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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 45-47

USG-guided diagnostic block and hydro dissection for spinal accessory nerve entrapment syndrome

1 Department of Pain Medicine, Daradia Pain Hospital, Newtown, Kolkatta, West Bengal, India
2 Department of Anaesthesia, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
3 Department of Pain Medicine, Daradia Pain Hospital, Newtown, Kolkatta; Department of Anaesthesia, Manipal Teaching Hospital, Pokhara, Nepal, West Bengal, India
4 Department of Pain Medicine, Daradia Pain Hospital, Kolkatta, West Bengal, India

Date of Submission25-Mar-2021
Date of Acceptance16-Jul-2021
Date of Web Publication22-Oct-2021

Correspondence Address:
Sukhdeo Satyanarayan Gupta
403/B Building No. 4 Parishram CHS, Chakkikhan Santacruz East, Mumbai - 400 055, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_3_21

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Spinal accessory nerve entrapment is difficult to diagnose due to its overlapping clinical features with other common diseases and nerve entrapments. It severely affects the life of an individual as normal neuronal physiology of the nerve is important for proper functioning and stability of the shoulder girdle. The patient develops symptoms like pain over the shoulder and neck, drooping of the shoulder, and weakness of overhead abduction of the arm. Ultrasound-guided block of this nerve has been described in the literature, but hydro-dissection using ultrasound as treatment has not been described yet. We have reported a case of spinal accessory nerve entrapment following sebaceous cyst excision in the posterior neck which was diagnosed clinically and confirmed using ultrasound-guided block and managed simultaneously by hydro-dissection. A case of 56 years female who underwent sebaceous cyst excision in the posterior triangle of the neck on the right side in May 2016. After 6 weeks of surgery, the patient developed pain in the right shoulder and gradually developed weakness in the overhead abduction of the arm. She went from one hospital to another for her pain relief but her pain remained undiagnosed and untreated. She came to Daradia Pain Hospital with complaint of pain in her right shoulder.

Keywords: Diagnostic block, entrapment, hydro-dissection, spinal accessory nerve

How to cite this article:
Gupta SS, Bhavya Reddy H A, Poudel H, Manna S, Das G. USG-guided diagnostic block and hydro dissection for spinal accessory nerve entrapment syndrome. J Recent Adv Pain 2020;6:45-7

How to cite this URL:
Gupta SS, Bhavya Reddy H A, Poudel H, Manna S, Das G. USG-guided diagnostic block and hydro dissection for spinal accessory nerve entrapment syndrome. J Recent Adv Pain [serial online] 2020 [cited 2023 Jan 29];6:45-7. Available from: http://www.jorapain.com/text.asp?2020/6/3/45/329012

  Background Top

Spinal accessory nerve entrapment or injury is commonly seen after surgical procedures in the posterior triangle of the neck.[1] One should have a high index of suspicion to diagnose it. Although uncommon, it adversely affects day-to-day activities and living of the patient. The spinal accessory nerve supplies the trapezius muscle which has an important role in shoulder girdle function. It helps in rotation, elevation, and retraction of the scapula.[1] The clinical presentations of spinal accessory nerve dysfunction are pain in the shoulder and neck sometimes radiating to the arm, weakness in overhead abduction, winging of scapula, and atrophy of trapezius muscle.[1],[2],[3]

The diagnosis of this condition is usually missed due to the presence of other common overlapping clinical features representing pathological conditions like facet joint arthropathy, cervical spine radiculopathy, and trapezius myofascial pain syndrome.[4] The clinical features also overlap with the entrapment of some other nerves such as dorsal scapular and long thoracic nerve.[2],[5]

  Case Report Top

A 54-year-old female patient came to the outpatient clinic of Daradia Pain Hospital with complaint of pain in the right shoulder radiating to the ipsilateral neck and upper limb up to the mid-arm with drooping of right shoulder [Figure 1] for the past 5 years. The patient was apparently alright till May 2016, when she underwent surgical excision of sebaceous cyst in the right posterior triangle of the neck. After 6 weeks of surgery, she started developing pain in the right shoulder which gradually increased in severity and was associated with occasional tingling. Pain radiated to upper arm up to mid-arm and neck. She noticed weakness in the right arm while doing work involving the movement of the arm above shoulder level. She also noticed gradual drooping of right shoulder and hallowing of the neck region above collar bone on the right side [Figure 2]. The patient visited many hospitals and underwent various investigations and therapeutic managements within the last 5 years without any pain relief and was apparently diagnosed and treated as cervical radiculopathy. Weakness gradually recovered after physiotherapy, but the pain persisted.
Figure 1: Shoulder drooping seen right side

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Figure 2: Prominent deltopectoral groove or subclavicular pit right side

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Physical examination revealed scar of previous surgery, asymmetry of both the shoulders alignment with right shoulder drooping [Figure 1], prominent right side deltopectoral groove also known as sub clavicular pit [Figure 2]. Right-sided scapular winging was present which was more prominent on the abduction of the shoulder. There was significant wasting of trapezius muscle with decreased shrugging of the right shoulder. There were few tender points over the trapezius muscle. Wasting and weakness were not observed in the ipsilateral sternocleidomastoid muscle. No signs of brachial plexus injury were present. Spurling and Spalding's sign were negative [Figure 3].
Figure 3: Winging of right scapula

