Accessory neuropathy

1. Intracranially, a tumor such as a schwannoma or meningioma can cause .

2. In jugular foramen, the IX, X, XI nerve involvement is called " Vernet's syndrome" which is due, in order of frequency, to metastases, primary tumors such as schwannomas, an idiopathic syndrome with spontaneous recovery, and sarcoidosis.

3. In the neck, lymph node dissection in the posterior triangle remains the commonest cause, and may also affect the lesser occipital nerve. Other neck dissections, postoperative radiation, carotid endarterectomy, and cannulation of the IJ vein are also reported. Trauma to the posterior triangle from blunt injury, compression from wearing slings, hanging attempt- related injuries, stretch injuries from heavy lifting, glass or knife lacerations, tuberculosis of the cervical lymph nodes (scrofula) or idiopathic causes.

Presentation: Shoulder weakness and pain, and drooping of the shoulder. Trapezius wasting may occur. Paresthesias over the shoulder and scapula may occur.

Examination: Wasting of any part of the three parts of the trapezius. Scapular winging occurs at rest and with movement affecting the upper part of the scapula (v. the lower part with serratus anterior weakness). Shrugging of the shoulders is "worthless" because the levator scapulae (direct innervation from C3 and C4) can do this. Ask the patient to abduct the arms through 180 degrees from side to above the head, straight sideways. The second ninety degrees is accomplished by rotation of the scapula by the upper trapezius and cannot be accomplished otherwise. The middle trapezius is tested by asking the patient to lie prone, and abduct the arm at 90 degrees from the body. The middle trap can be palpated and the stability of the scapula can be assessed. The lower third is assessed with the patient prone, arms lying alongside head, lifting arms, and palpating the lower traps.

If the damage is proximal, the scm (sternocleidomastoid) is usually wasted. Its hard to assess the deltoid/rhomboid,spinati, and serratus anterior if scapula is not stabilized by the trapezius.

Evaluation-- EMG and NCS of the three parts of the trapezius separately. CT/MRI of base of skull/jugular foramen.

Management-- idiopathic-- none. Neck dissection-- may graft the greater auricular nerve. Surgical stabilization of scapula is better than orthotics which usually do not work. The levators and rhomboids can be transferred to scapula effectively. The procedure is effective but rarely done.