rotation of the scapulae and falling down of the shoulder girdle. A 38- year-old male with left shoulder pain, scapular deviation and weakness in the left upper extremity, whose symptoms developed over a two-year period following a traffic accident, is presented herein. In the electromyography (EMG) study, partial spinal accessory nerve palsy was detected. The patient was treated conservatively for the nerve palsy since the time elapsed rendered surgical intervention inappropriate. We report a case in which spinal accessory nerve palsy developed two years after a traffic accident. Accessory nerve injury following a traffic accident is very uncommon.

[Villaret's syndrome caused by internal carotid artery dissection].

We report a patient with Villaret's syndrome (left hypoglossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve palsies and left Horner's sign) caused by internal carotid artery dissection. He had neck pain on the left side, Horner's sign on the left side and paralysis of the left hypoglossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve. Brain MRI revealed no signal from the left internal carotid artery and no brain infarction, although a tumor-like lesion was observed in the left internal carotid artery. Subsequent MRI studies revealed intramural hematoma in the left internal carotid artery, and on the basis of this finding, he was diagnosed with internal carotid artery dissection. He received anticoagulant and antiplatelet therapy. His symptoms improved gradually. The symptoms of internal carotid artery dissection are neck pain, Horner's sign, brain infarction, and lower cranial nerve palsy. A characteristic feature in this case was that brain infarction was not observed. Only 3 similar cases have been reported in the past In all these cases, the patients had a good clinical course and showed complete recovery from the symptoms. Compared with western countries, in Japan, carotid artery dissection is rare. Carotid artery dissection should be considered as a differential diagnosis of lower cranial nerve palsy.

Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: a literature review.

BACKGROUND: Neck dissection is an operation that can result in accessory nerve injury. Accessory nerve shoulder dysfunction (ANSD) describes the pain and impaired range of motion that may occur following neck dissection. The aim of this review was to establish the level of evidence for the effectiveness of physiotherapy in the postoperative management of ANSD. METHODS: A literature search of physiotherapy and ANSD using Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), and Cochrane Library databases was undertaken. RESULTS: Physiotherapy has been shown to be well tolerated in this patient group following surgery. However, few studies exist as to the effect of physiotherapy on ANSD. CONCLUSIONS: There is a need for research to investigate the effects of early, appropriate physiotherapy on the development of ANSD following neck dissection surgery. Such a study has the potential to improve the functional outcome and quality of life in this patient group, and ultimately to promote best practice guidelines for management.

Combined injury of the accessory nerve and brachial plexus.

BACKGROUND: Stretch-induced spinal accessory nerve palsy has been considered extremely rare, with only a few cases reported. OBJECTIVE: In 357 patients with stretch lesions of the brachial plexus, we investigated the prevalence, course, and surgical treatment of accessory nerve palsy. METHODS: Accessory nerve palsy was ascertained when the patient was unable to shrug the ipsilateral shoulder. Patients underwent brachial plexus reconstruction between 6 and 8 months after trauma. To confirm paralysis, during surgery, the accessory nerve was stimulated electrically. RESULTS: Accessory nerve palsy occurred in 19 of the 327 patients (6%) with upper type or complete palsy of the brachial plexus. Proximal injuries of the accessory nerve accompanied by voice alteration and complete palsy of the sternocleidomastoid and trapezius muscle occurred in 2 patients. Proximal palsy without vocal alterations was observed in 6 patients. Palsy of the trapezius muscle with preservation of the sternocleidomastoid muscle occurred in 11 patients. All 7 patients who demonstrated muscle contractions upon electrical stimulation of the accessory nerve during surgery recovered completely. Patients with surgical reconstruction of the accessory nerve through grafting (n = 2) or repair by platysma motor nerve transfer (n = 2) recovered active shoulder shrugging within 36 months of surgery. Seven of the 8 patients without accessory nerve reconstruction recovered from their drop shoulder and head tilt, but remained unable to shrug. CONCLUSION: If intraoperative electrical stimulation produces contraction of the upper trapezius muscle, no repair is needed. In proximal injuries, the platysma motor branch should be transferred to the accessory nerve; whereas in paralysis distal to the sternocleidomastoid muscle, the accessory nerve should be explored and grafted.

