Andrew Saleeb, BS
Medical Student
Vanderbilt University School of Medicine
Aliso Viejo, California, United States
Carsen R. Cash, MD
Resident Physician
Vanderbilt University School of Medicine
Nashville, Tennessee, United States
Cristina Kline-Quiroz, DO
Assistant Professor
Department of Physical Medicine & Rehabilitation
Nashville, Tennessee, United States
Spinal accessory and long thoracic neuropathy
Case Description:
A 70-year-old man with history of p16+ T3N2 oropharyngeal squamous cell carcinoma status post concurrent chemoradiation presented to clinic one year following completion of treatment with chronic right shoulder pain and stiffness, limited range of motion, and scapular dyskinesia and winging. He was referred to physical therapy but initially was not making improvements. Electrodiagnostic workup demonstrated incomplete injuries to both the right spinal accessory and right long thoracic nerves with continuity of the nerves preserved. There was no electrodiagnostic evidence of injury to the brachial plexus, nerve roots, or other peripheral nerves. Physical therapy interventions were adjusted with a focus on optimizing biomechanics and joint protection techniques. He was subsequently able to make significant improvements.
Discussions:
Radiation therapy (RT) is a common modality utilized to treat head and neck cancers (HNC) to deliver targeted treatment while mitigating adverse systemic effects. Radiation fibrosis syndrome (RFS) presents with a myriad of clinical sequelae that may presents months to years following treatment. This can cause neuromuscular damage and impaired function. Among the structures commonly affected by RT in HNC patients are sternocleidomastoids, scalenes, and trapezius muscles, in addition to cervical nerve roots, the brachial plexus, and peripheral nerves. Such damage can cause significant dysfunction in ADLs, as well as pain. These findings are consistent with the local effects of RT, as both nerves exit 2 cm apart [CC4] in the medial middle scalene. The patient has improved pain and weakness with physical therapy.
Conclusions:
This case presents an atypical etiology of shoulder pain, stiffness, and weakness, with scapular winging as a result of both spinal accessory and long thoracic nerve injury from RFS. Keeping a broad differential diagnosis and utilizing electrodiagnostics are important in evaluation and management of shoulder pain in HNC particularly for those not responding as anticipated.
