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Background Shoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve injury by modulating the brain-derived neurotrophic growth factor (BDNF) pathways. The objective of this study was to evaluate the effect of BES on postoperative shoulder function following oncologic neck dissection. Methods Adult participants with a new diagnosis of HNC undergoing Level IIb +/− V neck dissection were recruited. Those in the treatment group received intraoperative BES applied to the spinal accessory nerve (SAN) after completion of neck dissection for 60 min of continuous 20 Hz stimulation at 3-5 V of 0.1 msec balanced biphasic pulses, while those in the control group received no stimulation (NS). The primary outcome measured was the Constant-Murley Shoulder (CMS) Score, comparing changes from baseline to 12 months post-neck dissection. Secondary outcomes included the change in the Neck Dissection Impairment Index (ΔNDII) score and the change in compound muscle action potential amplitude (ΔCMAP) over the same period. Results Fifty-four patients were randomized to the treatment or control group with a 1:1 allocation scheme. No differences in demographics, tumor characteristics, or neck dissection types were found between groups. Significantly lower ΔCMS scores were observed in the BES group at 12 months, indicating better preservation of shoulder function ( p  = 0.007). Only four in the BES group compared to 17 patients in the NS groups saw decreases greater than the minimally important clinical difference (MICD) of the CMS ( p  = 0.023). However, NDII scores ( p  = 0.089) and CMAP amplitudes ( p  = 0.067) between the groups did not reach statistical significance at 12 months. BES participants with Level IIb + V neck dissections had significantly better ΔCMS and ΔCMAP scores at 12 months ( p  = 0.048 and p  = 0.025, respectively). Conclusions Application of BES to the SAN may help reduce impaired shoulder function in patients undergoing oncologic neck dissection, and may be considered a viable adjunct to functional rehabilitation therapies. Trial registration Clinicaltrials.gov ( NCT02268344 , October 17, 2014).

Abstract ObjectiveTo determine the accuracy of preoperative ultrasound and MRI in surgically confirmed spinal accessory nerve injuries and present the benefits of a multimodality image review.Materials and methodsA retrospective review of 38 consecutive patients referred to a peripheral nerve surgical practice at an academic teaching hospital with surgically confirmed spinal accessory nerve injuries. All cases were reviewed for patient demographics, date and cause of injury, preoperative EMG, and surgical diagnosis and management. Additionally, prospective interpretation of preoperative ultrasound and MRI reports were reviewed for concordance or discordance with the surgical diagnosis.ResultsIatrogenic injury was present in 37 (97%) cases and most commonly a result of an excisional lymph node biopsy (68%). Surgically confirmed spinal accessory nerve injury diagnoses consisted of 25 (66%) stump neuromas and 13 (34%) incomplete nerve injuries. Nine months was the average time from injury to surgery. Twenty-nine patients underwent preoperative ultrasound and/or MRI evaluation: 12 ultrasound only, 10 MRI only, and seven with both ultrasound and MRI. Eighteen (95%) preoperative ultrasound reports compared to four (24%) preoperative MRI reports were concordant with the surgical diagnosis. In the seven cases with both preoperative ultrasound and MRI, six had discordant ultrasound and MRI imaging diagnoses for which the ultrasound was concordant with the surgical diagnoses in all cases.ConclusionPreoperative ultrasound more accurately characterizes spinal accessory nerve injuries compared to MRI and should serve as the modality of choice when a spinal accessory nerve injury is suspected.

Transfer of the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) is a common surgical intervention employed for restoring shoulder function in both obstetric and traumatic brachial plexus injury (TBPI). Despite widespread use, there is a paucity of evidence surrounding the efficacy of this procedure. A systematic search of the literature in the National Institutes of Health MEDLINE and Embase databases was performed in accordance with the PRISMA guidelines. Patients had to have a minimum postoperative follow-up of 6 months. Cohorts containing patients with obstetric brachial plexus injuries were excluded. We extracted data on shoulder abduction strength, measured using the British Medical Research Council (MRC) scale and range of motion (ROM) of shoulder abduction. Of the 298 studies screened, 12 with 311 total participants met our inclusion criteria. The average age of participants was 27.03 ± 3.05 years and the male:female ratio was 25.4:1. All patients underwent surgery following TBPI and average time-to surgery was 5.91 ± 1.52 months. 66.37 % of patients achieved a post-operative MRC grade of shoulder abduction of ≥M3 with a mean MRC score of 2.67 ± 1.02. Average post-operative shoulder abduction ROM was 56.97 degrees. Average follow-up time for all reported outcomes was 24.64 ± 7.47 weeks. Nine studies comprising 243 patients were included in the meta-analysis, which revealed a cumulative weighted effect size of 56.83 degrees (95 % CI = 52.31, 61.34). These findings suggest that SAN-SSN transfer is an effective intervention for the restoration of shoulder function following TBPI. •SAN-SSC transfer produces satisfactory post-operative outcomes for shoulder abduction according to the MRC grading scale.•SAN-SSC transfer restores shoulder abduction to an average of beyond 50 degrees.•Larger studies with consistent outcome measures are required to validate the use of SAN-SSC transfer in routine care.

