Investigations into shoulder function after radical neck dissection

]. Cranio-Max.-Fac.Surg. I6 (1988)

143

J.Cranio-Max.-Fac. Surg. 16 (1988) 143-147

© Georg Thieme Verlag Stuttgart - New York

Investigations into Shoulder Function after Radical Neck Dissection Veronika Fialkal, Kurt Vinzenz2

•Instituteof PhysicalMedicine(Head:Prof.H. Jantsch,M. D.)

Clinicof MaxillofacialSurgery(Head:Prof. S. Wunderer,M. D., D. M. D.), Universityof Vienna,Austria

Submitted 4 . 2 . 1987; accepted 8 . 6 . 1 9 8 7

Indtroduction In the head and neck region, cancer surgery is characterized by the coincidence of manifold medical and ethical problems; this is due to the fact that a life-threatening disease has to be treated in a region of the body that is not only most exposed but also a centre of fundamental physiological functions as well as of essential, individual and aesthetic characteristics. Despite intensive studies performed in recent years, in terms of prognosis there has been no substantial improvement for these patients; this led to a more critical discussion of turnout surgery with regard to both indications and results. Special emphasis was laid on the problem of avoiding postoperative, aesthetic-functional impairments (Harrison, 1985), comparing functional-surgical concepts - supported by combination therapy (surgery combined with radio- and/or chemotherapy) - to radical surgery, as e. g. in lymph node surgery of the neck ("radical neck dissection - RND" vs. ~'modified neck dissection - M N D " combined with postoperative radiotherapy in " N 1 - N 3 neck", elective neck dissection vs. elective radiotherapy in "NO neck")(Schuller, 1983, Wetmore and Suen, 1984; Byers and Ballantyne, 1985). Moreover, measures of reconstructive surgery aiming at the re-establishment of impaired abilities of speaking (Singer et al., 1984; Ehrenbergeret al., 1985), swallowing and chewing (Lawson and Biller, 1982; Conley et al., 1982; Bakamijan, 1985), immunobiological, nutritionalphysiological (Bassett and Dobie, 1983; Wolf, 1984), aesthetic aspects as well as the social reintegration of these patients are considered extremly relevant (Wenger, 1985). The standard method of radical surgical removal of lymph nodes in the neck was introduced by Crile in 1906. The most obvious impairment caused by this method is postoperative reduction of shoulder mobility, due to resection of the XI Nerve, and painful stiffness, occasionally even turning into a "cervicobrachial syndrome". Other consequences of this method are those due to resection of the submandibular gland, the lower pole of parotid, sternocleido-mastoid muscle, int. jugular vene; moreover, impairments of peripheral nerves (VII, IX, XII, cervical plexus, P. syrup, cerv.) inducing dysfunctions of mouth-angle innervation (N. marg. mandib. - ~ of cases), disturbances of taste sensitivity of the posterior pharyngeal part; additionally, Homer-complex due to resection of syrup, nervous

Summary In order to determine shoulder function after radical neck dissection, and to evaluate the outcome of postoperative physical treatment, 43 patients were investigated 10 days up to 1 month after this procedure. Shoulder function was judged by means of (a) clinical investigation of the shoulder girdle and by (b) electromyographic testing of the trapezius muscle. Our results demonstrated a correlation between the extent of atrophy and clinical parameters such as abduction and lateral displacement of the scapula. Electromyography revealed damage present mainly in the descending part of the trapezius, while in the majority of patients the ascending part was only slightly damaged or normal. Electromyography proved a valuable tool for the determination of the clinical state after neck dissection. There was also evidence supporting the efficacy of physical therapy in case of irreversible shoulder disability.

