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Shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve
Shoulder Pain and Function After Neck Dissection With or Without Preservation of the Spinal Accessory Nerve
Steven 0. Short, MD, Seattle, Washington Jory N. Kaplan, MD, Seattle, Washington George E. Laramore, MD, Seattle, Washington Charles W. Cummings, MD, Seattle, Washington
In 1906, Crile [I] first described radical neck dissection for the treatment of head and neck tumors. He emphasized the need for excision of the internal jugular vein with its adnexal tissues and the spinal accessory nerve. Although preservation of the vagus, lingual, and hypoglossal nerves was routine in most neck dissections, removal of the spinal accessory nerve was considered essential since the associated spinal accessory chain lymph nodes were said to be at high risk for tumor involvement [I]. In 1961, Nahum et al [2] defined a syndrome that results from radical neck dissection. The authors evaluated seven patients who underwent radical neck dissection and found common features among them. A dull, nonlocalizing shoulder ache was present in all and it was exacerbated by motion. They found limitation of shoulder abduction but normal and full passive range of motion. Other shoulder muscles, particularly the rhomboids, were found to be unusually prominent. With electromyographic testing, they found only partial denervation in some trapezius muscles, which suggests innervation of the trapezius muscle by nerves other than the spinal accessory nerve. Ewing and Martin [3], in 1951, evaluated 100 radical neck dissection patients regarding assessment of work capacity. They purposely searched for younger patients in the hope of better answering their question. Forty-two of their patients complained of shoulder discomfort and some found relief with the use of a shoulder brace. In 60 patients, they found a decrease in the range of motion of the shoulder but noted that stiffness was the real problem. In two of the patients From the Departments of Otolaryngology, Head and Neck Surgery, and Radiation Oncology, University of Washington, Seattle, Washington. Requests for reprints should be addressed to Steven 0. Short, MD, Department of Otolaryngology, Head and Neck Surgery, University of Washington, RL-30, Seattle, Washington, 98195. Presented at the 30th Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, May 13-17. 1984.
479
the trapezius appeared to be normal, which suggested that the nerve supply was uninterrupted. As the preservation of the spinal accessory nerve in neck dissections for head and neck tumors has gained acceptance, the benefits are often mentioned [4]. The report by Nahum et al [2] is frequently been cited as support for preservation, although they defined the shoulder syndrome from their work on patients who had radical neck dissection. No comparison of patients with preservation of the spinal accessory nerve could be made. Their series consisted of only seven patients and they recognized the variation in the amount of pain and disability among them. Until recently, no comparison of the difference in pain and physical disability had been made between patients who had preservation versus sacrifice of the spinal accessory nerve [5]. It is the goal of this study to compare the difference in degree of pain as well as functional disability of the shoulder in patients who underwent neck dissection with and without spinal accessory nerve preservation. Material
and Methods
Patients who had undergone either radical neck dissection, modified radical neck dissection, conservative neck dissection, or radiation treatment to the neck without surgery of the neck at the University, Veterans Administration, or Pacific Medical Center Hospitals from November 1977 to September 1983 took part in the study. Modified radical neck dissection differs from radical neck dissection in that the spinal accessory nerve is preserved, whereas in conservative neck dissection, the sternomastoid muscle and jugular vein are also preserved. Patients with bilateral neck disssection or tumor still present and those who were less than 6 weeks postoperative were excluded. The hospital charts were reviewed, and the operative note was used to determine whether the spinal accessory nerve had been preserved or sacrificed. All patients received physical therapy postoperatively.