Open functional neck dissection: surgical efficacy and electrophysiologic status of the neck and accessory nerve.

OBJECTIVE: To compare a novel functional neck dissection technique that offers wider exposure and reduced morbidity compared to classic functional neck dissection, which is the gold standard for neck treatment of squamous cell carcinoma of the head and neck. STUDY DESIGN: A prospective, double-blind, controlled clinical study. SETTING: Fifty surgical neck dissections were performed on 25 patients diagnosed with laryngeal cancer. SUBJECTS AND METHODS (MAIN OUTCOME MEASURES): The open neck dissection technique was used on the primary tumour side (study group) and functional neck dissection was used on the other side (control group). Electromyographic measurements of the trapezius and sternocleidomastoid muscles and neurologic evaluations were performed preoperatively and at 1 and 6 months postoperatively. Also, the number and tumour stages of lymph nodes excised during neck dissection were evaluated by histopathologic examination as a measure of surgical efficacy. RESULTS: The electromyographic measurements of the study group at 1 and 6 months postoperatively were found to be superior to those of the control group, although the difference between the groups was not significant. The mean number of dissected lymph nodes was significantly higher in the study group than in the control group. CONCLUSION: The open functional neck dissection procedure described in this study allows wider exposure, reduces the acute morbidity associated with the spinal accessory nerve compared to classic modified neck dissection, and offers improved surgical efficacy with respect to lymphadenectomy.

Accessory nerve palsies.

Accessory nerve palsies may cause considerable functional disability and they unfortunately continue to occur as a complication of surgery in and, around the posterior triangle of the neck. Here the causes of accessory nerve palsies are reviewed and the symptoms and signs arising as a consequence are summarised. In addition, the various treatments and their indications are highlighted and discussed.

Idiopathic spinal accessory nerve palsy. A case report.

Spinal accessory nerve palsy may lead to dysfunction or paralysis of the trapezius muscle. Common causes are iatrogenic or secondary due to trauma, infection or tumour. Idiopathic palsy is considered extremely rare. We present the case of a 42-year-old Caucasian male suffering from a unilateral, isolated paralysis of his ipsilateral trapezius muscle. There was no related trauma, nor any past history of surgical procedures. An electromyographic study confirmed the idiopathic paralysis of the distal segment of the spinal accessory nerve.

A case of Collet-Sicard syndrome presenting to the Oral and Maxillofacial Surgery Department and a review of the literature.

A case of Collet-Sicard Syndrome caused by skull base metastasis of probable breast adenocarcinoma is reported. A 79-year-old lady presented to the Oral and Maxillofacial Surgery Department with progressive left-sided tongue symptoms that she described as swelling. This was initially attributed to local disease, and a biopsy showed the patient was suffering from Necrotizing Sialometaplasia. However, her symptoms rapidly evolved into cranial nerve palsies affecting IX-XII, not initially diagnosed. Subsequent imaging revealed the cause of her worsening symptoms to be a metastatic lesion at her left skull base. Cranial nerve palsies due to metastases to the skull base are rare, and the authors would advise clinicians to adopt a high-index of suspicion in ruling out cranial nerve pathology at the skull base when encountering unusual signs and symptoms in the head and neck region.

Microvascular decompression of the accessory nerve for treatment of spasmodic torticollis: early results in 12 cases.

PURPOSE: To describe the early effectiveness of microvascular decompression (MVD) for the treatment of spasmodic torticollis (ST). METHODS: Twelve patients with spasmodic torticollis were treated by microvascular decompression of the accessory nerves using a microscopic neurosurgical technique via the retrosigmoid approach. The most common compressing blood vessels were the ipsilateral posterior inferior cerebral artery (PICA) and/or the vertebral artery. The intraoperative monitor was introduced to detect the accessory nerve and to avoid unnecessary damage to the nerve. RESULTS: Ten patients were cured (83%), and the other two (17%) improved with moderate spasms. In most cases, the improvement was noticed 1 week after the operation. No operation-related complications were observed during the follow-up period, which ranged from 2 months to 3 years. CONCLUSIONS: The early effect of MVD for some patients with spasmodic torticollis was satisfactory, but the long-term results need to be assessed further.