Key-Words Radical neck dissection - Shoulder function - Physical diagnosis and therapy

tissue in case of scarification of the carotid artery (in up to of cases each), pareses of the phrenic nerve with elevation of the diaphragm (10 %) or considerable loss of sensitivity in the extended region of shoulder, neck, thorax (Swift, 1970). In order to avoid reduction of shoulder function some surgeons used to preserve XI N. in the case of radical neck dissection; another approach is the "modified" or "functional" neck dissection (Bocca and Pignataro, 1967), based upon many investigations into special indications and applied particularly in the anglo-american area in the past few decades (Wetmore and Suen, 1984). Moreover, there were reports of successes in one-sided reconstruction of the accessory nerve with free nerve transplants following radical lymph node dissection in the neck (Anderson and Flower, 1969; Sikken and H6Itje, 1980). Recently, physical therapy with the objective of shoulder rehabilitation after radical neck dissection is gaining increasing importance (Saunders, 1985). The goal of the present study was to measure postoperative shoulder dysfunction clinically and electro-diagnostically after radical neck dissection; the parameters obtained should provide a tool for evaluating both the success of postoperative physical therapy of the impaired shoulder and/or the effect of free nerve grafts in a subsequent study.

Material and Methods

Patients In an initial investigation 43 patients were tested. In all of them radical neck dissection was performed in association with the removal of the primary tumour in the head-neck

144

J. Cranio-Max.-Fac. Surg. 16 (1988)

V. Fialka, K. Vinzenz Table1

Patients' characteristics (total n = 43)

a) Sex: female: male:

n = 12 (27.9%) n = 31 (72.1%)

b) Age:

x = 53.3 _ 12.4

c) Side: left: right:

n = 23 (53.5%) n = 20 (46.5%)

d) Atrophy: none: slight: moderate: marked:

n n n n

Total: e) Pain: *0(none): 1 (mild): 2 (moderate): 3 (strong): 4 (severe): 5(intolerable):

Fig. 1 Measuring lateral displacement of the medial margin of the scapula at the level of 4th thoracic spinal process: distance of medial margin of scapula was measured on both sides of the 4th thoracic spinal process; lateral difference in mm. between normal and affected side was evaluated,

region. Radical neck dissection consisted of the removal of the accessory nerve and cutaneous branches of the cervical plexus or descending branches of the hypoglossal nerve. The first investigation was carried out 10 days up to 1 month after surgery (Table I - patient characteristics obtained by the first investigation). Eighteen patients were investigated on another occasion after physical therapy given twice weekly for several months; therapy consisted of constant current, exponential and progressive current for the trapezius, massage for neck and shoulders and therapeutic exercises to the affected shoulder. The second test took place after 4 months on average (min. 12, max. 20 weeks).

Clinical Investigations Measurement of a) abduction of the affected shoulder in angular degrees. b) lateral displacement of the medial margin of the scapula at the level of the 4th thoracic spinal process in mm. (in comparison with the sound side). c) classification of pain from 0-5 according to "subjective rating scale" (0 = no pain, 5 = intolerable pain) (Table 1). d) atrophy of the trapezius, graded from 0-3 (0 = no atrophy, 1 = slight, 2 = moderate, 3 = severe) (Table 1). For measuring procedures see Fig. 1.

EIectrophysiological Investigation (Electromyography) For electromyography, a constant current system - "Irapulsator", Schuhfried Co. - was used (Jantsch and Schuhfried, 1981). Current power was regulated continuously, current duration (measured range 0.03 ms.-1000ms.) as well as current interval (0.2 ms.-5000 ms.) were adjusted gradually; bipolar stimulation was performed by means of two button electrodes (4 qcm.).

Total:

= 2 (4.7%) = 18 (41.9%) = 13 (30.2 %) = 10 (23.2%)

n = 43 (100%)

n n n n n n

= 4 (9.3%) = 2 (4.7%) = 3 (7.0%) = 11 (25.6%) = 22 (51.2 %) = 1 (2.3%)

n = 43 (100%)

*VRS = verbal rating scale (0-5: classification of pain) n = number of patients

Parameters measured were: 1) Rheobase, defined as the threshold intensity of a rectangular impulse (FI) with a duration and interval of 500 msec., sufficient to induce a minimal twitch; 2) accomodation, i.e. threshold intensity of a triangular impulse (A), duration and interval 500 msec., inducing just a minimal twitch; and, 3) chronaxy in ms. (the impulse duration requiring an intensity of twice the rheobase to achieve a minimal twitch). Chronaxy < 1 is normal, > 1 is an indication of nerve damage. Evaluation was performed in terms of accomodation quotient (ratio rheobase: accommodation - normal: A/ H > 1.8) and chronaxy (normal < I ms.). Measurements were carried out on all three parts of the trapezius (descending, horizontal, ascending).