TheAmerican
Journal of Surgery
The Shoulder After Neck Dissection
A questionnaire was given to each patient. They were asked if they were right or left handed. They were then asked if they had pain in their shoulders and which shoulder was affected. A scale of 0 to 5 was used with 0 meaning no pain and 5 meaning severe pain. Next, they were asked to rate from 0 to 5 the difficulty of performing certain tasks after having had neck surgery or radiation treatment. Zero meant that there was no difference in performing the tasks since surgery or radiation, and 5 meant that they could not perform the task at all. The tasks were combing their hair, washing their hair, hanging clothes in a closet, and reaching for something on a shelf. Then a physical examination was performed to measure the strength of the right and left shoulders when lifted straight up in a shrug. This test, called trapexius, illustrates the supportive role of the muscle, and the amount of strength is measured by applying downward pressure over the acromioclavicular joint. The test called abduction is performed by having the patient abduct his or her arms, sequentially to 90 degrees, and then a downward force is applied over the wrist. The strength reflected in both tests was ranked from 0 to 5. Five meant that the position could not be overcome until a strong force was applied, four implied a mild to moderate force was required to overcome the position, three meant that the position could not be held against a force greater than gravity, two meant that only a 45 to 90 degree angle could be obtained, and one signified movement to less than a 45 degree angle. All patients fell between two and five with all functions. Statistical calculations were performed using the Mann-Whitney test which was carried out on a DEC-lO@ computer using Minitabe software. Results
A total of 35 patients who had neck dissection were evaluated. Twenty-seven were male and 8 female. Eight patients who had radiation treatment to the neck but no neck dissection were also evaluated. The average age of patients with preserved spinal accessory nerves (those who had modified radical neck dissection or conservative neck dissection) was 60 years, with a range of 22 to 86 years. Twenty-three patients comprised this group. The average age of patients with sacrificed spinal accessory nerves (those who had radical neck dissection) was also 60 years, with a range of 49 to 75 years. Twelve patients were in this radical neck dissection group. The average age of the eight patients who comprise the radiation treatment only group was 66 years, with a range of 39 to 78 years. Thirty-four of the surgery patients had squamous cell carcinoma and one patient had a melanoma. There were 12 tumors in the larynx, 6 in the hypopharynx, 3 in the oropharynx, 19 in the oral cavity, and 3 in other locations. Twenty-nine of the 35 surgery patients received either preoperative or postoperative radiation treatments to the neck. The dosages were between 5,000 and 6,000 rads. The stages of the primary tumors in the patients who had neck dissection were as follows: One was a carcinoma in situ, six were Ti tumors, 12 were Tz
Voluma 148, October 1984
tumors, 9 were Ts tumors, 6 were T4 tumors, and 9 were unstaged or unknown due to lack of description of the site of the tumor. Three patients had multiple primary tumors. At time of treatment, there were 14 patients in stage No, 6 in stage Ni, 2 in stage Ns, and 1 unknown in the conservative neck dissection or modified radical neck dissection group. In the radical neck dissection group there were two patients in stage No, five in stage N1, one in stage Nz, two in stage Na, and two unknown. There were five patient in stage No and three in stage Ni in the radiation treatment only group. Of the eight patients who received primary radiation treatment to the neck, none underwent neck dissection. Two of the patients had partial laryngectomy, and one had complete laryngectomy for treatment of their primary tumor. They received neck radiation in doses of 4,500 to 6,600 rads. Seven had squamous cell carcinomas and one had a spindle cell carcinoma. Four patients had primary tumors in the larynx, three had them in the oral cavity, and one patient had one in the oropharynx. Questionnaire Responses
Pain: Twenty-six patients had pain in their operated shoulders and 9 did not. All patients who underwent radical neck dissection had shoulder pain, whereas 9 of the 23 patients (39 percent) who underwent modified radical neck dissection or conservative neck disection had none. Six of the eight patients (75 percent) who received only neck radiation had no shoulder pain. Among the 23 patients who had preservation of their spinal accessory nerve, an average of 1.6 was obtained from the scale of 0 to 5. Among the 12 patients who had sacrifice of the spinal accessory nerve, an average of 2.7 was obtained for pain level. The average pain level for the radiation treatment only group was 0.6 (Table I, Figure 1). The difference between the radical neck dissection and radiation treatment only groups and the radical neck dissection and modified radical neck dissection or conservative neck dissection groups were significant at p <0.05. The difference between the modified radical neck dissection or conservative neck dissection and the radiation treatment only groups was not statistically significant. Performance: The responses to the four questions pertaining to the performance of the tasks were averaged. A value of 0.8 was obtained for patients who had preservation of their spinal accessory nerves, an average of 2.1 was obtained for the 12 patients who had sacrifice of their nerves, and an average of 0.1 was found for the radiation treatment only group (Table I, Figure 1). The radical neck dissection group compared with the modified radical neck dissection or conservative neck dissection group and the radiation treatment only group was significant at p
479
Short et al
TABLE I
Results of Ouestionnaire and Physical Examination: Average VelUeS
Group
Trapezius Test
Abduction Test
Patients (n)
Pain
Performance
6
0.6
0.1
5
5
23 10
1.6 2.4
0.6 1.3
4.7 4.9
4.2 4.1
13
0.9
0.3
5
4.6
12 7
2.7 2.7
2.1 2.6
4.6 4.5
3.5 3.7
5
2.6
1.4
4.6
3.1
XRT MND or CND Same side as handedness Opposite side ashandedness RND Same side as handedness Opposite side as handedness
CND = Conservative neck dissection; MND = modified neck dissection; RND = radical neck dissection; XRT = radiation treatment
1
SRCRIFICED
RIDIcVIOL XI
NERUE
Flgun 1. Coqarbn of fhs average pain and fmctlon values for 1he radlatlon, preserved nerve, and sacrlflced nerve groups.XI = spinsI acceaaoty narva.
