Parker Nguyen, MD
Resident Physician
NewYork-Presbyterian
New York, New York, United States
Ymi Ton, MD, MS
Resident Physician
NewYork-Presbyterian
New York, California, United States
Ella C. D'Amico, MD
Sports Medicine Fellow
NewYork-Presbyterian
New York, New York, United States
Rebecca Cox, MD
Resident Physician
Medstar/Georgetown
Washington, District of Columbia, United States
Christopher J. Visco, MD
Attending Physician
NewYork-Presbyterian
New York, New York, United States
Spinal accessory nerve palsy after cervical lymph node biopsy
Case Description:
31-year-old man with history of tuberculosis cervical lymphadenitis presented to clinic with right neck/shoulder pain after lymph node biopsy (LNB) one year prior. He also endorsed right shoulder abduction weakness. Symptoms mildly improved with physical therapy. Recent MRI brachial plexus revealed atrophy of the right trapezius. Electrodiagnostics showed decreased recruitment of the right trapezius, suggestive of a right spinal accessory nerve (SAN) mononeuropathy. Examination revealed right upper/middle trapezius atrophy and right lateral scapular winging with shoulder abduction. He had difficulty activating the latissimus dorsi with shoulder depression. Diagnostic ultrasound of the right neck revealed two oligo-fascicular bundles of the SAN (one SAN bundle transected at the LNB site with the second bundle intact) and lymph node (LN) enlargement with mass effect on the SAN and local cervical sensory nerves. Muscle activation of the trapezius was observed, suggesting partial ongoing innervation.
Discussions:
His symptoms are likely due to (1) SAN palsy after LNB with secondary scapular dyskinesis and (2) persistent cervical lymphadenopathy with mass effect on local cervical sensory nerves. He was prescribed physical therapy focusing on latissimus dorsi strengthening for scapula stabilization and referred to neurosurgery for consideration of SAN anastomosis and otolaryngology for possible cervical LN resection.
Ultrasound has previously been established as a useful diagnostic tool for SAN injury, particularly given its specificity in localizing SAN pathology to assist with surgical planning. We present a unique anatomical finding of two SAN bundles with only one affected by LNB and concurrent LN mass effect likely attributing to patient’s symptoms. Additionally, this case highlights the physiatrist’s critical role in developing a specific rehabilitation protocol based on clinical exam findings.
Conclusions:
This case highlights the complexity of diagnosing and managing SAN palsy, emphasizing the utility of diagnostic ultrasound and importance of a tailored rehabilitation.