Comparison of Clinical and Electrodiagnostic Parameter Both to Each Other and Before~After Therapy a) atrophy/lateral displacement/abduction b) accommodation and chronaxy/three muscle parts c) accommodation and chronaxy/abduction d) abduction, lateral displacement, atrophy, pain, accommodation and chronaxy (3 sections) before and after physical therapy. Results Of the 43 patients (mean age 53.3 + 12.4; 12 females, 31 males) 41 (95.3 %) displayed more or less marked atrophy of the upper part of the trapezius - characteristic of paresis of the accesory nerve (Fig. 2). Atrophy was marked in 23 % (10/43) atrophy was accompanied by very strong, severe or even intolerable pain in the shoulder (Table 1).

Investigations into Shoulder Function after Radical Neck Dissection

J. Cranio-Max.-Fac. Surg. 16 (i 988)

145

Table2 Comparison of degree of atrophy with lateral displacement and abduction (no. of patients n = 43) Atrophy

n

Lateral displacement > 10mm.

Abduction < 60 °

none/slight moderate marked

20 13 10

5 (25.0 %) ab 6 (46.2%) bo 10 (100%) a°

4 (20.0 %) ab 6 (46.2%) bo 9 (90.0%) a°

Fisher Exact-test:

a : p < 0.05 b, c: n.s.

Table3 Accommodation quotient (A/R) and chronaxy (m/sec.) in the three parts of M. trapezius (no. of patients n = 42) Extent of impairment

Descending part (no. of patients)

J_ (acc. > 1.8; C hr. < 1 ) 15 (35.7 %) (acc. < 1.8; Chr. < 1) 8(19.0%) ,I, (acc. ~ 1.8; Chr. > 1) 19 (45.2%) Fig. 2 Moderate atrophy of the right trapezius muscle after radical neck dissection.

The extent of atrophy was correlated to both lateral displacement and abduction. In all patients (10/10) displaying marked atrophy there was also lateral displacement > 10 ram, and in 90 % (9/10) abduction was less than 60 degrees (Table 2). Only 25 % (5/20) of patients with no or slight atrophy displayed a lateral displacement > 10 mm., and only 20 % (4/20) had an abduction of less than 60 degrees (Table 2). Measurement of accommodation and chronaxy in the 3 parts of the trapezius revealed marked pathological values, particularly in the descending part, in 45.2 % (19/42) of patients (A/H_> or -< 1.8; chronaxy > 1, and normal ones (A/I] > 1.8; chronaxy < 1) in only 35.7 % (15/42) (Table 3). In contrast, values obtained from the ascending part were normal or only slighty impaired in 83 % of the patients, and severely pathological in only 16.7 % (7/42) (Table 3). Additionally, it was possible to establish a correlation between the extent of abduction (0-90 degrees; > 90 degrees) and the number of patients with normal values determined by electromyography (A/I] > 1.8; chronaxy < 1); 71% (5/7) of the patients with an abduction > 90 degrees displayed normal values in the descending part of the trapezius, whereas this was true for only 28 % of the patients with an abduction of 0 - 9 0 degrees (p < 0.05) (Table 4). Though not significantly so, the situation was similar in the horizontal part of the trapezius, i.e. 37.1% (13/35) of patients with abduction 0 - 9 0 degrees vs. 57.1% (4/7) with > 90 degrees, with normal electromyographic values in both groups (Table 4). No differences were detected in this respect in the ascending part of the trapezius. Postoperative physical treatment (Table5) failed to increase the number of patients with good abduction (> 90 degrees) (2 and 3/18 patients, resp.). The number of patients with pathological position of the scapula (lateral displacement > 5 mm.) could not be reduced significantly ei-

