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601 - A Case of Radiation-Induced Spinal Accessory Nerve Palsy and Shoulder Dysfunction

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

Jeffrey Nagler, BS

Medical Student
TouroCOM-Harlem
Brooklyn, New York, United States

Co-Author(s)

LB

Lucila Beuses, MD, MS

Resident
Icahn School of Medicine at Mount Sinai
New York, New York, United States
MH

Michael Harbus, DO

Assistant Professor
Icahn School of Medicine at Mount Sinai
New York City, New York, United States

Case Diagnosis: Radiation-induced spinal accessory nerve palsy and shoulder dysfunction

Case Description:

53-year-old female with a history of right posterior maxillectomy, partial pharyngectomy, marginal mandibular resection, neck dissection, radiation, and chemotherapy for SCC of the buccal mucosa in 2014 presented to the physiatry pain medicine clinic with right-sided neck and shoulder pain. The pain worsened over 10 years and was severe, sharp, and exacerbated by movement of the right upper extremity. She noted her right scapula felt out of place. Physical exam revealed limited neck and right shoulder range of motion in all planes, lateral winging of the right scapula, and positive right Neer’s, Hawkins, and Empty Can tests. Evaluation was concerning for spinal accessory nerve injury and rotator cuff pathology.

Discussions:

Head and neck cancer treatments place patients at risk for spinal accessory nerve palsy and shoulder dysfunction. Neck dissection commonly results in spinal accessory nerve injury, while radiation therapy rarely damages this cranial nerve. However, symptoms from a radiation-damaged cranial nerve, like the spinal accessory nerve, may not present for years after radiation given that a comparable process is well-documented to occur in peripheral nerves. Spinal accessory nerve palsy typically affects the sternocleidomastoid and trapezius, presenting with weakness in turning the head contralaterally, ipsilateral shoulder drop, and lateral scapular winging. Furthermore, radiation can damage cervical nerve roots, the brachial plexus, and peripheral nerves of rotator cuff muscles causing shoulder pain and weakness. Long-term management of these complications involves physical therapy and pain management. To our knowledge, this is the first documented case of spinal accessory nerve palsy following radiation therapy.

Conclusions:

Physicians should look out for shoulder pain in head and neck cancer patients years after radiation therapy. Recognizing neuromuscular and musculoskeletal complications from radiation, like spinal accessory nerve palsy, can guide appropriate management to improve outcomes and quality of life in these patients.