Accessory Nerve Research Articles

Identifying safety zone of invasive procedures in the sternocleidomastoid muscle using ultrasonography.

Dysfunctions of the sternocleidomastoid (SCM) muscle, such as myofascial syndrome, torticollis, and cervical dystonia, have been treated using several invasive procedures. In such situations, it is possible to injure the adjacent nerves. This study aimed to demonstrate the course of these nerves in healthy volunteers using ultrasound. The great auricular nerve (GAN), spinal accessory nerve (SAN), transverse cervical nerve (TCN), and supraclavicular nerve (SCN) were scanned by ultrasonography in 26 healthy volunteers. The neck was scanned in the supine position with the head turned 45° to the contralateral side. The cervical plexus was detected in half of the SCM muscle. Each nerve was then traced to the level of contact with the anterior border of the SCM muscle. The following features of the nerves were recorded bilaterally: vertical and horizontal positions of each nerve at the posterior border of the SCM and the cross-sectional area and depth of each nerve at the reference line and anterior border of the SCM. The mean proportions of GAN, SAN, TCN, and SCN were 26%, 26%, 48%, and 80%, respectively near the posterior border, whereas they were 18%, 23%, and 51% for GAN, SAN, and TCN, respectively, at the level of the reference line. Notably, SCN was not visible at the level of the reference line. The mean TCN proportion was 47% at the anterior border of the SCM. The precise location of the nerves and their relationship with the SCM muscle should be considered during invasive procedures. It is recommended that the procedure be performed in the lower half of the SCM muscle, which refers to 50 to 80% of the proportions in our study.

Anatomical and Radiological Assessments of Injectate Spread Stratified by the Volume of the Pericapsular Nerve Group Block.

The pericapsular nerve group (PENG) block was recently suggested as a regional technique for managing acute pain after hip surgery. However, few anatomical studies have confirmed the spread of injectate during the PENG block. This cadaver study aimed to analyze injectate spread to the target nerves during single-injection ultrasound-guided PENG block. Ultrasound-guided PENG block with 3 different injectate volumes (10, 20, or 30 mL) was performed in 18 cadavers. Injectate spread by the volume was first evaluated on computed tomography, followed by cadaver dissection. The spread of the dye over the pelvis and lower limb was evaluated. The articular branches of the femoral nerve were stained nearly sufficiently with 20- and 30-mL specimens. The femoral nerve itself was stained simultaneously in six of 12 (50%) 20-mL specimens and 12 of 12 (100%) 30-mL specimens. The accessory obturator nerve was observed only in three (9%) of 36 specimens. The articular branches of the obturator nerve were rarely affected, regardless of injectate volume (1/12, 10 mL specimens; 2/12, 20 mL specimens; 1/12, 30 mL specimens; P > .999). Rather, the obturator nerve was affected. However, the obturator nerve was not stained consistently even with 30 mL of injectate (50%). After combining the dissection and radiological findings, the single-injection ultrasound-guided PENG blocks with volumes of 10, 20, and 30 mL do not support motor sparing or selective anterior hip capsule innervation in a clinical setting. If early rehabilitation is needed, high-volume PENG block might not be the ideal option, and persisting pain after PENG block might be attributed in part to the lack of obturator nerve articular branches blockade.

A marginal process of the zygomatic bone predicts a lateral exit of the zygomaticotemporal nerve: An anatomical study with application to surgery around the midface.

Previous studies have not verified the contents of accessory foramina of the zygomatic bone on dry skulls and thus could not conclude whether they carried accessory zygomaticofacial nerve branches or branches or the entire trunk of the zygomaticotemporal nerve (ZTN). Therefore, the aim of the current study is to present findings from cadaveric dissections to clarify this relationship. Fifty, fresh frozen, adult cadaveric sides underwent dissection of the ZTN. When identified, these nerves were quantified and their relationship to the zygomatic bone further documented by dissecting through the bone following the course of the nerve from a superficial to deep perspective. Additionally, 100 dry, adult, human skulls were analyzed looking for lateral foramina on the zygomatic bone. On three cadaveric sides (6%), the ZTN was found to pierce the zygomatic bone deeply and exit its superficial lateral surface. For dry skull specimens, a lateral zygomaticotemporal foramen (ZTF) was identified on nine sides (4.5%). For both groups, the presence of a strong marginal process of the zygomatic bone was strongly correlated to a ZTF exiting the lateral surface of the zygomatic bone. Although relatively uncommon, the ZTN can pierce the lateral aspect of the zygomatic bone and thus can be located superficial to the cheek. Such findings should be borne in mind during surgical or other invasive procedures in this area in order to minimize iatrogenic injury to the ZTN.