Horizontal part

Ascending part

17 (40.5 %) 10(23.8%) 15(35.7%)

21 (50.0 %) 14(33.3%) 7(16.7%)

J_ normal, ~ slightly impaired, 1,markedly impaired

Table4 Comparison of extent of abduction/number of patients with normal electromyographic values in the three parts of M. trapezius (no. of patients n = 42) Abduction

n

Descending no. of patients

Horizontal with / > 1.8

Ascending Ch < 1 msec

A: 0-90 o B: > 90 °

35 7

10 (28.6%) 5 (71.4%) a

13 (37.1%). 4 (57.1%)jb

18 (51.4%)~ 3 (42.9%)] c

Total

42

15 (35.7%)

17 (40.5%)

21 (50.0%)

Statistics: Fisher Exact-test:

a : p < 0.05 b, c: n.s.

ther (83.3%, 15/18 vs. 66.7%, 12/18) (Table5). Yet the low number of patients (15 vs. 12/18) with lateral displacement > 5 ram. after physical therapy - a result pointing to a trend - was taken into account in calculating the mean values of the lateral displacement in relation to the entire patient numbers; moreover, there was a significant effect of training (18.2 _ 12.8 mm vs. 12.8 ± 13.5 ram. Pearson: ~ = 0.01, no of patients n = 18). Since physical treatment did not lead to the improvement of abduction hoped for, electromyographic values in the descending and horizontal parts of the trapezius did not improve either. Yet it should be noted that the progressive deterioration of shoulder function, together with pathological-anatomical substrates of stiffness, muscle fibrosis, subluxation of the sternoclavicular joint - events well known clinically and from the literature to appear in the months after surgery can be avoided. Electromyography also demonstrated a significant effect in the ascending, double-innervated part of trapezius (17.6 %, 3/17 vs. 64.7 %, 11/17 patients showing normal values after therapy; Table 5).

146

J. Cranio-Max.-Fac. Surg. 16 (1988)

V. Fialka, K. Vinzenz

Table 5 Effect of physical therapy on clinical and electrodiagnostic parameters Parameter

no. Before therapy After therapy of pts.

Sign.

A Abduction > 9 0 °

18

2 (11.1%)

3 (16.7%)

n.s,

B Lateral displacement >5ram 18

15(83.3%)

12(66.7%)

n.s.

mean values

18.1 +_ 12.8 mm. 12.8 _+ 13.5 ram. s *1

C A c c : A /I] >1.8 Chr: < 1 m./sec a descending part b horizontal part c ascending part

17 17 17

6 (35.3%) 6 (35.3 %) 3 (17.6%)

5 (29.4%) 6 (35,3 %) 11 (64.7%)

n. s, n. s, s **)

D Atrophy marked/moderate

14

6 (42.9%)

0 (0.0%)

s **)

18

12 (66.7 %)

6 (33.3 %)

s **)

E Pain VRS: intolerable/severe

Statistics: .i Pearson: c~ = 0.01 **) Fisher-Exact-test: p < 0,05

Postoperative physical therapy not only proved beneficial for the ascending part of the trapezius, but also for the other shoulder muscles (M. serratus ant., M. rhomboideus, M. levator scapulae); it also resulted in improved stabilization of the scapula - providing an improved "basis" for shoulder mobility - and, consequently, to a significant reduction in the number of patients with severe pain (66.7%, 12/18 vs. 33.3 %, 6/18 patients; severe/intolerable pain - LRS; before/after treatment; Table 5). Moreover, marked atrophy, stiffness and pathological changes in the affected shoulder were almost entirely prevented (Table 5). Discussion and Conclusions In radical neck dissection, 11-15cm. of the accessory nerve (XI) have to be removed due to the proximity to the most important lymph drainage between the wall of the jugular vein, and lower plane of the sternocleidomastoid muscle. Depending on the tumour type and site, the functional neck dissection introduced by Bocca in 1966 allows preservation of the accessory nerve and thereby trapezius function - particularly when combined with other therapies. Postoperatively, this method eliminates the "shoulder pain/disability syndrome" (Nahum et al., 1961; Haas and Sollberg, 1962; Pfeifle and Koch, 1973) and the cervicobrachial syndrome appearing subsequent to tumour surgery in the neck. According to Pfeifle and Koch (1973) the cervicobrachial syndrome is characterized by complaints due to the permanent tension caused by the dropping of the trapezius. Initially, there are exostosis - like distortion of the sternoclavicular joint (Pfeifle and Koch, 1973), limited ability to lift the arm above the horizontal (Laumann and Esser, 1980), loss of power, easily fatigued. Subsequently, the

