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Indian Journal of Surgery, Vol. 69, No. 2, March-April, 2007, pp. 65-67 Case Report Winging of scapula following lymph node biopsy in posterior triangle of neck Hemant Sharma, Navneet K. Goel, Lalit Maini* Department of Orthopaedics, Aruna Asaf Ali Govt. Hospital, Rajpur Road, New Delhi Code Number: is07022 Abstract Injury to accessory nerve in the posterior triangle of neck leads to disabling paralysis of the trapezius muscle. It is a well-known but frequently forgotten complication of lymph node biopsy taken casually in minor operation theatre under local anesthesia. We describe such a patient with emphasis on prevention, early diagnosis and management.Keywords: Accessory nerve, biopsy, lymph node, paralysis, scapula Introduction Accessory nerve may be injured at any point during its course because of its superficial location in posterior cervical triangle. [1] It is susceptible to damage from penetrating injury, infection, stretch, during radical neck dissection, cannulation of internal jugular vein, thyroidectomy, cervicofacial lift and carotid endarterectomy. But this injury usually follows simple lymph node biopsy, so called minor surgery, in posterior triangle of neck. [2],[3] Most of the problems arise from failure to diagnose or acknowledge the injury in immediate post-operative period or hoping that it will resolve spontaneously. If diagnosed early it can be managed by neurorraphy with good results otherwise muscle transfer surgeries are required. The purpose of this report is to reemphasize the fact that this injury frequently follows a simple lymph node biopsy in the posterior triangle of neck. Moreover. accessory nerve injury during lymph node biopsy is not acceptable from medico-legal standpoint. [1],[4]Case Report A 25-year-old male patient presented in outpatient department with difficulty and pain on over head movements of left upper limb. On detailed history, patient reported about a lymph node biopsy in neck region two years ago under local anesthesia. He mentioned taking medicines for six months after the operation, probably antitubercular drugs. Since few days after surgery he noticed difficulty in overhead movement of left upper limb but ignored it initially and latter was convinced by the operating surgeon that it will improve with time. On clinical examination patient had healed operated transverse scar about 3.5 cm in posterior triangle of neck [Figure - 1]. He had wasting of muscles of neck and shoulder region. His scapula was rotated distally and laterally and slightly flared up. Inferior angle of scapula was close to midline then its superior angle [Figure - 2]. This position was accentuated when arm was abducted and disappeared when arm was raised anteriorly. Scapula became even more prominent when patient actively externally rotated shoulder against resistance. Patient had no sensory deficit. Since this patient presented two years after injury he was advised transfer of levator scapulae and rhomboids for paralysis of trapezius (Eden-Lange procedure). Patient refused surgery as he was the only earning member of the family in view of longer rehabilitation procedure required. Patient was referred to physical and occupational therapy department for home exercise programme. Discussion Spinal accessory nerve runs from jugular foramen to the border of trapezius. Accessory nerve consists of two parts cranial and spinal. It is the spinal portion of accessory nerve, which is important for head and neck surgeons. Throughout its course in the posterior triangle it is engulfed in fibrofatty tissue and associated with a chain of five to 10 lymph nodes. The nerve may course superficial to lymph nodes. [1] There are landmarks for identifying the course of the nerve. The proximal internal jugular vein in the anterior and Erb′s point in the posterior triangle. Trapezius is a major shoulder stabilizer. It is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating and retracting the scapula. [5] Prevention of accessory nerve injury is the best management. It is almost impossible to define surgical anatomy of accessory nerve in posterior triangle given its wide variations in man. Injury to spinal accessory nerve can not be prevented by adhering to surface marking given in text books, but only by careful dissection in the posterior triangle. [4] Careful documentation of shoulder function in pre and post-operative period should be routine. High index of suspicion is required in patients with discomfort and weakness in shoulder and neck area immediate postoperatively. This should not simply be attributed to post-surgical discomfort. Simple shrugging of shoulder is not adequate test. The trapezius should be tested with the arm abducted and pronated. In this position greater tuberosity of the humerus abuts against the acromion at 90 degrees and fixes glenohumeral movement. Another test described is resisted active external rotation of shoulder leading to prominence of scapula. [6] These clinical tests should be supplemented with electroneurographic tests. The biopsy should be done under general anesthesia without use of muscle relaxant so as to use nerve stimulator if required. One should be careful with the incision and elevation of skin flaps because nerve is superficial and there is no platysma. Incision should be liberal with minimal traction on the soft tissues. One should always isolate accessory nerve by careful dissection. One should not use electro-cautery except in immediate subdermal vessels and then only when accessory nerve has been identified. The use of bipolar cautery is preferred. There may be significant transmission over short distance i.e., 0.5 to 1cm. Use of magnifying loop may be useful. Fine needle aspiration biopsy is very accurate and can be performed in several of the cases for which open biopsy of lymph node is required. [7] Good results may be expected from repair of accessory nerve if it is performed within twenty months after injury. Conservative therapy is less predictable and risks delaying more effective operative treatment. [2] This nerve is basically a motor nerve and distance from site of injury to motor end plate is short. [3] Recovery is also related to survival time of denervated striated muscle. [8] This signifies the importance of early diagnosis and repair of nerve by a surgeon familiar with microsurgical techniques References
Copyright 2007 - Indian Journal of Surgery The following images related to this document are available:Photo images[is07022f2.jpg] [is07022f1.jpg] |
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