Thread by @TJQPNI

[With consent] What can you notice about this individual? He has had difficult lifting his left arm for 15 months.

Left shoulder movement is limited as shown.

What can be seen when active abduction of the left shoulder (glenohumeral joint) is attempted?

He had no pain but slow loss of function. He takes no analgesia. In his past history 3 years ago he had radiotherapy treatment for left throat cancer.

So reduced trapezius bulk, no trapezius function, dorsal scapular function good, deltoid and rotator cuff, serratus and lat all working well. Limited active abduction. No Tinel in the neck. Normal sensation and sympathetic function in the arm. Diagnosis in next tweet…

Yes many have arrived at the diagnosis- a late complication of radiotherapy (often at aroubd 2 years after) is a fibrosis which causes a deep conduction block which can go on to a degenerative lesion. Here creating a spinal accessory nerve palsy distal to Sternocleidomastoid.

So where does the conversation go next? Treatment?? What are the options to improve function in a chronic post radiotherapy spinal accessory nerve injury (likely majority deep conduction block)? #nervenerds

It is a long time since onset (>>12 months) so any chance of recovering function is low, but if it is conduction block it is a non zero chance. So the first step of my management is an operative assessment neurophysiological assessment & neurolysis of the spinal accessory nerve

This may allow recovery of function. Preop data will help and Intraop neurophys (cross lesional studies and distal conduction) will assist with diagnosis. If this is a conduction block this is the only chance for a return of some function. #spinalacessorynerve

If this is unsuccessful (it should be given 3 months at least to recover post op) there is a reconstructive option that improves the scapula posture and the shoulder function. It is a tendon transfer to improve the mechanical advantage of the dorsal scapular territory muscles…

This is the #Eden-Lange tendon transfer which intends to improve function in trapezius palsy. The Levator scapulae and major & minor rhomboids are advanced (I take them with a bone block) to return the scapula to its position & stability (Credit to #MayoClinic for illustration)

Note the resting posture of the scapula is already lateralised. See the lack of any trapezius bulk over the spine of scapula and rhomboids. See the rhomboids trying to hold the scapula. The lack of stabilisation abduction or rotation then winging of the scapula.

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