unphysiological stress on the shoulder leads, apart from pain due to permanent tension on the brachial plexus (Pfeifie and Koch, 1973), to subluxation of the sternoclavicutar joint (Lamb, 1976) and, occasionally, fractures of the clavicle caused by fatigue or overstressing (Cummings and First, 1975; Ord and Langdon, 1986). Despite the removal of the accessory nerve, in some patients the trapezius recovered after a while - as reported by Ewing and Martin (1952). This gave rise to considerations regarding a double-innervation. The viewpoint of Ballantyne and Guinn (1966), Anderson and Flower (1969) and St6hr (1980) regarding innervation of the three trapezius parts by XI N. alone was contradicted by the great majority of anatomists who proposed an alternative innerration by the accessory nerve and cervical plexus (C3/C4) in different modifications. Mumenthaler and Schliack (1973), Fahrer et al. (1974) and Caliot et al. (1984) suggested an innervation of the three parts by the accessory nerve and C3/C4; in WoodhaII's (1952) and Szunyogh's (1959) opinion, the descending part is innervated by XI N. alone, the horizontal and ascending ones by C3/C4. Eisen and Bertrand (1972) assume an innervation by XI N. for the descending and horizontal parts and by C3/C4 for the ascending one (occasionally also a double innervation by XI N.). According to Haas and Sollberg (1962) the descending part is innervated by XI N. and C3/C4, the ascending one by XI N. Despite the differing views in terms of innervation of the trapezius, the importance of the C3/C4 branches of the cervical plexus for the double-innervation is increasingly emphasized. In a study performed in 1983, Stell and Jones demonstrated the possibility of both preserving the C3/C4 branches and minimizing postoperative shoulder dysfunction in cases of radical neck dissection. When comparing pain and function of the shoulder after neck dissection with/without conservation of XI, Short et al. (1984) observed significant differences in terms of postoperative pain and reduction of mobility. As a result of our investigation in 43 patients after radical neck dissection we found severe or intolerable pain in two thirds, and in more than half, a marked/pronounced atrophy of the shoulder. The extent of atrophy correlated with clinical parameters such as abduction of the shoulder and, with regard to dislocation of the shoulder girdle, lateral displacement of the scapula. In accord with other authors (Laumann and Esser, 1980) we succeeded in proving the relevance of, especially, the elevation of the scapula in the frontal plane (abduction) for assessing the functional situation of these parts of the trapezius. An abduction of > 90 degrees - the limit of slight shoulder dysfunction - was found in only 16.7 % (7/42) of the patients. In the majority of patients (83 %) tested electromyographically, damage was found predominantly in the descending part of the trapezius, with values only slightly impaired or normal in the ascending part. This suggests that the upper parts are innervated mainly by the accessory nerve, the lower ones (partly) by branches of the cervical plexus. A second assessment, performed after postoperative physical therapy, revealed improvement in the ascending, though not in the horizontal and descending, parts of the trapezius. These findings are supported also by the significant correlation of electrodiagnostic investigations results (accommodation quotient, chronaxy) and clinical parameters (abduction), in respect both of the postoperative investiga-