4_
El
PRES SO”E
PRES OPPOSITE r,
SPC Sa”E
FUNCTlDN PRIH
WC
DPPDSlTE
HERlIE
F&we 2. Mar/son OFIha average pa/n and functionvaluesfor preserved (PRES) and sacrked (SAC) nerve groups, cabgorized according to whOthOr surgery was on the same or opposite side OFhandedness.XI = spinal accessory nerve.
480
treatment only group was also significant at p <0.05. Handedness as a factor: The aforementioned results were again averaged in the same fashion but, in addition, they were categorized according to whether their neck surgery was on the same side or the opposite side of their dominant handedness (Figure 2). A pain average of 2.4 was obtained for these patients who had modified radical neck dissection or conservative neck dissection on the same side as handedness. Ten patients were in this group. The average pain level for patients with surgery opposite to their handedness in the preserved nerve group was 0.9. Thirteen patients were in this group. There was a significant difference between these groups (p <0.05). The sacrificed nerve group had an average pain level of 2.7 when surgery was performed on the same side as handedness (seven patients) and an average pain level of 2.6 when surgery was performed on the opposite side (five patients). The difference was not statistically significant. The results for the patients who had nerve preservation neck surgery on the same side as dominant handedness showed a performance average of 1.3, whereas those with surgery on the opposite side had an average of 0.3 (p
The American Journal of Surgery
The Shoulder After Neck Dissection
I
5 PRESERUED SLICRIFICED
I
85
B TRQPEZI”S
QGDUCTIDN H”SCL.E
GPDUP
Figure 3. lb average resutts of the pnvsicar examination (PE), comparing preserved and sacrifked nerve groups.
Flgmr 4. conpsrlson of the avere @@zal exmtkn reeutts when the difference between the normal and operated shoulder are calculated.
average was 4.6 (p CO.05). The average of the abduction test for the preserved nerve group was 4.2. The sacrificed nerve group average was 3.5 (p <0.05). The radiation treatment patients uniformly scored 5 in both the trapezius and abduction tests. In an attempt to control for variability in patient strength, the difference between the nonoperated and the operated sides was averaged (Figure 4). The preserved nerve group consistently showed less disability (normal function is represented by small numbers since this implies similar function between arms) and scored 0.08 and 0.4 for the trapezius and abduction tests, respectively. The sacrificed nerve group scored 0.3 and 1.3, respectively. There was a significant difference with the abduction test (p <0.05) but not the trapezius test (p <0.05). The radiation treatment patients scored 0 in both tests.
pain in their shoulders (26 percent) and high scores on their postoperative performance disability rating (9 percent). This variation in pain and function of the shoulder has been noted by other investigators [5 $1. As early as 1951, Ewing and Martin [3] noted normal trapezius function in two patients after sacrifice of the spinal accessory nerve. In 1961, Nahum et al [Z] found with electromyographic testing some patients who had only partial denervation of the trapezius muscle after radical neck dissection. The upper half of the trapezius muscle is innervated by the spinal accessory nerve and the lower half by the third and fourth cervical nerves [6,7]. However, some investigators believe that cervical nerve innervation is primarily proprioceptive [8,9]. The extent to which the variability in trapezius innervation contributes to the differences among patients postoperatively is uncertain, and this fact should not deter one from preserving the nerve given the overall favorable results. Radiation therapy has been suggested as a factor contributing to postoperative pain and disability 151. Although 25 percent of the patients treated with whole neck radiation but not neck dissection had mild to moderate pain in their shoulders after treatment (not significantly different from what was found in the nerve preservation group), their performance results were far superior to the surgical results. Only one of eight patients (12 percent) noticed a change in performance, and it was described as mild. Leipzig et al [5] reported that a significant number of patients who underwent modified radical neck dissection were found to have objective evidence of shoulder dysfunction but had no associated pain or functional disability. In our study, the physical examination was limited and did not detect this difference. The trapezius test, which is a common
Comments The results of this study show that, on the average, neck dissection patients with their spinal accessory nerve preserved have less pain in their shoulders, less functional disability, and were stronger on their physical examination than did those with a sacrificed spinal accessory nerve. In addition, it was found that the patients who received whole neck radiation treatment without neck dissection had little pain, infrequent and insignificant functional disability, and normal strength on physical examination. Although the averages suggest a firm difference between the groups, there was great variation among surgery patients within the same group. Some radical neck dissection patients had minimal pain (25 percent) and no postoperative performance difficulty (8 percent), whereas some patients with their spinal accessory nerve preserved had moderate to severe
