History

Cardinal symptoms associated with SAN injury

These include the following:

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 ^[14]
Late sequelae - Shoulder syndrome that consists of shoulder droop, atrophic trapezius, loss of abduction, paresthesias, and adhesive capsulitis resulting in a frozen shoulder

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).^[36]

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.^[20]

Range of motion (ROM) can be restricted, as follows:

Active abduction (30°-140° range)
Active forward flexion (50°-180° range) ^[38]

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

Pitfalls in Diagnosis

A dual or contributing nerve supply from the cervical plexus to the trapezius muscle that results in some retained motor function after SAN injury can make the diagnosis of an 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.^[14]

Workup

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Media Gallery

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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Author

Rohan R Walvekar, MD Clinical Professor, Mervin L Trail Endowed Chair in Head and Neck Oncology, Director, Salivary Endoscopy Service, Co-Director, ENT Service, Department of Otolaryngology-Head and Neck Surgery, University Medical Center, Louisiana State University Health Sciences Center

Rohan R 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.

Coauthor(s)

Neelam P Phalke, MD Resident Physician, Department of Otolaryngology-Head Neck Surgery, Louisiana State University Health Sciences Center

Neelam P Phalke, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, 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; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

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.

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.

Acknowledgements

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.