Craniofacial gunshot injury resulting in pseudoaneurysm of the left internal maxillary artery and Collet-Sicard syndrome.

Facial gunshot is a challenging medico-surgical emergency because of the complex neurovascular structure in the area. We present a patient who sustained a facial gunshot injury, with massive nasal and oral bleeding that resulted in shock. We review the management of gunshot injury to the internal maxillary artery, both in acute and chronic stages. In addition, we describe the clinical course of the rarely occurring Collet-Sicard syndrome, which involves injury to the 9th, 10th, 11th, and 12th cranial nerves associated with gunshot injury.

Accessory nerve lesion after cervicofacial lift: clinical and electrodiagnostic evaluations of two cases.

Two cases of accessory nerve lesion are reported that occurred within 2.5 weeks and 4.5 weeks, respectively, after surgery for cervicofacial lift. The patients were referred for electrodiagnostic examination because of persistent and unexplained unilateral shoulder pain and disability, 6 and 5 months, respectively, after face lift. In both cases clinical examination revealed severe right-shoulder weakness related to trapezius palsy, without trapezius muscle atrophy in the first case and with trapezius atrophy in the second. Electrodiagnosis revealed bilateral accessory nerve lesions in the first case and a unilateral lesion in the second case. Recovery for both cases was progressive but delayed, and both were evaluated 11 and 10 months, respectively, after the first evaluation. Clinical and especially electrodiagnostic findings suggested that the accessory nerve lesion was related to conduction block in the first case and severe axonal loss in the second case.

Infantile myofibromatosis of the craniovertebral junction.

Infantile myofibromatosis (IM) is a rare pathological entity characterized by solitary or multiple nodular skin, soft tissues or bony lesions. Craniovertebral (CV) junction lesions are rare. We report the successful management of a solitary IM involving the posterior elements of the CV junction in a 6-month-old child.

Spinal accessory nerve palsy: associated signs and symptoms.

STUDY DESIGN: Retrospective case series. BACKGROUND: Spinal accessory nerve palsy (SANP) is common following neck dissection surgery and can occur with blunt or penetrating trauma to the lateral neck region and cervical stretch injuries. Early detection of SANP remains a clinical challenge and the condition is often misdiagnosed. The purpose of this case series is to describe the associated history, signs, and symptoms related to SANP and increase awareness of the scapular flip sign as a clinical sign associated with SANP. CASE SERIES DESCRIPTION: Twenty subjects (13 male, 7 female) presented with pain and decreased shoulder function following head and neck surgery or posttrauma. All patients were thoroughly examined and the scapular flip sign was assessed. All patients presented with a cluster of signs and symptoms including trapezius atrophy, shoulder girdle depression, limited active shoulder abduction to less than 90 degrees , shoulder pain, and shoulder weakness. A positive scapular flip sign was present in all cases. The middle and lower trapezius were rated as 0/5, based on manual muscle testing, indicating no identifiable muscle activation against resistance. DISCUSSION: A typical history and consistent signs and symptoms were found related to SANP. A strong relationship appeared between the presence of the scapular flip sign and SANP. The suspected mechanism for the scapular flip sign is the unopposed pull of the humeral external rotators by the inactive middle and lower trapezius. Early identification of SANP can assist with the prognosis, explain persistent impairments and functional deficits, motivate appropriate diagnostic testing and interventions, and help maximize outcome. Further research to validate the scapular flip sign and establish a clinical prediction rule for the diagnosis of SANP should be performed.

Spinal accessory neuropathy after deep brain stimulation for Parkinson's disease.

We report a man with Parkinson's disease who developed right spinal accessory neuropathy after right subthalamic nucleus deep brain stimulator and infraclavicular pulse generator implantation. He complained of right shoulder pain and weakness in the post-operative period. He was subsequently diagnosed with a right spinal accessory nerve injury, confirmed by neuromuscular electrodiagnostic studies - electromyography (EMG) and nerve conduction (NC) -, possibly caused by a stretch injury to the nerve at the time of creation of the subcutaneous tunnel for placement of the extension lead of the deep brain stimulator system. However, he had near complete clinical resolution of the spinal accessory neuropathy within nine months after surgery. As a result of this complication, we now map the spinal accessory nerve electrophysiologically during deep brain stimulation surgery.