Valume149,October1984
481
Short et
al
clinical test used for evaluating spinal accessory nerve function, did not significantly differentiate between the nerve preservation and nerve sacrifice groups. However, the abduction test which measures range of motion to 90 degrees and strength of abduction did detect a significant difference between the preservation nerve group and the sacrificed nerve group. In a resting position, the trapezius muscle‘functions as a supporter of the shoulder. The rhomboid muscles, the levator scapulae, and the upper fibers of the serratus anterior muscles also function in a supportive capacity for the shoulder. With trapezius paralysis, these muscles are found to compensate [2,8,10] and probably account for the inability of the trapezius test to discern spinal accessory nerve integrity. When the results of pain and function were averaged for patients who had neck dissections on the same side and the opposite side as their dominant handedness, significant differences in pain and function were obtained (Figure 2, Table I). In both the preserved and sacrificed nerve groups, performance disability was significantly greater in the patients with surgery on the same side as handedness. In contrast, only the preserved nerve group showed a significant difference in pain levels when handedness was considered. The radical neck dissection patients had similar pain levels independent of the side operated on. Since it is hard to imagine that variation in trapezius innervation could account for these findings, we feel this represents howl disability is a function of the demand placed on thu trapezius muscle. A right handed person is more likely to notice a decrease in shoulder strength and proprioception if it were to occur on the side of handedness. A corollary to this statement is that a patient can benefit from physical therapy in that he or she can, through exercising, increase the strength of functioning muscles and can be taught alternate ways of performing tasks. It is worth noting that no significant differences were found between same and opposite handedness groups on physical examination. Preservation of the spinal accessory nerve in neck dissections for head and neck tumors, on the average, yields more favorable postoperative shoulder function and less pain. This difference is most pronounced when the operation occurs on the same side as the patient’s handedness. There is great variation in the degree of functional disability and pain in patients with similar operations. The amount of
482
physical therapy received postoperatively, injury to the spinal accessory nerve intraoperatively, and variation in innervatino of the trapezius muscle have been suggested as factors that contribute to the unpredictable outcome. Radiation therapy appears to contribute little to pain or physical disability. Summary To compare the difference in the degree of pain and functional disability of the shoulder in patients who underwent neck dissection for the treatment of head and neck cancer, 23 patients with and 12 patients without spinal accessory nerve preservation were evaluated with a questionnaire and a physical examination. In addition, to determine what effect radiation treatment has on pain and shoulder disability, eight patients who had whole neck radiation but no neck dissection were similarly evaluated. The results of this study show that, on the average, neck dissection patients with their spinal accessory nerve preserved have less pain in their shoulders, less functional disability, and stronger results on their physical examination than did those with their spinal accessory nerve sacrificed. It was also found that the patients who received whole neck radiation treatment without neck dissection had little pain, infrequent and insignificant functional disability, and normal strength on physical examination. References 1. Crile GW. Excision of cancer of the head and neck. JAMA 1982;47:1780-6. 2. Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Dtolaryngol 1961;74:82-6. 3. Ewing MB, Martin H. Disability following radical neck dissection. Cancer 1952;5:873-83. 4. Becker GD. Parell GJ. Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 1977;89:827-31. 5. Leipzig B, Suen JY, English JL, Barnes J, l-looper M. Functional evaluation of the spinal accessory nerve after neck dissection. Am J Surg 1983;146:526-30. 6. Szunyogh B. Shoulder disability following radical neck dissection. Am J Surg 1959;25:194-8. 7. Dewar FP, Harris RI. Restoration of function of shoulder following paralysis of the trapezius by fascial sling fixation and transplantation of the levator scapulae. Ann Surg 1950; 132:1111-5. 8. Ballantyne AJ, Guinn GA. Reduction of shoulder disability after neck dissection. Am J Surg 1966;112:662-5. 9. Gray H. Anatomy of the human body. Goss CM. ed. 29th ed. Philadelphia: Lea & Febiger, 1973. 10. Mead S. Posterior triangle operations and trapezius paralysis. AMA Arch Surg 1952;64:752-5.
