SPINAL ACCESSORY NERVE PALSY

TAHIR SULEHRIASPRING 2014

SPINAL ACCESSORY NERVE CNXI

● IS IT TRUE CRANIAL NERVE?

● ITS SPINAL ROOTS ORIGINATE FROM UPPER CERVICAL SPINAL LEVEL AND ASCEND IN TO CRANIUM VIA FORAMEN MAGNUM AND EXIT THROUGH JUGULAR FORAMEN AND HENCE CALLED CRANIAL NERVE CNXI

● ITS CRANIAL ROOTS ORIGINATE FROM BRAIN STEM JOIN IT BUT AS IT EXIT FROM CRANIUM THEY JOIN CNX THE VAGUS.

MUSCLES

SPINAL ACCESSORY SPINAL NERVE (CNXI)

● IT IS MOTOR NERVE● INNERVATES TWO NECK MUSCLES● TRAPEZIUS MUSCLETRAPEZIUS MUSCLE &

STERNOCLEDOMASTOID MUSCLE

TRAPEZIUS MUSCLE

● ELEVATES,RETRACTS AND ROTATES SCAPULA SUPERIORLY

● ASCENDING (SUPERIOR)FIBERS :ELEVATES PECTORAL GIRDLE,MAINTAIN THE LEVEL OF SHOULDER AGAINST GRAVITY OR RESISTANCE.

● TRANSVERSE (MIDDLE): RETRACT SCAPULA

● DESCENDING(INFERIOR) FIBERS:DEPRESS SHOULDER

● WITH SHOULDER FIXED: BILATERAL CONTRACTION EXTEND NECK

● UNILATERAL CONTRACTION PRODUCES LATERAL FLEXION OF NECK TO SAME SIDE

STERNOCLEDOMASTOID M

● UNILATERAL CONTRACTION :TILTS HEAD TO SAME SIDE & ROTATES IT SO FACE IS TURNED SUPERIORLY TOWARDS OPPOSITE SIDE

● BILATERAL CONTRACTION

● 1).EXTEND NECK AT ATLANTO-OCIPITAL JOINT

● 2).FLEXES CERVICAL VERTEBRAE SO THAT CHIN APROACHES MANUBRIUM

● 3).EXTEND SUPERIOR CERVICAL VERTEBRAEWHILE FLEXING INFERIOR VERTEBRAE SO CHIN IS THRUST FORWARD WITH HEAD KEPT LEVEL

● ALSO CALLED ACCESSORY RESPIRATORY MUSCLE(assisting pump-handle action of deep respiration)

Case ● An abscess was surgically removed from

middle of the posterior triangle on the right side .During recovery the patient noticed that her right shoulder drooped and she could no longer raise her right hand above her head to brush her hair.

● What damaged during surgery?● Why shoulder drooped?● Why she could no longer able to raise her

hand above her head?

SYMPTOMS CNXI PALSY

● ATROPHY OF TREPEZIUS● DROOPING OF SHOULDER● DIFFICULTY IN OVER HEAD

ABDUCTION OF UPPER LIMB(OBOVE HORIZONTAL LEVEL)

● THE NORMAL PROMINENCE IN THE NECK PRODUCED BY THE TREPEZIUS ALSO REDUCED.

DROOPING OF SHOULDERS

STERNOCLEDOMASTIOD M

● WEAKNESS IN TURNING THE HEAD TO THE OPPOSITE SIDE AGAINST RESISTANCE.

HOW CAN WE DAMMAGESPINAL ACCESSORY NERVE?

● SURGICAL PROCEDURES IN LATERAL CERVICAL REGION (posterior triangle)

● TRAUMA TO THE NECK● DURING DIFFICULT DELIVERY● COMPRESION IN JUGULAR FORAMEN

ALGORITHM FOR MANAGEMENT OF SAN INJURY

● PENETRATING TRAUMA OR IATROGENIC TRAUMA(BY THE SURGEON)

● IMMEDIATE SURGICAL INTERVENTION● REANASTOMOSIS ● NERVE GRAFTING

DELAYED PRESSENTATION

● PREVIOUS NECK DISSECTION● SPONTANOUS PALSY● BLUNT TRAUMA

DIAGNOSISDIAGNOSIS● CLINICAL EXAMINATION● EMG● MRI● HR-ULTRASOUND

SAN IN CONTINUITY

● CONSERVATIVE MANANGEMENT● PHYSICAL THERAPY● SHOULDER SOPPORT

● IF NO IMPROVEMENT THEN SURGICAL TREATMENT

LOSS OF SAN CONTINUITY

● NEUROMA● TRAPEZIUS ATROPHY● SCARING OR CONTRACTURE

● SURGICAL TREATMENT

SURGICAL THERAPY

● PREOP DELAY:<12M

NEUROLYSIS OR NERVE GRAFTING● PREOP DELAY:>12M <20 M

-NEUROLYSIS IF POSSIBLE INTRAOPERATIVE DISTAL RESPONSE

-GRAFTING● PREOP DELAY:>20 M

EDEN-LANGE PROCEDURE

Eden-Lange procedure