Download Injury to the long thoracic nerve as a complication of neck dissection

British Journal of Oral and Maxillofacial Surgery 43 (2005) 526–527
Short communication
Injury to the long thoracic nerve as a complication of
neck dissection: A case report
Christopher L. Hankins ∗
St. George’s Hospital, Division of Plastic Surgery, Blackshaw Road, Tooting, London SW17 0QT, UK Plastic Surgery Department,
Pinderfields General Hospital, Aberford Road, Wakefield, West Yorkshire WF1 4DG, UK
Received 6 August 2004; accepted 24 February 2005
Available online 15 July 2005
Abstract
Injury to nerves by dissection of the neck is well recognised. A case report of injury to the long thoracic nerve follows, which has not been
previously described.
© 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Injuries to nerves caused by dissections in the neck have
been well described, and include those to the brachial
plexus, phrenic, spinal accessory, and the marginal mandibular branch of the facial nerve (Eibling, 1997; Watkinson et
al., 2000a, 2000b). A case of injury to the long thoracic
nerve of Bell (nerve to the serratus anterior) resulting from
neck dissection for the treatment of metastatic melanoma is
reported. This complication has not been described previously.
Case report
A 21-year-old White man presented with a cutaneous
malignant melanoma in the left supraclavicular fossa that
had been treated by tangential excision elsewhere. An
accurate measurement of the Breslow thickness was not
possible because of the technique of removal. The clinical
appearance indicated that it was a thick tumour.
The patient was admitted for treatment by wide local excision and sentinel node biopsy. Lymphoscintigraphy showed
∗
Tel.: +44 7951 015846; fax: +44 1132 683499.
that there was a single node adjacent to the insertion of the
left sternocleidomastoid muscle, which was identified intraoperatively and removed for histological examination. The
patient made an uneventful recovery and was discharged on
the first postoperative day.
The sentinel node contained metastatic disease. The
patient was offered a Type 1 selective dissection of the neck
and had a total body computed tomogram for staging purposes, which showed no metastases. As the patient would
not tolerate a short delay in being operated on the National
Health Service, he was operated on at a private hospital
elsewhere. Subsequently, he returned to our unit for followup. Clinical examination showed winging of the scapula
(Figs. 1 and 2). This had been noted immediately postoperatively.
Six months later there was no improvement in the extent
of scapular winging.
Discussion
The long thoracic nerve arises from the brachial plexus close
to the origin of C5, C6, and C7 from the intervertebral foramina. The roots at the C5 and C6 level both pierce the scalenus
medius muscle, whereas the root at the C7 level passes anterior to the muscle (Berry et al., 1995). The three roots join to
0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2005.02.006
C.L. Hankins / British Journal of Oral and Maxillofacial Surgery 43 (2005) 526–527
Fig. 1. The scar resulting from the neck dissection. The dependent part of
the scar is hypertrophic.
form the long thoracic nerve, which descends on the anterior
surface of the scalenus medius, subsequently passing between
the first rib and the axillary artery to supply the serratus anterior muscle on its lateral surface.
527
The injury seems to have occurred at the time of dissection
of the neck. The notes of the operation do not mention any
complications at the time of surgery. Either the course of the
nerve was aberrant and ran superficial to the muscles (making it more susceptible to injury) or the plane of dissection
traversed the deep fascial plane. This is conceivable if the
main bulk of the tissue to be excised was retracted forcibly,
causing tenting of the deeper structures.
Although winging of the scapula can occur from injury to
the spinal accessory nerve, a recognised complication of neck
dissection (Eibling, 1997; Watkinson et al., 2000a, 2000b),
the resultant pattern of winging differs from that seen after
injury to the long thoracic nerve. Injury to the spinal accessory nerve, which causes paralysis of the trapezius, results
in drooping of the shoulder girdle, with downward and lateral translation of the scapula in addition to winging (Wiater
and Bigliani, 1999). In contrast, patients with injury to the
long thoracic nerve, which causes paralysis of the serratus
anterior, have scapular winging with medial rotation of the
scapula, rotation of the inferior angle towards the midline,
and prominence of the vertebral border (Wiater and Flatow,
1999). The deformity is accentuated by attempts to abduct
the arm (Warner and Navarro, 1998).
References
Fig. 2. Scapular winging with medial rotation of the scapula, rotation of the
inferior angle towards the midline, and prominence of the vertebral border
of the scapula.
Berry M, Bannister LH, Standring SM. Nervous system. In: Bannister LH,
Berry MM, Collins P, et al., editors. Gray’s Anatomy. 38th ed. Churchill
Livingstone: Edinburgh; 1995. p. 1267–8.
Eibling DE. Neck dissections. In: Myers EN, editor. Head and Neck Surgery.
Philadelphia: W.B. Saunders; 1997. p. 676–718.
Warner JJP, Navarro RA. Serratus anterior dysfunction: recognition and
treatment. Clin Orthop Rel Res 1998;349:139–48.
Watkinson JC, Gaze MN, Wilson JA. Complications. In: Watkinson JC,
editor. Stell and Maran’s Head and Neck Surgery. fourth ed. Oxford:
Butterworth Heinemann; 2000a. p. 83–9.
Watkinson JC, Gaze MN, Wilson JA. Neck dissection. In: Watkinson JC,
editor. Stell and Maran’s Head and Neck Surgery. fourth ed. Oxford:
Butterworth Heinemann; 2000b. p. 215–32.
Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop Rel Res
1999;358:5–16.
Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Rel Res
1999;368:17–27.