Surgical reconstruction for shoulder pain after radical neck dissection

Surgical

Reconstruction

after Radical FRANKLIN T.

HOAGLUND,

Neck Dissection

Strong

T

HE SPINAL ACCESSORY NERVE may be inter-

by

traction

by direct injury

intentional transfer [3-51.

transection

during

to the nerve

surgical

triangle in

which

intentionally adequate

it

the

during

dissection

[I 1,

there

sory

nerve

after injury

firm

dissecor

are

variable

muscle.

Symptoms

sensations

include

entire shoulder

severe pain in the ipsilateral supraclavicular

tients may complain the shoulder, Physical

vary

because

of the trapezius

the

and

third

significant

occurs, have

the

tour

with

position, the

The

inferiorly. away

affected

above

evident.

fourth

from

the

of

nerves the

shoulder

will

the and

clavicle

loss of shoulder fossa

is displaced

vertebral midline

border so that

is the

a fascial

and

90 con-

depressed

patients

accessory

nerve

[1,8].

Surgical

after

paralysis

following The

and Harris the scapula

scapular

has proved

of five symptomatic the neck

in an

and im-

with lateral transfer

to improve

of operation of

recon-

of the shoulder.

by Dewar

sling to stabilize

radical

best result

symptoms

and power

scapulae type

with

has been

are aimed at resuspending

and superiorly

tion. This

spinal

is exemplified

useful

patients

accessory

dissections.

of

rota-

nerve

(Table

I.)

in the following

case report.

to

CASE REPORT

a

The patient (W. C.), a forty-five year old maintenance engineer, was admitted to Strong Memorial Hospital on July 2, 1963 because of a chronic ulceration of the lip which had been present for four years. Wedge resection of the lesion revealed infiltrating epidermoid carcinoma. Histologic section of

con-

will

laterally

clavicle

described

in the treatment

[ll].

appear

the motion

the levator

trapezius assuming

patients

beyond

of the shoulder

symptomatic

procedures

medially

of

the roots

with forward

In some

abduction

to relieve traction

utilizes

abducof

of

supraclavicular

scapula

The

from

cervical

paralysis

dropped

horizontal

prove

Pa-

of overlap

of

The operation

90 degrees. findings

inferior

[IS].

to the spinal

attempt

the

weakness

The

the scapula and assisting scapular rotation

aching or

loss of shoulder

enervation If

and

shoulder.

of generalized

including

tion beyond

or

limited

horizontal

struction

part of the neck,

arm,

fossa,

side.

[l].

direct suture of the nerve

or dragging

girdle and generalized

is

border may appear slightly

Roentgenograms

Treatment

acces-

scar or about

inferior muscle

TREATMENT

of the trapezius

pulling

in the operative

be

the

injury

[4,5,7,8,10-131

distance

the

of the trapezius

shoulder

rotated scapula

triangle.

to the spinal

related to the degree of paralysis

may

degrees.

SYMPTOMS AND PHYSICAL FINDINGS Disabilities

of the

to assure

in the posterior

is

the scapular spine appears more promi-

flexion

is most

inadvertently

atrophy

a greater

than

flared, a finding which disappears

posterior

in an attempt

laterally

processes

angle and vertebral

during

neck

spinous

nent than on the unaffected

pedicle

nerve

radical

is either

incised

the

is displaced

from

marked,

paralysis

occur

on

however,

divided

nerve

angle

angle. When

[Z], or by

nerve

may

procedures

[1,6-91;

commonly tions

from missiles hanging

for the relief of facial Injury

minor

trauma during

Pain

Rochester, New York, AND ROBERT B. DUTHIE, CH.M., F.R.c.s.E., Oxford, England

M.D.,

From the Department of Orthopaedic Surgery, Memorial Hospital, Rochester, New York.

rupted

for Shoulder

be and

rotated superior 522

American Journal of Surgery

Reconstruction

523

of Shoulder

TABLEI DEWAR

Patient

J. C. #184128 B. B. #174632

w. c.

#560534

E. R. #55091 J. R. #602850

Age :yr.)

