Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk

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OBJECTIVE

Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.

METHODS

Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.

RESULTS

All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.

CONCLUSIONS

Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.

ABBREVIATIONS AROM = active ROM; BMRC = British Medical Research Council; ROM = range of motion; SAN = spinal accessory nerve; VAS = visual analog scale.

Article Information

Correspondence Oskar C. Aszmann: Medical University of Vienna, Austria. oskar.aszmann@meduniwien.ac.at.

INCLUDE WHEN CITING Published online April 5, 2019; DOI: 10.3171/2018.12.SPINE18498.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    High-resolution ultrasound images, using a broad-band linear working with an 18-MHz linear array transducer, showing a tubular structure (arrows, left) corresponding to the dissected accessory nerve (yellow line, right) ending in a scar (star, left; orange area, right) after nuchal lymphadenectomy. In the right panel, the red area denotes the levator scapulae muscle. Figure is available in color online only.

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    Schematic illustration of the selective fascicular nerve transfer of the upper trunk to the SAN. The fascicular group harvested from the upper trunk related to axillary nerve function is indicated (star). Note that the coaptation is done prior to the division of the spinal accessory nerve into its terminal branches (upper, middle, and lower trapezius). Copyright Aron Cserveny. Published with permission. Figure is available in color online only.

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    Intraoperative photograph showing dissection of the SAN and the fascicles of the upper trunk prior to coaptation. UT = upper trunk fascicles. Figure is available in color online only.

  • View in gallery

    Case 1. A: Preoperative photograph showing maximal ROM. B: Follow-up photograph obtained 20 months after surgery. C: Follow-up photograph obtained 20 months after surgery showing maximal ROM. Figure is available in color online only.

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