The American Journal of Surgery
Steven 0. Short, MD, Seattle, Washington Jory N. Kaplan, MD, Seattle, Washington George E. Laramore, MD, Seattle, Washington Charles W. Cummings, MD, Seattle, Washington
In 1906, Crile [I] first described radical neck dissection for the treatment of head and neck tumors. He emphasized the need for excision of the internal jugular vein with its adnexal tissues and the spinal accessory nerve. Although preservation of the vagus, lingual, and hypoglossal nerves was routine in most neck dissections, removal of the spinal accessory nerve was considered essential since the associated spinal accessory chain lymph nodes were said to be at high risk for tumor involvement [I]. In 1961, Nahum et al [2] defined a syndrome that results from radical neck dissection. The authors evaluated seven patients who underwent radical neck dissection and found common features among them. A dull, nonlocalizing shoulder ache was present in all and it was exacerbated by motion. They found limitation of shoulder abduction but normal and full passive range of motion. Other shoulder muscles, particularly the rhomboids, were found to be unusually prominent. With electromyographic testing, they found only partial denervation in some trapezius muscles, which suggests innervation of the trapezius muscle by nerves other than the spinal accessory nerve. Ewing and Martin [3], in 1951, evaluated 100 radical neck dissection patients regarding assessment of work capacity. They purposely searched for younger patients in the hope of better answering their question. Forty-two of their patients complained of shoulder discomfort and some found relief with the use of a shoulder brace. In 60 patients, they found a decrease in the range of motion of the shoulder but noted that stiffness was the real problem. In two of the patients From the Departments of Otolaryngology, Head and Neck Surgery, and Radiation Oncology, University of Washington, Seattle, Washington. Requests for reprints should be addressed to Steven 0. Short, MD, Department of Otolaryngology, Head and Neck Surgery, University of Washington, RL-30, Seattle, Washington, 98195. Presented at the 30th Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, May 13-17. 1984.
479
the trapezius appeared to be normal, which suggested that the nerve supply was uninterrupted. As the preservation of the spinal accessory nerve in neck dissections for head and neck tumors has gained acceptance, the benefits are often mentioned [4]. The report by Nahum et al [2] is frequently been cited as support for preservation, although they defined the shoulder syndrome from their work on patients who had radical neck dissection. No comparison of patients with preservation of the spinal accessory nerve could be made. Their series consisted of only seven patients and they recognized the variation in the amount of pain and disability among them. Until recently, no comparison of the difference in pain and physical disability had been made between patients who had preservation versus sacrifice of the spinal accessory nerve [5]. It is the goal of this study to compare the difference in degree of pain as well as functional disability of the shoulder in patients who underwent neck dissection with and without spinal accessory nerve preservation. Material
and Methods
Patients who had undergone either radical neck dissection, modified radical neck dissection, conservative neck dissection, or radiation treatment to the neck without surgery of the neck at the University, Veterans Administration, or Pacific Medical Center Hospitals from November 1977 to September 1983 took part in the study. Modified radical neck dissection differs from radical neck dissection in that the spinal accessory nerve is preserved, whereas in conservative neck dissection, the sternomastoid muscle and jugular vein are also preserved. Patients with bilateral neck disssection or tumor still present and those who were less than 6 weeks postoperative were excluded. The hospital charts were reviewed, and the operative note was used to determine whether the spinal accessory nerve had been preserved or sacrificed. All patients received physical therapy postoperatively.
