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Accessory Nerve Injury Workup

  • Author: Rohan Ramchandra Walvekar, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: May 16, 2016

Imaging Studies

High-resolution ultrasonography (HRUS) allows visualization of the normal SAN as well as changes after accessory nerve injury. The SAN appears as a singular small (approximately 1 cm in diameter on ultrasound), hypoechoic tubular structure in the transverse plane and as a hypoechoic linear structure in the longitudinal plane. It is best identified in the posterior cervical triangle. In addition, HRUS is able to demonstrate hyperechoic and atrophic changes in the trapezius muscle, granuloma formation, and scar entrapment of the SAN in the region of the injury and the normal course of the nerve beyond. However, the actual transection of the SAN is not readily visualized by HRUS.[5]


Other Tests

Electrodiagnostic tests

Electrodiagnostic tests are most sensitive for the detection of nerve conduction impairment.[14]

Nerve conduction studies reveal prolonged latencies in nerve injury, while electromyography may reveal signs of denervation or reinnervation, depending on the timing of the study.[17]

Electrophysiologic integrity of the SAN does not correlate well with the clinical symptoms and outcome measures for shoulder dysfunction.[31]

However, EMG has shown a positive correlation with range-of-motion (ROM) tests, particularly active shoulder abduction with contralateral head rotation as a test of strength. Consequently, this physical examination maneuver serves as a reliable and cost-effective tool for evaluating the degree of upper trapezius denervation.

Electrodiagnostic tests can be used in the management of SAN injury as follows:

  • To monitor upper trapezius recovery of function
  • To plan a physical therapy course to reduce postoperative morbidity [14]
  • To confirm suspicions of SAN trauma that are related to traction or stretch injury of the nerve
  • To monitor the SAN nerve intraoperatively for identification and preservation [31]

Some patients with severe spinal accessory nerve (SAN) injury do not experience the degree of dysfunction that one would expect from their evaluations by electromyography (EMG). In contrast, patients treated with nerve-sparing neck procedures often present with symptoms and signs suggestive of nerve impairment. These apparently contradictory results can be explained by the influence of several factors, including age, gender, dominant hand, presence of concurrent myopathy or neuropathy, condition of other synergistic shoulder girdle muscles, preoperative or postoperative radiotherapy, and anatomic variations of SAN contributions to trapezius muscle innervation.[11, 32]

Clinical evaluation of shoulder function

ROM assessment by goniometry to evaluate flexion and abduction of the shoulder joint

Manual measure of muscle strength in the motions of elevation, flexion, and abduction[33]

The constant shoulder scale is as follows:

  • This weighted test takes 10 minutes to perform and combines patient symptom scores (35%) and objective measures of active shoulder function (65%) and is a validated clinical assessment with established accuracy across many diseases that affect the shoulder.
  • Scores range from 0-100, with higher scores indicating better shoulder function. [34]

The disease-specific quality-of-life (QOL) questionnaires are sensitive tools to evaluate shoulder function. Some more common questionnaires that have been validated for shoulder specific evaluations include the following:

  • The University of Washington QOL scale – shoulder domain
  • The neck dissection impairment index
  • The shoulder disability questionnaire (SDQ) [35]

Diagnostic Procedures

Intraoperative diagnosis is intuitive. A provoked movement of the shoulder in response to cautery or dissection must be carefully reviewed. Clinically examining the patient’s motor function postoperatively is best; in addition, widely explore the area during surgery to rule out an inadvertent injury.[10]

Cardinal symptoms associated with SAN injury

See the list below:

  • Pain over the muscle
  • Heaviness of the arm
  • Depressed motor functions that consist of an inability to lift the shoulder girdle and abduct the arm [10]
  • Late sequelae - Shoulder syndrome that consists of shoulder droop, atrophic trapezius, loss of abduction, paresthesias, and adhesive capsulitis resulting in a frozen shoulder (See the image below.)
    Eden-Lange procedure. Eden-Lange procedure.

Clinical signs associated with SAN injury

Pain around the shoulder and neck can be assessed on a 10-point visual analogue scale (VAS). The mean intensity associated with SAN-related shoulder syndrome can average around 7 (range, 6-9).[29]

The affected shoulder is depressed with inferior rotation of the lateral angle of the scapula.

Scapular “winging” can be accentuated by abduction of the arm.

Wasting of the trapezius may be evident in the upper part of the neck.[17]

ROM can be restricted.

  • Active abduction (30°-140° range)
  • Active forward flexion (50°-180° range) [36]

Serial clinical examinations and EMG studies that fail to show an improvement in function is a clinical sign associated with SAN injury.

Pitfalls in diagnosis

Dual or contributing nerve supply from the cervical plexus to the trapezius muscle that results in some retained motor function after SAN injury can thereby make the diagnosis of a SAN injury difficult.

Subjective symptoms that result from trapezial dysfunction secondary to myofascial pain syndromes, contralateral paresthesias, and radiculitis can make diagnosis difficult.

Variations in presentations can also be attributed to the anatomic level of SAN injury, amount of collateral tissue damage, and subjective pain thresholds.[10]

Contributor Information and Disclosures

Rohan Ramchandra Walvekar, MD Associate Professor, Department of Otolaryngology, Louisiana State University School of Medicine in New Orleans

Rohan Ramchandra Walvekar, MD is a member of the following medical societies: American Head and Neck Society, Association of Otolaryngologists of India

Disclosure: Received royalty from Hood Laboratories for consulting; Received consulting fee from Cook Industries for consulting; Received consulting fee from Medtronic Xomed for consulting.


Kristin B Gendron, MD Consulting Staff, Midwest ENT Specialists

Kristin B Gendron, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Ryan J Li, MD Resident Physician, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital and Health System

Ryan J Li, MD is a member of the following medical societies: Alpha Omega Alpha, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Duncan Hanby, MD Resident Physician, Department of Otolaryngology and Head and Neck Surgery, Louisiana State University School of Medicine

Duncan Hanby, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.


The author would like to thank Dr. A.K. D’Cruz, MS, DNB, Professor and Chairman, Head/Neck Surgery, Tata Memorial Hospital, Mumbai, India, for Image 7, and Dr. Umamaheshwar Duvvuri, MD, PhD, Fellow, Head/Neck Surgery, MD Anderson Cancer Center, Houston, Texas, for Image 8.

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Course of the spinal accessory nerve (SAN) in the posterior cervical triangle. DG = posterior belly of digastric muscle; T = trapezius; LS = levator scapulae; IJV = internal jugular vein; black arrow = SAN.
Shoulder orthosis for scapulohumeral alignment.
Relationship of internal jugular vein to the spinal accessory nerve (SAN).
Spinal accessory nerve (SAN) posterior to the internal jugular vein.
Eden-Lange procedure.
Surgical landmarks for the identification of the spinal accessory nerve (SAN).
Shoulder syndrome.
Spinal accessory nerve (SAN) traversing a bifurcated internal jugular vein (IJV). (* = carotid artery, yellow arrow = SAN)
Algorithm for management of spinal accessory nerve (SAN) injury.
Surgical management for spinal accessory nerve (SAN) injury and preoperative delay in diagnosis.
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