AND

Tumor

53 Squamous carcinoma of soft palate 62 Squamous carcinoma of floor of mouth 16 Epidermoid carcinoma 55 Squamous carcinoma of vocal cord 48 Epidermoid carcinoma of vocal cord

HARRIS

PROCEDURES

Spinal Accessory Kerve (operative note)

Duration (yr.) before Procedure

1966

OF THE TRAPEZIUS

symptoms

MUSCLE

Duration (yr.1 of Follow-Up Study

Result

-

Kot mentioned

4.5

Left shoulder pain and swelling

5.5

Poor; died of pulmonary edema

Divided

7

Pain in left side of neck and left scapula; lost abduction

5

Improved motion and pain relief

Not mentioned

1

1

Improved motion and pain relief

Divided

3

Stiffness in left shoulder; discomfort in left side of neck; lost abduction Pain in left shoulder; lost abduction

Not mentioned

2

the excisional biopsy specimen showed satisfactory margins. A left submental lymph node which was firm and nontender subsequently developed for which left radical neck dissection was performed on November 29, 1963. No tumor was found in this specimen. Postoperatively he had weakness of shoulder abduction, inability to lift heavy objects, and a constant “dragging or pulling” sensation in the neck, supraclavicular fossa, and shoulder when his arm was unsupported. Despite range of motion exercises, massage, and short wave diathermy, his symptoms were unrelieved. He was readmitted on January 4, 1965 for a Dewar-type scapulopexy. On examination there was a well healed incision from the radical neck dissection without signs of induration or recurrent carcinoma. (Fig. 1.) Examination of the left shoulder revealed diffuse atrophy of the left trapezius with a prominent scapular spine. The superior scapular angle was displaced laterally, and the inferior angle was closer to the spinous process than on the unaffected side. Active abduction or flexion was limited to 90 degrees although a full passive range of shoulder motion was possible. Attempts at abduction were marked by winging of the superior scapular angle. Surgical reconstruction was carried out through a 15 cm. vertical incision medial to the vertebral border of the left scapula and a second incision parallel and proximal to the lateral aspect of the scapular spine. (Fig. 2.) The atrophic and fibrotic trapezius was reflected laterally from the spinous processes of the upper thoracic vertebrae exposing the vertebral border of the scapula. Through two Vol. 112, October

FOR PALSY

Dragging pain in left shoulder; lost abduction

10 mo.

Improved motion and partial pain relief

10 mo.

Improved motion and pain relief

drill holes at the base of the spine of the scapula, two strips of autologous fascia lata measuring 20 by 2 cm. were inserted and attached about the exposed spinous processes of the first and second thoracic vertebrae. After replacing the scapula into its normal position, fascial strips were sutured under moderate tension. The insertion of the levator scapulae was released and, through the second incision, reattached subperiosteally to the lateral third of the scapular spine (Fig. 3.) Postoperatively he was maintained for six weeks in a shoulder abduction splint with the arm at 110 degrees of abduction, 20 degrees of forward flexion, and neutral rotation. His arm was subsequently placed in a sling for two weeks and then active range of motion exercise started. He returned to work two months after surgery. Maximal shoulder function and muscle power developed approximately six months post surgery, during which time there was progressive hypertrophy of the transferred levator scapulae. The preoperative complaint of aching discomfort progressively resolved as his shoulder motion and power increased. At ten months post surgery he had 135 degrees of active arm abduction at the shoulder in comparison with 170 degrees on the unaffected side. There was 120 degrees of forward flexion in comparison with 145 degrees on the contralateral side. He had 70 degrees of external rotation in comparison with 80 degrees on the normal side. There was bilateral full internal rotation. He had been unaware of shoulder pain for the preceeding three months. Electromyography ten months after transfer of

524

Hoaglund and Duthie

1 2 FIG. 1. Patient (W. C.) with healed incision after left radical neck dissection with atrophy trapezius muscle.

of left

FIG. 2. Patient (W. C.) four months after lateral transfer of levator scapulae and fascial slings to vertebral border of scapula (L) showing position of incisions and contraction of levator scapulae (L, neck) during shoulder shrug.

the levator scapulae revealed a normal electromyogram of the transferred muscle with development of motor unit action-potential activity with shoulder shrug, but no evidence of motor unit activity with elevation of the left arm at the shoulder. (Fig. 4A.) The electromyogram confirmed the clini-

cal observation that the transfer was functioning only during shoulder shrug but not at rest or during arm abduction. An electromyogram of the upper trapezius indicated severe denervation. (Fig. 4B.) OTHER CASE MATERIAL AND RESULTS