TheAmerican
Journal of Surgery
The Shoulder After Neck Dissection
A questionnaire was given to each patient. They were asked if they were right or left handed. They were then asked if they had pain in their shoulders and which shoulder was affected. A scale of 0 to 5 was used with 0 meaning no pain and 5 meaning severe pain. Next, they were asked to rate from 0 to 5 the difficulty of performing certain tasks after having had neck surgery or radiation treatment. Zero meant that there was no difference in performing the tasks since surgery or radiation, and 5 meant that they could not perform the task at all. The tasks were combing their hair, washing their hair, hanging clothes in a closet, and reaching for something on a shelf. Then a physical examination was performed to measure the strength of the right and left shoulders when lifted straight up in a shrug. This test, called trapexius, illustrates the supportive role of the muscle, and the amount of strength is measured by applying downward pressure over the acromioclavicular joint. The test called abduction is performed by having the patient abduct his or her arms, sequentially to 90 degrees, and then a downward force is applied over the wrist. The strength reflected in both tests was ranked from 0 to 5. Five meant that the position could not be overcome until a strong force was applied, four implied a mild to moderate force was required to overcome the position, three meant that the position could not be held against a force greater than gravity, two meant that only a 45 to 90 degree angle could be obtained, and one signified movement to less than a 45 degree angle. All patients fell between two and five with all functions. Statistical calculations were performed using the Mann-Whitney test which was carried out on a DEC-lO@ computer using Minitabe software. Results
A total of 35 patients who had neck dissection were evaluated. Twenty-seven were male and 8 female. Eight patients who had radiation treatment to the neck but no neck dissection were also evaluated. The average age of patients with preserved spinal accessory nerves (those who had modified radical neck dissection or conservative neck dissection) was 60 years, with a range of 22 to 86 years. Twenty-three patients comprised this group. The average age of patients with sacrificed spinal accessory nerves (those who had radical neck dissection) was also 60 years, with a range of 49 to 75 years. Twelve patients were in this radical neck dissection group. The average age of the eight patients who comprise the radiation treatment only group was 66 years, with a range of 39 to 78 years. Thirty-four of the surgery patients had squamous cell carcinoma and one patient had a melanoma. There were 12 tumors in the larynx, 6 in the hypopharynx, 3 in the oropharynx, 19 in the oral cavity, and 3 in other locations. Twenty-nine of the 35 surgery patients received either preoperative or postoperative radiation treatments to the neck. The dosages were between 5,000 and 6,000 rads. The stages of the primary tumors in the patients who had neck dissection were as follows: One was a carcinoma in situ, six were Ti tumors, 12 were Tz
Voluma 148, October 1984
tumors, 9 were Ts tumors, 6 were T4 tumors, and 9 were unstaged or unknown due to lack of description of the site of the tumor. Three patients had multiple primary tumors. At time of treatment, there were 14 patients in stage No, 6 in stage Ni, 2 in stage Ns, and 1 unknown in the conservative neck dissection or modified radical neck dissection group. In the radical neck dissection group there were two patients in stage No, five in stage N1, one in stage Nz, two in stage Na, and two unknown. There were five patient in stage No and three in stage Ni in the radiation treatment only group. Of the eight patients who received primary radiation treatment to the neck, none underwent neck dissection. Two of the patients had partial laryngectomy, and one had complete laryngectomy for treatment of their primary tumor. They received neck radiation in doses of 4,500 to 6,600 rads. Seven had squamous cell carcinomas and one had a spindle cell carcinoma. Four patients had primary tumors in the larynx, three had them in the oral cavity, and one patient had one in the oropharynx. Questionnaire Responses
Pain: Twenty-six patients had pain in their operated shoulders and 9 did not. All patients who underwent radical neck dissection had shoulder pain, whereas 9 of the 23 patients (39 percent) who underwent modified radical neck dissection or conservative neck disection had none. Six of the eight patients (75 percent) who received only neck radiation had no shoulder pain. Among the 23 patients who had preservation of their spinal accessory nerve, an average of 1.6 was obtained from the scale of 0 to 5. Among the 12 patients who had sacrifice of the spinal accessory nerve, an average of 2.7 was obtained for pain level. The average pain level for the radiation treatment only group was 0.6 (Table I, Figure 1). The difference between the radical neck dissection and radiation treatment only groups and the radical neck dissection and modified radical neck dissection or conservative neck dissection groups were significant at p <0.05. The difference between the modified radical neck dissection or conservative neck dissection and the radiation treatment only groups was not statistically significant. Performance: The responses to the four questions pertaining to the performance of the tasks were averaged. A value of 0.8 was obtained for patients who had preservation of their spinal accessory nerves, an average of 2.1 was obtained for the 12 patients who had sacrifice of their nerves, and an average of 0.1 was found for the radiation treatment only group (Table I, Figure 1). The radical neck dissection group compared with the modified radical neck dissection or conservative neck dissection group and the radiation treatment only group was significant at p
479
Short et al
TABLE I
Results of Ouestionnaire and Physical Examination: Average VelUeS
Group
Trapezius Test
Abduction Test
Patients (n)
Pain
Performance
6
0.6
0.1
5
5
23 10
1.6 2.4
0.6 1.3
4.7 4.9
4.2 4.1
13
0.9
0.3
5
4.6
12 7
2.7 2.7
2.1 2.6
4.6 4.5
3.5 3.7
5
2.6
1.4
4.6
3.1
XRT MND or CND Same side as handedness Opposite side ashandedness RND Same side as handedness Opposite side as handedness
CND = Conservative neck dissection; MND = modified neck dissection; RND = radical neck dissection; XRT = radiation treatment
1
SRCRIFICED
RIDIcVIOL XI
NERUE
Flgun 1. Coqarbn of fhs average pain and fmctlon values for 1he radlatlon, preserved nerve, and sacrlflced nerve groups.XI = spinsI acceaaoty narva.
