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Title: Follow-up After Reconstruction of Iatrogenic Accessory Nerve Palsy from Lymph Node Biopsy.
PNS ID: 110325-1, Published: 3/25/2011, Updated: 3/25/2011.

Author(s): Andrew Yee BS, Susan E. Mackinnon MD.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

Abstract: This 35-year-old right hand dominant female presented to our institution six months after a left neck lymph node biopsy at an outside institution. Immediately after the biopsy, the patient lost the ability to abduct and partially flex her left shoulder. Electrodiagnostic studies demonstrated no motor unit potentials in the middle and lower trapezius muscles. Upon examination, a small slip of the upper trapezius muscle was functioning, but otherwise no trapezius function was noted. The patient reported severe pain in the general left shoulder and neck region. At the time of reconstructive surgery, the accessory nerve was found to be completely transected in the region of the biopsy. The neural scar tissue was excised until a normal fascicular nerve pattern was seen proximally and distally. A 4cm gap in the accessory nerve was present after removal of the scar tissue. The medial antebrachial cutaneous (MABC) nerve was harvested from the left arm for graft material, and a 5.5cm MABC nerve graft was used to reconstruct the accessory nerve. To restore rudimentary sensation to the MABC nerve distribution, the distal end of the transected MABC was transferred to the sensory component of the median nerve in an end-to-side fashion. By one year post-operatively, the patient recovered full range of motion for shoulder abduction and shoulder flexion, but exhibited an over-developed left upper trapezius muscle. No sensory donor site deficit was found within the MABC distribution one year post-operatively. This case describes a successful outcome in a reconstruction of an iatrogenic accessory nerve palsy with a 5.5cm MABC nerve graft. The patient was able to recovery accessory nerve function with no residual MABC nerve donor deficit.

Figures and Videos

Video 1 – Pre-operative Examination Following Lymph Node Biopsy.  Patient presented with a left spinal accessory nerve injury to our institution following a left neck lymph node biopsy. Upon examination, the patient was only able to forward flex the left shoulder to 90°. In addition, scapular winging is evident on the left shoulder. The patient was only able to abduct the left shoulder to approximately 45°.

Video 2 – Post-operative Recovery Following the Spinal Accessory Nerve Repair.  Upon examination one year following the spinal accessory nerve repair, the patient recovered spinal accessory nerve function. The patient recovered full range-of-motion shoulder abduction. The patient also recovered full range-of-motion shoulder forward flexion. This is a typical result for this type of reconstruction. The results are excellent on this reconstruction possibly due to the accessory nerve being a true motor reconstruction without any sensory component. Even though there exists a long distance to reinnervate the middle and lower trapezius, our experience has seen this type of outstanding recovery following reconstruction of a complete accessory nerve injury with a short nerve graft.