Assistant Professor Emory Orthopaedics and Spine Center Atlanta, Georgia, United States
Case Diagnosis: Spinal accessory nerve injury
Case Description: A 54-year-old active male presented after a bicycle accident in which the patient was projected down a flight of stairs. Initial imaging showed both skull base and C1 vertebral fractures. The patient was managed conservatively with a cervical collar and stayed in the ICU for one week. A few months after discharge the patient was referred to clinic when he began experiencing worsening right shoulder pain and weakness. Physical exam was positive for right trapezius muscle atrophy, winging of the scapula, and decreased cervical range of motion. Needle electromyography confirmed right proximal spinal accessory nerve lesion and marked denervation in the right trapezius and sternocleidomastoid (SCM) muscles. The patient was referred to an upper extremity Orthopedic surgeon for evaluation for triple-tendon transfer.
Discussions: Accessory nerve injuries commonly present with weakness and depression of the ipsilateral shoulder. Patients report pain radiating to the neck, back, and arm, and can eventually develop atrophy of the trapezius and SCM. Sensory loss is not seen from injury of this pure motor nerve. Conservative management includes physical therapy, shoulder orthoses, and pain control. Although non-penetrating injuries can recover after 6 to 12 months with conservative treatment, many patients do not recover function in this time frame and surgical intervention should be considered. Triple-tendon transfer utilizing the levator scapulae, rhomboid major, and rhomboid minor has shown successful outcomes in patients who fail conservative management.
Conclusions: This case demonstrates the interdisciplinary approach to workup and management of accessory nerve injuries. The multifaceted nature of PM&R allowed for accurate diagnosis using a combination of physical exam, musculoskeletal anatomy, and electrodiagnostic medicine. Physicians should have an understanding of the clinical presentation and NCS/EMG findings in spinal accessory nerve injuries.