The clinical features of trapezius palsy include pain, loss of shoulder
abduction, and winging of the scapula. Surgical biopsy of lymph nodes is the
main cause of the palsy.
The surgical technique (nerve repair or palliative surgery) depends on the
etiology, the time since the onset of the palsy, and the patient
characteristics.
Nerve Surgery
The procedure is performed with the patient under general anesthesia. The
patient is placed in the supine position, with his or her head turned to the
contralateral side and fixed in that position. The cervical area, including
the whole upper limb, is draped to allow for easy manipulation of the
extremity. The ipsilateral lower limb is also draped to allow for the
harvesting of a free sural nerve graft, if needed. The incision incorporates
previous incisions and is extended on both ends to create a z-shaped incision,
2 cm behind the posterior border of the sternocleidomastoid and the trapezius
bulge. The first step in the dissection is to expose the posterior margin of
the sternocleidomastoid and the anterior margin of the trapezius muscles. The
great auricular nerve is identified as it wraps around the posterior margin of
the sternocleidomastoid. Then the proximal part of the spinal accessory nerve
is identified, with the dissection being extended to the anterior margin of
the sternocleidomastoid if necessary. The distal part of the spinal accessory
nerve is then exposed close to the fascia of the trapezius. If the nerve is in
continuity, intraoperative stimulation is performed at 0.2 mA with an
electro-stimulator. If a response is obtained distally with a trapezius muscle
contraction, only an extrafascicular neurolysis is performed. Otherwise, the
nerve is transected, the neuroma-in-continuity is resected, and the nerve ends
are trimmed until normal fasciculi are obtained (as indicated by neatly
arranged fasciculi without surrounding fibrosis as seen under the microscope).
Then, an end-to-end suture or a repair with use of a free single sural nerve
graft is performed (Figs. 1-A
and 1-B), depending on the
tension in the nerve and on the size of the gap between the nerve ends. The
nerve repair is performed under magnification with 10-0 nylon suture. In the
case of free grafting, the donor nerve is always the sural nerve. The nerve is
identified through a short transverse incision at the level of the lateral
malleolus. With use of a second incision, 3 cm proximal to the first, the
nerve is again identified at this level. With gentle traction, the nerve,
which may have two or three branches at this level, can be mobilized and each
branch is transected. It is then gently pulled out at the level of the
proximal incision and, then, with gentle traction applied to the distal end,
the course of the nerve is followed proximally up to the middle part of the
leg. The nerve is exposed here and transected. The three to five small
transverse incisions created with this technique are cosmetically quite
acceptable.
The incision is closed in two layers. Free active and passive motion of the
shoulder is allowed immediately. The patient is allowed to leave the hospital
on the third postoperative day.
CRITICAL CONCEPTSINDICATIONS (FIG.
6):Nerve surgery can be attempted between twelve and twenty months after the
nerve injury. If a contraction of the trapezius muscle is obtained on
intraoperative stimulation, a neurolysis should be performed. When there is no
contraction of the muscle during the intraoperative stimulation or when there
is complete transection of the nerve, repair or grafting should be performed,
depending on the age of the patient, the length of the nerve gap after
resection of the cut ends, and the extent of local fibrosis. In our opinion,
there is no indication for performing both a nerve procedure and the muscle
transfer at the same time.Palliative surgery should be pursued after failure of microsurgical repair
of the spinal accessory nerve, in cases of spontaneous palsy of the trapezius,
after a radical neck dissection, or when more than twenty months have elapsed
since the injury.CONTRAINDICATIONS:There are no real contraindications. However, because of anatomical
variation and because of compensation by the levator scapulae, the clinical
consequences of an injury to the spinal accessory nerve must be carefully
evaluated in each patient. Nonoperative treatment for active patients is
usually unsuccessful, although rehabilitation and physiotherapy can reduce
pain for older and sedentary
patients3.Two significant factors were found to be predictive of a poor result in our
study: a patient age of more than fifty years and a spinal accessory nerve
lesion caused by radical neck dissection, penetrating injury, or spontaneous
palsy.PITFALLS:The preparation of the nerve ends is a very important step of the
operation. In a case of complete sectioning or loss of nerve tissue, a neuroma
will have developed on the proximal stump of the spinal accessory nerve. The
neuroma has to be resected, and both nerve ends have to be prepared. Segments
of each nerve stump are resected, with use of a sharp knife, until normal
nerve tissue is reached.To suture a free single nerve graft, the technique of epineurial repair is
used. The epineurial repair proceeds with accurate placement of the suture in
the epineurium but not into the substance of the nerve fascicle itself. The
appropriate tension is achieved when the underlying fascicles have been
coapted but the ends are not overlapping or malaligned. Three to five sutures
usually are sufficient to achieve appropriate repair of the spinal accessory
nerve. At the completion of a successful repair, the epineurium should be
closed, without herniation of fascicular tissue between the sutures.AUTHOR UPDATE:In the original study, one patient with a spontaneous palsy was managed
with a simple neurolysis because a trapezius muscle contraction was obtained
during intraoperative stimulation. The result, however, was very poor, with no
recovery of trapezius function. In cases of spontaneous palsy, we now perform
only reconstructive surgery with muscle transfers.
CRITICAL CONCEPTS
INDICATIONS (FIG.