Investigations into Shoulder Function after Radical Neck Dissection tion and that after physical therapy. Evidently, this method provides a useful tool for an objective determination of shoulder function. Despite the failure of electrodiagnostic improvement in the two upper parts o f the trapezius muscle, physical therapy proved highly beneficial in cases of m a r k e d atrophy. On the one hand, there is indication of a re-innervation of trapezius fibres f r o m branches o f the only partly d a m a g e d cervical plexus, by electrotherapy. O n the other hand, the other muscles o f the shoulder belt (Ms. serratus anterior, deltoid, levator scapulae, rhomboidei) were strengthened by intensive training, leading also to a stabilisation o f the scapula. Thus, further d r o o p i n g o f the shoulder girdle is prevented, as well as strain on the capsular ligamentous apparatus, subluxation o f the sternoclavicular joint, nerve r o o t irritation, stress a n d / o r pull on the brachial plexus (Pfeifle and Koch, 1973) and a c c o m p a n y ing vessels (Ord and Langdon, 1986). Purposeful active and passive mobility training o f the upper extremities also provides sufficient circulatory supply to the shoulder joint, thus preventing capsular "stickiness" together with further functional limitation and subsequent painful stiffness of the shoulder as well as reducing pain remarkably. Eventually it should be mentioned that physical therapy did not lead to a functional i m p a i r m e n t of the shoulder girdle in any o f the patients treated. The results o f these therapeutic measures encourage us to say: t r e a t m e n t m a y be beneficial even if the prognosis appears to be poor.

Acknowledgement The authors wish, to thank Harald Raiman, M. D., Institute of Medical Statistics for his sound statistical advice.

References Anderson, t~, S. I~ S. Flower: Free grafts of the spinal accessory nerve during radical neck dissection. Am. J. Surg. 118 (1969) 796 Bakamijan, V.Y.: Tongue flaps in cancer surgery of the oral cavity. In: Chretien, Johns, Shedd, Strong, Ward (eds.): Head and neck cancer, vol. i, Decker, Philadelphia-Toronto (1985), 169 Ballantyne, A. J., G. A. Guinn: Reduction of shoulder disability after neck dissection. Am J. Surg. 112 (1966) 662 Bassett, M.R., R.A. Dobie: Patterns of nutrition and deficiency in head and neck cancer. Otolaryngol. Head Neck Surg. 91 (1983) 119 Bocca, E., 0. Pignataro: A conservation technique in radical neck dissection. Am. Oto-Rhino-Laryngol. 76 (1967) 975 Byers, R.M., A.J. Ballantyne: Selection criteria for modified neck dissection with postoperative irradiation N3 stages cervical metastases. In: Chretien, Johns, Shedd, Strong, Ward (eds.): Head and neck cancer, vol. 1. Decker, Philadelphia Toronto (1985), 157 Caliot, P., P. Cabani~, V. Bousquet, D. Midy: A contribution to the study of the innervation of the sternocleidomastoid muscle. Anat. Clin. 6 (1984) 21 Conley, J., M. Sales, 1~ Parke: The new tongue. Otolaryngol. Head Neck Surg. 90 (1982) 58 Crilk, G.: Excision of cancer of the head and neck. J. Am. Med. 47 (1906) 1780 Cummings, C. W., R. First: Stress fractures of the clavicle after a radical neck dissection. Plast. Reconstr. Surg. 55 (1975) 366 Ehrenberger, K., W. Wicke, H. Piza, R. Roka, M. Grasl, H. Swoboda: Jejunal grafts for reconstructing a phonatory neoglottis in laryngectomized patients. Arch. Otorhinolaryngol. 242 (1985) 217 Eisen, A., G. Bertrand: Isolated accessory nerve palsy of spontaneous origin. Arch. Neurol. 27 (1972) 496