Gracilis Muscle-Free Flap Objective Improvement of Oral Commissure Excursion in Facial Palsy Reanimation Surgery: Systematic Review and Meta-Analysis.

Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.

Posterior division of ipsilateral C7 transfer to C5 for shoulder abduction limitation.

Reparation of C5 by proximal selective ipsilateral C7 transfer has been reported for the treatment of neurogenic shoulder abduction limitation as an alternative to the reparation of the suprascapular nerve (SSN) and the axillary nerve (AXN) by distal nerve transfers. However, there is a lack of evidence to support either strategy leading to better outcomes based on long-term follow-up. The purpose of the study was to investigate the safety and long-term outcomes of the posterior division of ipsilateral C7 (PDIC7) transfer to C5 in treating neurogenic shoulder abduction limitation. A total of 27 cases with limited shoulder abduction caused by C5 injury (24 cases of trauma, 2 cases of neuritis, and 1 case of iatrogenic injury) underwent PDIC7 transfer to the C5 root. A total of 12 cases (11 cases of trauma and 1 case of neuritis) of C5 injury underwent spinal accessory nerve (SAN) transfer to SSN plus the triceps muscular branch of the radial nerve (TMBRN) transfer to AXN. The patients were followed up for at least 12 months for muscle strength and shoulder abduction range of motion (ROM). In cases that underwent PDIC7 transfer, the average shoulder abduction was 105.9° at the 12-month follow-up. In total, 26 of 27 patients recovered at least M3 (13 reached M4) (Medical Research Council Grading) of the deltoid. In cases that underwent SAN transfer to SSN plus TMBRN to AXN, the average shoulder abduction was 84.6° at the 12-month follow-up. In total, 11 of 12 patients recovered at least M3 (4 reached M4) of the deltoid. Posterior division of ipsilateral C7 transfer is a one-stage, safe, and effective surgical procedure for patients with neurogenic shoulder abduction limitation.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BackgroundThe subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle. PurposeTo provide comprehensive gross anatomy description of the variant “subclavius posticus muscle” and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression. Basic proceduresA scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed. Main findingsThe scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all. Principal conclusionsThe subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

Complications of neck dissection and their management: Retrospective study

Neck dissection (ND) is a surgical procedure performed in treating head and neck cancer patients with or without cervical nodal neck metastasis. The aim of neck dissection is to achieve loco-regional control thus optimizing the cancer cure rate. Various complications may potentially occur following this surgery. Previous studies done have documented the complication rate following neck dissection surgery to range between 5% to 15%. Most of the complications are inevitable and various efforts have been made to try and reduce complications by modifying the aggressive surgical procedure. The objective of this study is to report the various complications, its rate in various neck dissection procedures, their management and to seek improved patient care and outcome. : A systematic review of 73 patients who underwent neck dissection for various head and neck cancers from August 2017 to July 2020. These patients were studied for post-operative complications and their management.Out of 73 patients, Vascular injury observed in the current study was internal jugular vein (IJV) and was seen in 22.7%) cases and was repaired intraoperatively. Throracic duct injury was identified in 3(4.1%) and it was identified and ligated intraoperatively. Immediate post-operative complication being hemorrhage was seen among 2 cases, both the cases were re-opened. Marginal mandibular nerve and spinal accessory nerve injury was observed in 3 cases and they both came under the delayed type of complications.: A careful preoperative assessment, meticulous surgical technique, high quality postoperative care and appropriate rehabilitation are the cornerstone of preventing and managing complications.

Dural Arteriovenous Fistula with Hypoglossal Nerve Paralysis

A male in his early 30s presented with a swelling just below the angle of his left mandible for the last 2 months. The swelling had insidious onset, progressive and painless. Examination found 4 × 4cm, diffuse, soft to firm, pulsatile swelling in the upper part of the neck on left side ([Fig. 1]). An oral examination revealed left hypoglossal nerve paralysis. Further examination was noncontributory, including vagus and accessory spinal nerve examination. A probable diagnosis of carotid body tumor was kept, and the patient was subjected to computerized angiography. Angiography revealed dural arteriovenous fistula (DAVF), a rare clinical entity leading to hypoglossal nerve paralysis ([Figs. 2 (A, B)]). Patient was advised to undergo digital subtraction angiography for further management, but he refused and chose conservative care with regular follow-up.