This type of surgical suspension of the shoulder has been carried out in five patients with paralysis of the trapezius muscle after previous radical neck dissections for carcinoma of the head and neck (one epidermoid carcinoma of the lip, two squamous oral carcinomas, and two carcinomas of the vocal cords). Neck dissections were performed one and a half to seven years prior to the shoulder surgery. Pain was the indication for surgery and included the characteristic pulling or dragging sensation in the neck, shoulder, or arm and supraclavicular or shoulder pain which could be relieved by supporting the arm. All patients had mobilizing and strengthening exercises for the shoulder with diathermy in an attempt to relieve symptoms prior to surgical reconstruction. All patients revealed a dropped shoulder with the scapula displaced laterally

and the vertebral border rotated away from the midline. Atrophy was constant in the upper fibers of the trapezius in all patients with variable atrophy in the lower portions. The surgical treatment and postoperative care previously described herein were essentially the same in all patients. Patients were examined ten months to five years after scapulopexy. One patient died from hypertensive cardiovascular disease and tuberculosis five years after surgery. He was the only one of the five who did not benefit by relief of symptoms. However, he had had previous thoracoplasty on the same side, resulting in palsy of the serratus anterior muscle in addition to the thoracic deformity. Mayr [15] reported one patient with palsy of both the trapezius and serratus anterior muscles also with a poor result after levator scapulae transfer. The remaining four patients all had significant relief of their symptoms. All showed improvement in active arm abduction and forward flexion with increased strength. These patients were able actively to abduct or flex the arm forward beyond 110 degrees. Preoperatively, 90 degrees was the maximal range of abduction or forward flexion. One patient had complete relief of preoperative symptoms and the remaining three patients had partial relief. All had significant relief to justify surgery. FuncAmerican Journal of Surgery

Reconstruction

of Shoulder

325

tion in the transferred levator scapulae varied in each patient. In one patient with the greatest improvement in symptoms, no clinical function of the levator scapulae was noted during active arm abduction to 135 degrees (confirmed by electromyography). (Fig. 4B.) However, gross contraction of the levator scapulae was observed during shoulder shrug. In the three other patients with good results, levator scapulae contraction was present during the first 40 to 90 degrees of arm abduction at the shoulder. COMMENTS

Loss of shoulder motion and power, the drooped shoulder configuration, and minor symptoms of discomfort are common after injury to the spinal accessory nerve, but more severe disabilities are infrequent [12]. Nahum, Mullally, and Marmor [16] were able to produce shoulder symptoms by spinal accessory nerve block by local anesthesia. The reason for the variable clinical course after radical neck dissections in which the spinal accessory is routinely excised is best explained by differences in overlap of trapezius enervation by the spinal accessory and branches of roots of the third and fourth cervical nerves. Woodhall [1] described overlap of the enervation between the third and fourth cervical nerves and spinal accessory only in the inferior two thirds of the trapezius. Haas and Sollberg [ll 1, using electromyographic studies in symptomatic patients, found complete paralysis of the lower third and concluded that it is the upper two thirds of the trapezius which receives dual enervation. The patients in the present series had consistent atrophy of the upper trapezius. These differences indicate variation in areas of overlap as well as in extent of dual enervation. FIG. 4. A, electromyogram of transferred levator scapulae in patient (W. C.) during maximal shoulder shrug showing a good number of motor unit action potentials Incomplete activity is attributed to pain from site of electromyogram needle. Ordinate 1 mv./ cm.; abscissa 10 msec./cm. B, of upper traelectromyogram pezius at rest showing fibrillation potentials. Ordinate 0.2 mv./ cm.; abscissa 5 msec./cm.

Vol. 112. October 1966

FIG. 3. Levator scapulae is detached from insertion on vertebral border and reattached to lateral portion of scapular spine. Fascial slings are inserted at vertebral border and looped about spinous processes at the level of the first and second thoracic vertebrae.

Inman, Saunders, and Abbott [17] have shown that the upper and lower thirds of the trapezius rotate the scapula during abduction of the arm while the middle third stabilizes the scapula medially. The upper third of the trapezius has an action potential at rest and is responsible for suspending the scapula. Abduction of the arm normally requires scapular rotation provided by the upper and lower thirds of the trapezius, levator scapulae, and serratus anterior muscles [17]. In the presence of impaired trapezius function, the fulcrum for the scapula is lost, and the serratus anterior draws the scapula forward instead of providing rotation [18]. Therefore, the amount of arm abduction provided by scapular motion is lost. With downward and forward displacement of the scapula on the thorax, traction is exerted on