J. Cranio-Max.-Fac. Surg. 16 (1988)

147

Ewing, M.R., H. Martin: Disability following radical neck dissection. Cancer 5 (1952) 873 Fahrer, H., H.P. Ludin, M. Mumenthaler, M. Neiger: The innervation of the trapezius muscle - an electrophysiological study. J. Neurol. 207 (1974) 183 Haas, E., G. Sollberg: Untersuchungen tiber die Funktion des Schultergtirtels nach Durchschneidung des Nervus accessorius. Z. Laryngol, otol. 41 (1962) 669 Harrison, D. F. N.: Head and neck surgery in the 1980s: The role of more or less. In: Chretien, Johns, Shedd, Strong, Ward (eds.): Head and neck cancer, vol. 1. Decker, Philadelphia-Toronto 1985, 27 Jantsch. H., F. Schuhfried: Niederfrequente Str6me zur Diagnostik und Therapie. 2. Ed. Maudrich, Wien-Miinchen-Bern (1981), 80 Lamb, C. E. M.: Sternoclavicular joint enlargement following block dissection. Br. J. Snrg. 63 (1976) 488 Laumann, U., E. Esser: Funktionelle Beeintr/ichtigung des Schultergiirtels nach radikaler Neck dissection. Dtsch. Z. Mund-Kiefer-Gesichtschir. 4 (1980) 405 Lawson, W., H.F. Biller: Mandibular reconstruction - bone graft techniques. Otolaryngol. Head Neck Surg. 90 (1982) 589 Mumenthaler, M., H. SchIiack: L/isionen peripherer Nerven. 2nd Ed., Thieme, Stuttgart-New York (1973), 195 Nahum, A.M., W. Mullaly, L. Marmor: A syndrome resulting from radical neck dissection. Arch. Otolaryngol. 74 (1961) 424 Ord, R. A., J. D. Langdon: Stress fracture of the clavicle - a rare late complication of radical neck dissection. J. Max.-Fac. Surg. 14 (1986) 281 Pfeifle, K., H. Koch: Schmerzsyndrome als Sp~itfolge nach "Neck dissection". Dtsch. Zahn/irztl. Z. 28 (1973) 968 Saunders, W. H.: Shoulder rehabilitation. In: Chretien, Johns, Shedd, Strong, Ward (eds.): Head and neck cancer, vol. 1. Decker, Philadelphia Toronto (1985), 544 SchulIer, D.E.: Analysis of disability resulting from treatment including radical neck dissection or modified neck dissection. Head Neck Surg. 6 (1983) 551 Short, S. 0., N. J. Kaplan, G. E. Laramore, C. W. Cummings: Shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve. Am. J. Surg. 184 (1984) 478 Sikken, I , W.J. H61tje: Die Rekonstruktion des N. accessorius nach radikaler Neck dissection. Dtsch. Z. Mund-Kiefer-Gesichtschir. 4 (1980) 36 Singer, M. I., E. D. Biota, R. C. Hemeker: Surgical restoration of the voice after laryngectomy. In: Wolf: Head and neck oncology, Nijhoff, Boston (1984) 83 SteII, P.M., T. A. Jones: Radical neck dissection. Preservation of the function of the shoulder. J. Laryngol. Otol. 8 (1983) 106 St6hr, M.: Iatrogene Nervenl/isionen. Thieme, Stuttgart-New York (1980) 93 Swift, T.R.: Involvement of peripheral nerves in radical neck dissection. Am. J. Surg. 119 (197,0) 694 Szunyogh, B.: Shoulder disability following radical neck dissection. Am. J. Surg. 25 (1959) 194 Wetmore, S.J., J.Y. Suen: Clinical management of regional metastases. In: Wolf, G. (ed.): Head and neck oncology. Nijhoff, Boston 1984, 1 Woodhall, B.: Trapezius paralysis following minor surgical procedures in the posterior cervical triangle. Am. Surg. 136/3 (1952) 375 Wolf, G.T.'. Tumor immunity; immune surveillance and immunotherapy of head and neck squamous carcinoma. In: Wolf (ed.): Head and neck oncology, Nijhoff, Boston (1984) 37

Veronika Fialka, M. D. Institute of Physical Medicine, Vienna University Alser Strafle4 A-1090 Vienna Austria