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Based on history and clinical findings, the provisional diagnosis of spinal nerve accessory entrapment was made. To confirm the diagnosis, ultrasound-guided identification of the nerve followed by the diagnostic block with local anesthetics under real-time Ultra Sono Graphy (USG) was carried out. The patient indicated pain relief of more than 80% after diagnostic block with 1% lignocaine in few minutes. Hence, the diagnosis of spinal accessory nerve entrapment was confirmed. Simultaneously, hydro-dissection of the spinal accessory nerve was done using normal saline [Figure 4].
Figure 4: USG: Ultra Sono Graphy. SCM: Sternocleidomastoid muscle (red color), LS: Levator Scapulae (green color), Spinal accessory nerve (yellow color), Needle marked with the arrow

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The patient was discharged after two hours of observation with advice to take tablet containing combination of gabapentin 400 mg and nortriptyline 10 mg twice daily for 3 months and tablet paracetamol 1000 mg thrice daily for 7 days. The patient was advised to review if pain reappears for hydro-dissection with steroid injection.

  Discussion Top

Trapezius muscle which is supplied by the spinal accessory nerve plays an important role in shoulder girdle kinesiology. It supports the weight of the upper extremity along with levator scapulae muscle in the erect posture. Its middle portion helps in the initiation of upward rotation of the scapula. It is also responsible for shrugging of the shoulder and retraction of the scapula.[1]

Trapezius muscle dysfunction causes asymmetry of the neck line, winging of scapula and weakness during forward elevation and abduction of the shoulder. It can cause severe pain due to muscle spasm, traction of brachial plexus, frozen shoulder, or subacromial impingement.[1],[2],[3],[5] Shoulder, neck, and arm pain can also be seen in cervical facet joint arthropathy, cervical radiculopathy, and trapezius myofascial pain syndrome.[4] Weakness of the scapular muscles can be a part of generalized muscular disorder such as facioscapulohumeral dystrophy, or due to a nerve lesion of the long thoracic nerve, the spinal accessory nerve, or the dorsal scapular nerve.[2]

The accessory nerve consists of two parts cranial and spinal. Cranial fibers come from the nucleus ambiguous, and spinal fibers from upper cervical motor neurons. The trapezius muscle has three functional components. It is responsible for elevating, rotating, and retracting the scapula.[2] Patients with isolated accessory nerve injury present with a mild shoulder droop and marked winging of the scapula when abducting the arm. The spinal accessory nerve is more prone to injury in the posterior triangle of the neck where it is superficial. Other causes are compression by tumors at the base of the skull, fractures involving the jugular foramen, blunt/penetrating injuries to the neck, or amyotrophic shoulder neuralgia (ParsonageTurner syndrome).[2] The long thoracic nerve originates from the C5–C7 and innervates the serratus anterior muscle. Injuries to the long thoracic nerve cause winging of the scapula, especially with the arms in anterior elevation. Scapular winging is more prominent in pushing the arm against the wall.[2] The dorsoscapular nerve arises from the nerve roots from C4 to C5 and innervates the levator scapulae, and rhomboid muscles.[2] Dysfunction of the rhomboid muscles causes a more lateral position of the scapula with some winging of its medial margin, particularly the inferior angle.[5] Long thoracic nerve, accessory, and dorsal scapular nerve lesions cannot always be differentiated clinically. Dysfunction of the serratus anterior muscle normally causes scapular winging mainly when elevating the arms, while scapular winging is most pronounced when abducting the arms in a case of trapezius muscle dysfunction.[2]

  Conclusion Top

It is very important to have early diagnosis and management for the spinal accessory nerve entrapment to prevent nerve damage and its associated complications. One should have a high index of suspicion to diagnose it. Our patient also went from one hospital to another for almost 5 years for pain relief and presented to us very late. Ultrasound-guided block with simultaneous hydro-dissection can be an effective method in diagnosing and treating spinal accessory nerve impingement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

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Conflicts of interest

There are no conflicts of interest.

  References Top

Charopoulos IN, Hadjinicolaou N, Aktselis I, Lyritis GP, Papaioannou N, Kokoroghiannis C. Unusual insidious spinal accessory nerve palsy: A case report. J Med Case Rep 2010;4:158.  Back to cited text no. 1
van Tuijl JH, Schmid A, van Kranen-Mastenbroek VH, Faber CG, Vles JS. Isolated spinal accessory neuropathy in an adolescent: A case study. Eur J Paediatr Neurol 2006;10:83-5.  Back to cited text no. 2
Addas BM, Clarke DB. Accessory Nerve (Cranial Nerve XI). In: Encyclopedia of the Neurological Sciences. Academic Press; 2003. https://doi.org/10.1016/B0-12-226870-9/00754-1.  Back to cited text no. 3
Townsley P, Ravenscroft A, Bedforth N. Ultrasound-guided spinal accessory nerve blockade in the diagnosis and management of trapezius muscle-related myofascial pain. Anaesthesia 2011;66:386 9.  Back to cited text no. 4
Andrea M. Trescot. Peripheral Nerve Entrapments Clinical Diagnosis and Management Book. Springer International Publishing Switzerland 2016.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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