BACKGROUND: The course of the spinal accessory nerve in the neck is long andsuperficial rendering it at high risk of injury during procedures performed in theposterior triangle. The majority of spinal accessory nerve injuries are iatrogenic innature. This is associated with significant morbidity including reduction in shouldermovements, drooping of the shoulder, winging of the scapula and neuropathicpain. Knowledge of the nerve anatomy reduces the risk of intra-operative nerveinjury. Traditional teaching describes the point of entry into the posterior triangleas the intersection between the upper and middle third of the posterior borderof sternocleidomastoid. The aim of this study was to determine whether this isin fact the case and if so, whether this landmark can reliably be used to identifythe spinal accessory nerve in order to improve patient outcomes. MATERIALS AND METHODS: The spinal accessory nerve was identified unilaterallyin 26 cadavers. The total length of sternocleidomastoid was measured as wellas the length along the posterior border from the inferior aspect of the mastoidprocess to the point at which the accessory nerve enters the posterior triangleof the neck. These measurements were used to calculate the ratio of the entrypoint of the nerve into the posterior triangle along the length of the posteriorborder of sternocleidomastoid from its superior insertion point. The mean ratiowas 0.35 with 95% confidence intervals of 0.33 to 0.36. RESULTS AND CONCLUSIONS: Our findings confirm the traditional description of theentry point of the spinal accessory nerve into the posterior triangle of the neck. Wedescribe a so-called ‘safe zone’ inferior to the midpoint of the posterior border ofsternocleidomastoid within which the spinal accessory nerve is unlikely to be found,thereby reducing the risk of iatrogenic injury

This study assessed the feasibility of high-resolution ultrasound (HRUS) for visualizing the cervical spinal accessory nerve (SAN) and explored its sonographic characteristics, anatomical landmarks, and normative diameter measurements. A prospective study was conducted in 60 healthy volunteers, in whom the SAN was categorized into three segments: between the trapezius and levator scapulae (S1), from the surface of the levator scapulae to the posterior border of the sternocleidomastoid muscle (SCM) (S2), and from the posterior border of the SCM to the upper cervical region (S3). HRUS was utilized to evaluate SAN visibility and measure the maximum short-axis diameter (SD), with normative values statistically analyzed. In addition, a retrospective analysis was performed in 12 patients with clinically and electrophysiologically confirmed SAN injury to characterize sonographic abnormalities. HRUS successfully delineated the SAN and adjacent structures with a 100% visibility rate across all segments. No significant differences in SD were observed between sides, segments, or sexes, though SD exhibited a positive correlation with body mass index (BMI). In patients with SAN injury, HRUS identified complete nerve rupture, with all cases presenting trapezius muscle atrophy. These findings establish HRUS as a reliable, non-invasive imaging modality for assessing SAN morphology and diagnosing nerve injuries.

The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment.

ObjectiveAnatomic variations have curicial importance during neck surgery. We present a fenestrated internal jugular vein variation and the accessory nerve passing through it. Also, we discuss preoperative diagnosis of this variation using ultrasonography.MethodThe possible recognition of this variation by ultrasonography is introduced.ResultsThe accessory nerve in an internal jugular vein fenestration can be seen using ultrasonography.ConclusionPreoperative identification of this rare variation may secure surgeon from potential complications.

BackgroundThe purpose of this study was to assess the results of elbow flexion strength fatigue, rather than the maximal power of strength, after brachial plexus re-innervation with phrenic and spinal accessory nerves. We designed a simple but specific test to study whether statistical differences were observed among those two donor nerves.MethodWe retrospectively reviewed patients with severe brachial plexus palsy for which either phrenic nerve (PN) or spinal accessory nerve (SAN) to musculocutaneous nerve (MCN) transfer was performed. A dynamometer was used to determine the maximal contraction strength. One and two kilograms circular weights were utilized to measure isometrically the duration of submaximal and near-maximal contraction time. Statistical analysis was performed between the two groups.ResultsTwenty-eight patients were included: 21 with a PN transfer while 7 with a SAN transfer for elbow flexion. The mean time from trauma to surgery was 7.1 months for spinal accessory nerve versus 5.2 for phrenic nerve, and the mean follow-up was 57.7 and 38.6 months, respectively. Statistical analysis showed a quicker fatigue for the PN, such that patients with the SAN transfer could hold weights of 1 kg and 2 kg for a mean of 91.0 and 61.6 s, respectively, while patients with transfer of the phrenic nerve could hold 1 kg and 2 kg weights for just a mean of 41.7 and 19.6 s, respectively. Both differences were statistically significant (at p = 0.006 and 0.011, respectively). Upon correlation analysis, endurances at 1 kg and 2 kg were strongly correlated, with r = 0.85 (p < 0.001).ConclusionsOur results suggest that phrenic to musculocutaneous nerve transfer showed an increased muscular fatigue when compared with spinal accessory nerve to musculocutaneous transfer. Further studies designed to analyze this relation should be performed to increase our knowledge about strength endurance/fatigue and muscle re-innervation.

Purpose Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. Methods We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. Results At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days–7 months) at presentation. Surgery was performed on average at 5.8 months of age (3–8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. Conclusion In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Background There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, “shoulder syndrome” appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1–2N0M0 oral squamous cell carcinoma (OSCC). Methods We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression–free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant–Murley scale to measure shoulder function. Discussion Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1–T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies. Trial registration Chinese Clinical Trial Registry, ChiCTR1800019128 . Registered on 26 October 2018.