Синдром крыловидной лопатки

Since A. Velpeau [1] first described a case of isolated paralysis of the anterior serratus muscle leading to the development of winged scapula syndrome, it has been shown that this lesion leads to shoulder joint dysfunction and the development of pain syndrome. Correct movement and positioning of the scapula relative to the rib cage is essential for proper shoulder joint function and positioning of the upper extremity in space. Weakness and loss of biomechanics of scapula motion leads to difficulty in lifting the upper extremity as well as lifting weights. According to the literature, the most common causes of winged scapula syndrome are injuries of the long thoracic nerve (paralysis of the anterior serratus muscle) and the spinal accessory nerve (paralysis of the trapezius muscle). The number of cases of anterior serratus muscle paralysis ranges from 0.0026 to 0.21% [2]. Most authors focus on nerve damage leading to paralysis of the anterior dentate and trapezius muscles. However, in 1930, S. Fichet described the development of winged scapula syndrome as a result of traumatic detachment of the muscles surrounding the scapula [3]. Traumatic detachment of the anterior serratus, trapezius, and rhomboid muscles is an important and understudied problem leading to shoulder joint dysfunction and development of winged scapula. The aim of the review is to study the main injuries leading to the development of wing-shaped scapula syndrome, as well as the main methods of diagnosis and treatment of this pathology.

Needle electromyography abnormalities in the upper trapezius muscle in neuromuscular disorders.

: Needle electromyography (EMG) abnormalities in the trapezius muscle (TM) can be seen in neuromuscular disorders. The aim was to determine the characteristics of needle EMG abnormalities observed in the TM in neuromuscular disorders. The data of patients who applied to the Clinical Neurophysiology Laboratory of University of Health Sciences Adana City Training and Research Hospital between December 2018 and October 2021 were reviewed. Polio survivors, amyotrophic lateral sclerosis (ALS) patients, patients with sensorimotor polyneuropathy, patients with spinal cord lesions involving C2/C3/C4 segments, patients with spinal accessory nerve (SAN) lesions, neuralgic amyotrophy (NA) patients, and patients with myopathy were included. Needle EMG findings of the upper TM of the patients were analyzed. Positive sharp waves, fibrillation potentials, fasciculation potentials, myotonic discharges, and motor unit action potential (MUAP) changes were considered needle EMG abnormalities. Eighty-one polio survivors, 23 ALS patients, 39 patients with sensorimotor polyneuropathy, 10 patients with cervical spinal lesions, eight NA patients, seven patients with SAN lesions, and three patients with myopathy were included in the study. Fifteen (65.2%) ALS patients, 18 (22.2%) polio survivors, three (30%) patients with cervical spinal lesions, two (5.1%) patients with sensorimotor neuropathy, one (12.5%) NA patient, seven (100%) patients with SAN lesions, and two (66.7%) patients with myopathies had at least one needle EMG abnormality in the TM. Fasciculation potentials in the TM were seen in 10 (43.5%) ALS patients. In four patients with SAN lesions and one polio survivor, MUAP could not be obtained from the TM. There may be more frequent needle EMG abnormalities, particularly in ALS patients and patients with SAN lesions. Since the number of patients with myopathy included in this study was low, it is difficult to comment on the needle EMG features of the TM for these patients. In addition, this study indicated that fasciculation potentials in the TM are typical in ALS patients and that MUAP may not be obtained from the TM in patients with SAN lesions.

An Unusual Case Report of Adult Cervical Cystic Hygroma

Cystic Lymphangioma (CL) is a rare condition that is typically observed as a congenital malformation in the head and neck. These congenital lesions usually appear before the age of two. Adult occurrences are extremely unusual, and only a few cases have been mentioned in the literature. CL is characterised by the collection of an epithelial lining of lymphatic fluid, which can be caused by lymphatic abnormalities, trauma, or surgery. In the present case report, the authors present the findings of a 49-year-old adult female who had painless, gradually increasing left-sided neck swelling for three years, with no other relevant medical history. The initial ultrasound revealed a large cystic lesion extending from the left sternocleidomastoid muscle to the left submandibular gland. The lesion measured 8×7×3 cm and exhibited narrow septae and loculation at the periphery. Avascularity was noted within the cyst wall and interlobular septae. The diagnosis favoured macrocytic lymphangioma/Congenital Lymphangioma (CH). During the surgical procedure, the cyst was dissected, and it was found to be located over the internal jugular vein, carotid artery, and spinal accessory nerve. The cyst was completely removed, and a surgical drain was left in place. The wound was sutured in two layers, and a sterile dressing was applied. The drain was removed on the third postoperative day, and the dressing with sutures was removed on the seventh postoperative day, revealing a healthy wound. The diagnosis was confirmed by histopathological examination {Haematoxylin and Eosin (H&E)} of the tissue specimen, which showed flattened epithelium lining the inside of the cyst. The cyst contained dilated gaps in a fibrocollagenous stroma infiltrated by lymphocytes. Therefore, CH can be considered as a differential diagnosis for head and neck masses in adults.