6):
Nerve surgery can be attempted between twelve and twenty months after the
nerve injury. If a contraction of the trapezius muscle is obtained on
intraoperative stimulation, a neurolysis should be performed. When there is no
contraction of the muscle during the intraoperative stimulation or when there
is complete transection of the nerve, repair or grafting should be performed,
depending on the age of the patient, the length of the nerve gap after
resection of the cut ends, and the extent of local fibrosis. In our opinion,
there is no indication for performing both a nerve procedure and the muscle
transfer at the same time.
Palliative surgery should be pursued after failure of microsurgical repair
of the spinal accessory nerve, in cases of spontaneous palsy of the trapezius,
after a radical neck dissection, or when more than twenty months have elapsed
since the injury.
CONTRAINDICATIONS:
There are no real contraindications. However, because of anatomical
variation and because of compensation by the levator scapulae, the clinical
consequences of an injury to the spinal accessory nerve must be carefully
evaluated in each patient. Nonoperative treatment for active patients is
usually unsuccessful, although rehabilitation and physiotherapy can reduce
pain for older and sedentary
patients3.
Two significant factors were found to be predictive of a poor result in our
study: a patient age of more than fifty years and a spinal accessory nerve
lesion caused by radical neck dissection, penetrating injury, or spontaneous
palsy.
PITFALLS:
The preparation of the nerve ends is a very important step of the
operation. In a case of complete sectioning or loss of nerve tissue, a neuroma
will have developed on the proximal stump of the spinal accessory nerve. The
neuroma has to be resected, and both nerve ends have to be prepared. Segments
of each nerve stump are resected, with use of a sharp knife, until normal
nerve tissue is reached.To suture a free single nerve graft, the technique of epineurial repair is
used. The epineurial repair proceeds with accurate placement of the suture in
the epineurium but not into the substance of the nerve fascicle itself. The
appropriate tension is achieved when the underlying fascicles have been
coapted but the ends are not overlapping or malaligned. Three to five sutures
usually are sufficient to achieve appropriate repair of the spinal accessory
nerve. At the completion of a successful repair, the epineurium should be
closed, without herniation of fascicular tissue between the sutures.
The preparation of the nerve ends is a very important step of the
operation. In a case of complete sectioning or loss of nerve tissue, a neuroma
will have developed on the proximal stump of the spinal accessory nerve. The
neuroma has to be resected, and both nerve ends have to be prepared. Segments
of each nerve stump are resected, with use of a sharp knife, until normal
nerve tissue is reached.
To suture a free single nerve graft, the technique of epineurial repair is
used. The epineurial repair proceeds with accurate placement of the suture in
the epineurium but not into the substance of the nerve fascicle itself. The
appropriate tension is achieved when the underlying fascicles have been
coapted but the ends are not overlapping or malaligned. Three to five sutures
usually are sufficient to achieve appropriate repair of the spinal accessory
nerve. At the completion of a successful repair, the epineurium should be
closed, without herniation of fascicular tissue between the sutures.
AUTHOR UPDATE:
In the original study, one patient with a spontaneous palsy was managed
with a simple neurolysis because a trapezius muscle contraction was obtained
during intraoperative stimulation. The result, however, was very poor, with no
recovery of trapezius function. In cases of spontaneous palsy, we now perform
only reconstructive surgery with muscle transfers.
Palliative Surgery: The Eden-Lange Procedure
The triple transfer of the levator scapulae, rhomboideus major, and
rhomboideus minor muscles was originally described by
Eden1 and later by
Lange2. The goal of
this transfer is to reconstruct the three parts of the trapezius muscle.
Because of their normal medial insertions, these muscles are incapable of
stabilizing the scapula in the presence of a trapezius palsy. Therefore, if
they are transferred laterally (Fig.
2), through the traction exerted by their contraction, the scapula
can be stabilized in a position of abduction and anterior flexion.
The patient is placed in the lateral decubitus position with the help of
thoracic, pubic, and sacral supports. The whole upper limb, including the
shoulder girdle, is draped free. A continuous incision is made, starting from
the spine of the scapula, continuing along its medial angle and spinal border,
and terminating 2 cm proximal to its inferior angle. The trapezius is incised
and retracted. Then, the levator scapulae, rhomboideus major, and rhomboideus
minor are dissected and are marked with a linen tape. The supraspinatus muscle
is elevated 1 to 2 cm. The rhomboid insertions are detached from the scapular
periosteum, and the levator scapulae insertion is detached along with a small
piece of bone from the superomedial angle of the scapula with use of an
oscillating saw (Fig. 3). The
infraspinatus muscle is also elevated, 2 to 3 cm. Then, the rhomboids are
advanced 3 cm laterally and are fixed to the scapular body with nonabsorbable,
transosseous sutures. The superior surface of the prominent portion of the
scapular spine (before it transforms into the acromion) is decorticated, and
the levator scapulae with its osseous fragment is fixed there with number-3,
8, or 10 stainless steel transosseous sutures (Figs.
4 and
5). The infraspinatus is then
sutured back to cover the new rhomboid insertion, and the incision is closed
in layers with two suction drains in place.
The limb is immobilized with a bandage that secures the arm to the chest
for six weeks. From the sixth week onward, gentle active and passive exercises
are started.