4_
El
PRES SO”E
PRES OPPOSITE r,
SPC Sa”E
FUNCTlDN PRIH
WC
DPPDSlTE
HERlIE
F&we 2. Mar/son OFIha average pa/n and functionvaluesfor preserved (PRES) and sacrked (SAC) nerve groups, cabgorized according to whOthOr surgery was on the same or opposite side OFhandedness.XI = spinal accessory nerve.
480
treatment only group was also significant at p <0.05. Handedness as a factor: The aforementioned results were again averaged in the same fashion but, in addition, they were categorized according to whether their neck surgery was on the same side or the opposite side of their dominant handedness (Figure 2). A pain average of 2.4 was obtained for these patients who had modified radical neck dissection or conservative neck dissection on the same side as handedness. Ten patients were in this group. The average pain level for patients with surgery opposite to their handedness in the preserved nerve group was 0.9. Thirteen patients were in this group. There was a significant difference between these groups (p <0.05). The sacrificed nerve group had an average pain level of 2.7 when surgery was performed on the same side as handedness (seven patients) and an average pain level of 2.6 when surgery was performed on the opposite side (five patients). The difference was not statistically significant. The results for the patients who had nerve preservation neck surgery on the same side as dominant handedness showed a performance average of 1.3, whereas those with surgery on the opposite side had an average of 0.3 (p
The American Journal of Surgery
The Shoulder After Neck Dissection
I
5 PRESERUED SLICRIFICED
I
85
B TRQPEZI”S
QGDUCTIDN H”SCL.E
GPDUP
Figure 3. lb average resutts of the pnvsicar examination (PE), comparing preserved and sacrifked nerve groups.
Flgmr 4. conpsrlson of the avere @@zal exmtkn reeutts when the difference between the normal and operated shoulder are calculated.
average was 4.6 (p CO.05). The average of the abduction test for the preserved nerve group was 4.2. The sacrificed nerve group average was 3.5 (p <0.05). The radiation treatment patients uniformly scored 5 in both the trapezius and abduction tests. In an attempt to control for variability in patient strength, the difference between the nonoperated and the operated sides was averaged (Figure 4). The preserved nerve group consistently showed less disability (normal function is represented by small numbers since this implies similar function between arms) and scored 0.08 and 0.4 for the trapezius and abduction tests, respectively. The sacrificed nerve group scored 0.3 and 1.3, respectively. There was a significant difference with the abduction test (p <0.05) but not the trapezius test (p <0.05). The radiation treatment patients scored 0 in both tests.
pain in their shoulders (26 percent) and high scores on their postoperative performance disability rating (9 percent). This variation in pain and function of the shoulder has been noted by other investigators [5 $1. As early as 1951, Ewing and Martin [3] noted normal trapezius function in two patients after sacrifice of the spinal accessory nerve. In 1961, Nahum et al [Z] found with electromyographic testing some patients who had only partial denervation of the trapezius muscle after radical neck dissection. The upper half of the trapezius muscle is innervated by the spinal accessory nerve and the lower half by the third and fourth cervical nerves [6,7]. However, some investigators believe that cervical nerve innervation is primarily proprioceptive [8,9]. The extent to which the variability in trapezius innervation contributes to the differences among patients postoperatively is uncertain, and this fact should not deter one from preserving the nerve given the overall favorable results. Radiation therapy has been suggested as a factor contributing to postoperative pain and disability 151. Although 25 percent of the patients treated with whole neck radiation but not neck dissection had mild to moderate pain in their shoulders after treatment (not significantly different from what was found in the nerve preservation group), their performance results were far superior to the surgical results. Only one of eight patients (12 percent) noticed a change in performance, and it was described as mild. Leipzig et al [5] reported that a significant number of patients who underwent modified radical neck dissection were found to have objective evidence of shoulder dysfunction but had no associated pain or functional disability. In our study, the physical examination was limited and did not detect this difference. The trapezius test, which is a common
Comments The results of this study show that, on the average, neck dissection patients with their spinal accessory nerve preserved have less pain in their shoulders, less functional disability, and were stronger on their physical examination than did those with a sacrificed spinal accessory nerve. In addition, it was found that the patients who received whole neck radiation treatment without neck dissection had little pain, infrequent and insignificant functional disability, and normal strength on physical examination. Although the averages suggest a firm difference between the groups, there was great variation among surgery patients within the same group. Some radical neck dissection patients had minimal pain (25 percent) and no postoperative performance difficulty (8 percent), whereas some patients with their spinal accessory nerve preserved had moderate to severe