Modified Eden-Lange Triple-Tendon Transfer for Chronic Trapezius Palsy

Background: Trapezius palsy can occur due to traumatic or idiopathic spinal accessory nerve injury. As a result of trapezius palsy, shoulder girdle imbalance can develop and present as lateral scapular winging and diminished shoulder range of motion and function. The modified Eden-Lange triple-tendon transfer procedure is a notable salvage operation which can treat chronic trapezius palsy after failure of conservative and nonsalvage interventions. Indications: A 42-year-old right-hand dominant woman who underwent a cervical lymph node biopsy 3 years before presents with chronic left shoulder weakness, severe shoulder pain, and scapular winging. On presentation, she has failed conservative treatments and operative interventions including attempted spinal accessory nerve exploration and repair with ansa cervicalis autograft. Technique Description: A modified Eden-Lange triple-tendon transfer, using the Elhassan modification, was performed to treat the patient’s chronic trapezius palsy. The levator scapulae, rhomboid minor, and rhomboid major were sequentially transferred to the lateral scapular spine, central scapular spine, and medial scapular spine, respectively. Results: At interval follow-up, the patient was recovering well from her operation and with progressively improving range of motion and strength. Discussion/Conclusion: The modified Eden-Lange triple-tendon transfer technique is a salvage procedure for treating chronic trapezius palsy by anatomically reconstructing the force vectors of the native trapezius muscle. Effective restoration of proper scapular and shoulder kinematics via the triple-tendon transfer technique can result in improved pain and shoulder girdle function. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Speech therapy rehabilitation in Tapia´s syndrome: case report

Tapia’s syndrome is charaterized by damage to the recurrent laryngeal nerve (branch of the Xth) and the hypoglossal nerve (XIIth), and in some cases, the accessory nerve (XIth) may also be affected. The cause is usually trauma to the point where the hypoglossal and vagus intersect. This results in lingual hemiparesis, vocal fold paralysis and dysphagia. Objective: to present the results of speech therapy in a case that evolved with Tapia´s Syndrome after the excision of a tumour in the parapharyngeal space. Case report: male patient, 71 years old, submitted to excision of a Schwannoma in the vagus nerve, with parotid invasion. Evolved with: dysarthria; severe dysphagia; lack of flow control; dysphonia; facial paralysis and dyspnoea. Six months after surgery, thyroplasty and botulinum toxin injections were performed in the cricopharyngeal muscle and salivary glands, which ensured a temporary improvement in voice and control of salivary flow. Results: The rehabilitation process consisted of stimulating the mobility of the muscles responsible for facial mimicry, reintegration of stomatognathic functions, swallowing and voice. After two years of speech therapy, the patient showed improvement in the mobility of the facial mimic muscles, a slight improvement in the vocal pattern, in addition to an improvement in the breathing pattern. Conclusion: despite the limitations and functional complexities encountered in the postoperative period, there was evidence of improvement in the patient’s quality of life after performing clinical procedures combined with the therapeutic process.

Peri-Capsular Nerve Group Blocks in the Emergency Department (ED) - A Broad Overview

Hip fractures and related conditions present significant challenges in emergency departments (EDs, necessitating effective pain management for diagnostic evaluations and immediate interventions. The Pericapsular Nerve Group (PENG) block, a recent innovation in regional anesthesia, has gained prominence for its profound impact on pain control in hip fractures. This article comprehensively reviews the evolution, anatomy, and applications of PENG blocks in emergency medicine. PENG blocks offer precise, sensory-focused pain relief, crucial for patients experiencing severe acute pain due to hip fractures. By comprehensively targeting articular branches of the femoral, obturator, and accessory obturator nerves with a single injection, PENG blocks preserve motor function and reduce reliance on systemic opioids, leading to more comfortable reductions of hip dislocations and improved patient experiences. The PENG block emerges as a valuable asset in revolutionizing pain management for hip fractures within emergency departments, aligning with the overarching goal of enhancing patient care and well-being. As healthcare confronts the challenges of patient comfort and the opioid crisis, further research, including Randomized Controlled Trials and comprehensive Metaanalyses, is warranted to establish definitive recommendations for ED practices in this domain.