526

Hoaglund and Duthie

the supraclavicular neurovascular and muscular structures to produce pain. By supporting the arm with a sling or abduction splint or just resting the arm on the arm of a chair, some patients with paralysis of the trapezius can have relief of their symptoms. The scapulopexy method of Dewar and Harris [18] resuspends the scapula in its normal position with fascial slings and attempts to provide a motor muscle to assist scapular rotation. The end result is to decrease the traction on the neck and supraclavicular structures and to improve shoulder motion by improving scapular rotation. One patient in the present series had improved function of arm abduction at the shoulder in the absence of levator scapulae function during shoulder abduction. This indicates the necessity for medial and superior suspension of the scapula to provide a fulcrum for serratus anterior action. A similar surgical procedure applying the same principles has been utilized by Lange [19] and Mayr [15] to provide a dynamic vertical and medial support for the scapula. In addition to lateral transfer of the levator scapulae, rhomboid muscles are reattached laterally at the mid-point of the infraspinatus fossa. Their combined experience in over fifty cases of symptomatic palsy of the spinal accessory nerve has given good results for the relief of pain and the improvement of shoulder motion.

REFERENCES 1. WOODHALL, B. Trapezius

2. 3.

4.

5.

6.

7. 8. 9.

10. 11.

12.

13.

SUMMARY

Shoulder disability after transection of the spinal accessory nerve is variable. Symptomatic patients obtain relief of pain and improved shoulder motion by resuspension of the scapula. Five patients with symptomatic paralysis of the trapezius muscle after radical neck dissection have had a DewarHarris type of shoulder suspension operation. One patient who had associated paralysis of the serratus anterior muscle was not improved. The remaining four patients had improved abduction and significant relief of pain. This operation is recommended for the patient with shoulder symptoms due to paralysis of the trapezius muscle and who does not respond to conservative measures.

14.

15.

16.

17.

18.

19.

paralysis following minor surgery procedures in the posterior surgical triangle. Ann. Surg., 136: 375, 1952. BELL, D. S. Pressure palsy of accessory nerve. &it. M. J., 1: 1483, 1964. COLEMAN, C. C. Results of facie-hypoglossal anastomosis in the treatment of joint paralysis. Ann. Surg., 111: 958, 1940. COLEMAN, C. C. and WALKER, J. C. Technic of anastomosis of the branches of the facial nerve with the spinal accessory for facial paralysis. Ann. Surg., 131: 960, 1950. MCKENZIE, F. G. and ALEXANDER, E. Restoration of facial function by nerve anastomosis. Ann. Surg., 132: 411, 1950. HANFORD, J. M. Surgical excision of tuberculous lymph nodes of the neck. A report of 131 patients with followup results. S. Clin. North America, 13: 301, 1933. MEAD, S. Posterior triangle operations and trapezius paralysis. Arch. Surg., 64: 752, 1952. NORDEN, A. Peripheral injuries to the spinal accessory nerve. Acta chir. scandinav., 94: 515, 1946. WULFF, A. B. The treatment of tuberculous cervical lymphoma: late results in 230 cases treated partly surgical partly radiological. Acta chir. scandinav., 84: 343, 1941. SZUNYOGH,B. Shoulder disability following radical neck dissection. Am. Surgeon, 25: 194, 1959. HAAS, VON E. and SOLLBERG, G. Untersuchungen iiber die Funktion des Schiiltergiitels nach Durchschneiderung des N. Accessorius. Ztschr. Larnyg., 41: 669, 1962. EWING, M. R. and MARTIN, A. Disability following radical neck dissection: an assessment based on postoperative evaluation of 100 patients. Cancer, 5: 873, 1952. THULIN, C. A., PETERSEN, I., and GRANHOLM, L. Following studies of spinal accessory facial nerve anastomosis with special reference to electromyographic findings. J. Neurol. Neurosurg. 6 Psych&, 27: 502, 1964. SIMPSON, S. A., GORDON, S., JORGENS, J., and RIGLER, L. G. Roentgen changes following radical neck dissection. Radiology, 67: 704, 1956. MAYR, H. Bad tolz TrapeziuslHhmung nach operativer Behandlung Tuber Koloser Halslymphdriiisen. Miinchen. med. Wchnschr., 95: 170,1953. NAHUM, A. M., MULLALLY, W., and MARMOR, L. Syndrome resulting from radical neck dissection. Arch. Otol., 74: 424, 1961. INMAN, U. T., SAUNDERS,J. B. D. M., and ABBOTT, L. C. Observations on the function of the shoulder joint. J. Bone 6 Joint Surg., 26: 1, 1944. DEWAR, F. P. and HARRIS, R. I. Restoration of function of the shoulder following paralysis of the trapezius by fascial sling hation and transplantation of the levator scapulae. Ann. Surg., 132: 1111, 1950. LANGE, M. Die operative Behandlung der irreparablen Trapeziusllhmung. Tip. fak. Met. (Istanbul), 22: 137, 1959.

American

Journal of Surgery