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      Unusual insidious spinal accessory nerve palsy: a case report


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          Isolated spinal accessory nerve dysfunction has a major detrimental impact on the functional performance of the shoulder girdle, and is a well-documented complication of surgical procedures in the posterior triangle of the neck. To the best of our knowledge, the natural course and the most effective way of handling spontaneous spinal accessory nerve palsy has been described in only a few instances in the literature.

          Case presentation

          We report the case of a 36-year-old Caucasian, Greek man with spontaneous unilateral trapezius palsy with an insidious course. To the best of our knowledge, few such cases have been documented in the literature. The unusual clinical presentation and functional performance mismatch with the imaging findings were also observed. Our patient showed a deterioration that was different from the usual course of this pathology, with an early onset of irreversible trapezius muscle dysfunction two months after the first clinical signs started to manifest. A surgical reconstruction was proposed as the most efficient treatment, but our patient declined this. Although he failed to recover fully after conservative treatment for eight months, he regained moderate function and is currently virtually pain-free.


          Clinicians have to be aware that due to anatomical variation and the potential for compensation by the levator scapulae, the clinical consequences of any injury to the spinal accessory nerve may vary.

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          Most cited references13

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          Scapular Winging.

          Scapular winging, one of the more common scapulothoracic disorders, is caused by a number of pathologic conditions. It can be classified as primary, secondary, or voluntary. Primary scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial conditions and resolves after the primary pathologic condition has been addressed. Voluntary scapular winging is not caused by an anatomic disorder and may be associated with underlying psychological issues. The evaluation and treatment of these three types are discussed.
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            Sports and peripheral nerve injury.

            Peripheral nerve injury is one of the serious complications of athletic injuries; however, they have rarely been reported. According to the report by Takazawa et al., there were only 28 cases of peripheral nerve injury among 9,550 cases of sports injuries which had been treated in the previous 5 years at the clinic of the Japanese Athletic Association. The authors have encountered 1,167 cases of peripheral nerve injury during the past 18 years. Sixty-six of these cases were related to sports (5.7%). The nerves most frequently involved were: brachial plexus, radial nerve, ulnar, peroneal, and axillary nerves (in their order of frequency). The most common causes of such injuries were mountain climbing, gymnastics, and baseball. More often, peripheral nerve injury seemed to be caused by continuous compression and repeated trauma to the involved nerve. Usually it appeared as an entrapment neuropathy and the symptoms could be improved by conservative treatment. Some of the cases were complicated by fractures and surgical exploration became necessary. Results of treatment produced excellent to good improvement in 87.9% of the cases. With regard to compartment syndrome, the authors stress the importance of early and precise diagnosis and a fasciotomy.
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              The winged scapula.

              Twenty-five patients with 23 different types of winging of the scapula are described. A simple clinical and etiologic classification of the winged scapula is proposed based on the study of these patients in conjunction with a review of the literature. Winging of the scapula is either static or dynamic. Static winging is due to fixed deformity in the shoulder girdle, spine, or ribs. Dynamic winging is due to a neuromuscular disorder. The great variety of lesions that produce winging of the scapula may be classified anatomically into four types: Type I, nerve; Type II, muscle; Type III, bone; and Type IV, joint. Winging of the scapula is a surprisingly common physical sign, but because it is often asymptomatic it receives little attention. However, symptoms of pain, weakness, or cosmetic deformity may demand attention, and it is hoped that this classification will help in the diagnosis and assessment of these patients.

                Author and article information

                J Med Case Reports
                Journal of Medical Case Reports
                BioMed Central
                27 May 2010
                : 4
                : 158
                [1 ]Fifth Orthopedic Department, KAT Hospital, 14561, Greece
                [2 ]Laboratory for Musculoskeletal System Research, Medical School, University of Athens, Greece
                Copyright ©2010 Charopoulos et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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