Modified Eden-Lange Triple Tendon Transfer Procedure for Idiopathic Spinal Accessory Nerve Palsy and Scapular Winging

The scapula serves as the transition point at which the energy from the lower body and core transmits through the scapulothoracic articulation and the upper extremity. Spinal accessory nerve palsy leads to lateral winging of the scapula and abnormal scapulothoracic motion. Resultant abnormal motion and asynchrony of the scapulothoracic articulation can disrupt the upper extremity kinetic chain, leading to pain, atrophy, and dysfunction of the shoulder. Disruption of this kinetic chain can severely impair patients and athletes who engage in physically demanding activities. Conservative management alone with anti-inflammatories, lifestyle changes, and physical therapy has not produced encouraging results. Surgical management options include a tendon transfer (Eden-Lange, triple tendon transfer) or nerve repair. We present a case of an active duty service member with idiopathic spinal accessory nerve palsy treated with triple tendon transfer. After the triple tendon transfer, this patient experienced improvements in pain, range of motion, and function at 1-year postoperatively, also maintaining enough strength and function to pass their physical fitness assessments and remain on active duty. As such, these findings may suggest the triple tendon transfer procedure offers a viable option in the treatment of spinal accessory nerve palsy in the active patient populations who require a high level of physical function.

Quality of life and shoulder function among oral cancer patients treated with selective neck dissection: A cross-sectional study.

There is no doubt about the oncologic effectiveness of neck dissections (NDs). But the quality of life (QoL) of patients with oral cancer and the morbidity associated with ND like shoulder dysfunction remain uncertain. The present study aimed to assess the postoperative ND-related QoL and shoulder function of oral cancer patients who underwent selective neck dissection (SND). A cross-sectional study was conducted by using a self-administered, ND-related QoL questionnaire and arm abduction test (AAT) in 128 patients who had undergone only SND (up to Level IV) for oral cancer. Out of the 128 patients, 94 (73.8%) patients had better QoL, and 34 (26.2%) patients had worse QoL. Fifty-one (39.84%) participants were able to abduct up to or more than 150° but less than 180° (Score 3) followed by 31 (24.22%) participants who could abduct up to or more than 90° but not less than 150° (Score 2). Strong positive correlations ( r = 1.000) were observed between the ND QoL scores and the AAT scores. It was found to be statistically significant ( P = 0.000). SND, being a more conservative approach sparing the spinal accessory nerve, could still limit the QoL and could affect the shoulder function to a certain extent.

Iatrogenic Spinal Accessory Nerve Injury and Association with Great Auricular Nerve: A Report of Three Cases

Iatrogenic Spinal Accessory Nerve Injury and Association with Great Auricular Nerve: A Report of Three Cases

Supraclavicular approach for neonatal brachial plexus palsy.

Neonatal brachial plexus palsy describes injury to the brachial plexus in the perinatal period, resulting in motor and sensory deficits of the upper arm. Nerve reconstruction, including graft repair and nerve transfers, can be used to restore function in patients whose injury does not respond to conservative management. Despite the availability of these techniques, 30%-40% of children have lifelong disability, reflecting a 10-fold underutilization of surgery. Here, the authors demonstrate a supraclavicular approach for brachial plexus exploration, as well as a spinal accessory to suprascapular nerve transfer for restoration of shoulder abduction and external rotation. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22109.

Shoulder Dysfunction Post Spinal Accessory Nerve Preserving Neck Dissections: Our Experience.

Apart from complete surgical clearance of the malignancy, reducing morbidity and improving quality of life of the patient is also considered. One of the morbidities linked with neck dissections is shoulder dysfunction.The aim of our study is to analyse the functional outcomes in patients operated for various neck dissections with preservation of the Spinal accessory nerve.A single centre prospective observational study was conducted in a total of 45 patients with oral cancers. These patients underwent Wide local excision of the primary tumour along with neck dissection. Tests for assessing spinal accessory nerve function was elicited in all these patients preoperatively and postoperatively. Patients were examined for shoulder pain and shoulder disability using Arm abduction test.All 45 patients underwent spinal accessory nerve preserving neck dissection. On post operative day 10, 89% of patients showed arm abduction test score of 1 and 47% of patients had a pain score of 6 whereas 13% had a pain score of 8. After 6 months of rehabilitation and regular follow up, 62% of the patients had improved arm abduction test score of 4 and above and all 45 patients had pain score improved to score of 4 and less.Variable amount of shoulder dysfunction is seen even in spinal accessory nerve preserving neck dissections. But active rehabilitation and regular follow up of these patients reduces the morbidity associated with shoulder syndrome.

An Unusual Variation of the Accessory Nerve

In this manuscript, we report an anatomic variation of the spinal accessory nerve for the first time in the literature. The spinal accessory nerve was exited from the skull base in duplicate, and these two branches merged in the anterior triangle of the neck and continued as a common branch in a 68-year-old male patient who underwent total laryngectomy and bilateral modified neck dissection.