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clinical test used for evaluating spinal accessory nerve function, did not significantly differentiate between the nerve preservation and nerve sacrifice groups. However, the abduction test which measures range of motion to 90 degrees and strength of abduction did detect a significant difference between the preservation nerve group and the sacrificed nerve group. In a resting position, the trapezius muscle‘functions as a supporter of the shoulder. The rhomboid muscles, the levator scapulae, and the upper fibers of the serratus anterior muscles also function in a supportive capacity for the shoulder. With trapezius paralysis, these muscles are found to compensate [2,8,10] and probably account for the inability of the trapezius test to discern spinal accessory nerve integrity. When the results of pain and function were averaged for patients who had neck dissections on the same side and the opposite side as their dominant handedness, significant differences in pain and function were obtained (Figure 2, Table I). In both the preserved and sacrificed nerve groups, performance disability was significantly greater in the patients with surgery on the same side as handedness. In contrast, only the preserved nerve group showed a significant difference in pain levels when handedness was considered. The radical neck dissection patients had similar pain levels independent of the side operated on. Since it is hard to imagine that variation in trapezius innervation could account for these findings, we feel this represents howl disability is a function of the demand placed on thu trapezius muscle. A right handed person is more likely to notice a decrease in shoulder strength and proprioception if it were to occur on the side of handedness. A corollary to this statement is that a patient can benefit from physical therapy in that he or she can, through exercising, increase the strength of functioning muscles and can be taught alternate ways of performing tasks. It is worth noting that no significant differences were found between same and opposite handedness groups on physical examination. Preservation of the spinal accessory nerve in neck dissections for head and neck tumors, on the average, yields more favorable postoperative shoulder function and less pain. This difference is most pronounced when the operation occurs on the same side as the patient’s handedness. There is great variation in the degree of functional disability and pain in patients with similar operations. The amount of
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physical therapy received postoperatively, injury to the spinal accessory nerve intraoperatively, and variation in innervatino of the trapezius muscle have been suggested as factors that contribute to the unpredictable outcome. Radiation therapy appears to contribute little to pain or physical disability. Summary To compare the difference in the degree of pain and functional disability of the shoulder in patients who underwent neck dissection for the treatment of head and neck cancer, 23 patients with and 12 patients without spinal accessory nerve preservation were evaluated with a questionnaire and a physical examination. In addition, to determine what effect radiation treatment has on pain and shoulder disability, eight patients who had whole neck radiation but no neck dissection were similarly evaluated. The results of this study show that, on the average, neck dissection patients with their spinal accessory nerve preserved have less pain in their shoulders, less functional disability, and stronger results on their physical examination than did those with their spinal accessory nerve sacrificed. It was also found that the patients who received whole neck radiation treatment without neck dissection had little pain, infrequent and insignificant functional disability, and normal strength on physical examination. References 1. Crile GW. Excision of cancer of the head and neck. JAMA 1982;47:1780-6. 2. Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Dtolaryngol 1961;74:82-6. 3. Ewing MB, Martin H. Disability following radical neck dissection. Cancer 1952;5:873-83. 4. Becker GD. Parell GJ. Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 1977;89:827-31. 5. Leipzig B, Suen JY, English JL, Barnes J, l-looper M. Functional evaluation of the spinal accessory nerve after neck dissection. Am J Surg 1983;146:526-30. 6. Szunyogh B. Shoulder disability following radical neck dissection. Am J Surg 1959;25:194-8. 7. Dewar FP, Harris RI. Restoration of function of shoulder following paralysis of the trapezius by fascial sling fixation and transplantation of the levator scapulae. Ann Surg 1950; 132:1111-5. 8. Ballantyne AJ, Guinn GA. Reduction of shoulder disability after neck dissection. Am J Surg 1966;112:662-5. 9. Gray H. Anatomy of the human body. Goss CM. ed. 29th ed. Philadelphia: Lea & Febiger, 1973. 10. Mead S. Posterior triangle operations and trapezius paralysis. AMA Arch Surg 1952;64:752-5.
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