Chapter 32

Nerve Injuries of the Neck

Nicholas Brandmeir
Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
e-mail: [email protected]

INTRODUCTION This chapter reviews the general anatomy of the neck

with a detailed description of the anatomy of the peripheral
Peripheral nerve injuries represent a major source of mor- nerves. It provides the reader with an understanding of the
bidity to patients. Trauma is an extremely common cause common causes of injury to the different nerves of this
of injury. A review by Noble et al. found that peripheral region and the diagnostic evaluation for each nerve injury
nerve injury had a prevalence of 2.8% in a large trauma syndrome. Finally, it provides a review of the treatment
patient series (Noble, Munro, Prasad, & Midha, 1998). options for the different nerve palsies that can be encoun-
Further, in their review of 722 surgically treated cases of tered in the neck.
traumatic peripheral nerve injury, Kretschmer et al. reported
that 17.4% were iatrogenic lesions. Of those, the spinal
accessory nerve (SAN) had the highest rate of injury with
14 out of 126 injuries reported (Kretschmer, Antoniadis,
GENERAL ANATOMY
Braun, Rath, & Richter, 2001). These results are all the more The neck is divided into anatomic triangles for ease of
striking when the reader takes into account that other than the description and surgical localization. The two major triangles
SAN, no cranial nerves were included in their analysis. are the anterior and posterior triangles. They are separated by
Looking at the commonly injured nerves of the neck, it the sternocleidomastoid muscle (SCM) (Figure 32.1).
is clear, even without the analyses above, that nerve injuries The posterior triangle is bounded anteriorly by the SCM,
in the neck are a major problem. The combined incidence of inferiorly by the clavicle, posteriorly by the anterior border
temporary and permanent recurrent laryngeal nerve (RLN) of the trapezius muscle, and superiorly by the superior
palsy following anterior cervical discectomy, one of the nuchal line. It can be further divided into the occipital
most common neurosurgical procedures performed, is and supraclavicular triangles by the transversely running
reportedly as low as 3% (Kriskovich, Apfelbaum, & inferior belly of the omohyoid muscle. The occipital tri-
Haller, 2000) and as high as 11% (Heeneman, 1973). In angle is the superior of the two and contains the superficial
his review of RLN palsy, Myssiorek found the reported risk branches of the cervical plexus as well as the trunks of the
of nerve injury from thyroid surgery to range from 4-8% brachial plexus (BP), and the SAN. The supraclavicular
with 1% of patients having a preoperative deficit. Other sur- triangle (also known as the omoclavicular or subclavian
geries that commonly caused RLN palsy were skull base sur- triangle) contains mostly vascular structures including the
geries and carotid endarterectomy (Myssiorek, 2004). subclavian vein and artery as well as the suprascapular
Dealing with carotid endarterectomy specifically as a artery. Its position can be identified with surface anatomy
cause of nerve injury, Ballotta et al. found that 12.5% of by the supraclavicular fossa. Superficially, the posterior
carotid endarterectomy patients had a peripheral nerve triangle is roofed by the investing deep layer of cervical
lesion of some type postoperatively, with the hypoglossal fascia, which forms a sheath around both the trapezius
nerve being most frequently injured (Ballotta et al., 1999). and SCM. The supraclavicular triangle is crossed superfi-
With injuries, including iatrogenic injuries, to peripheral cially by the external jugular vein.
nerves of the neck being so common, it is no surprise that The anterior triangle of the neck is more complicated
injury to these nerves is also a major cause of medical mal- and contains more anatomic structures than the posterior tri-
practice claims. Müller-Vahl found that peripheral nerve angle. It is divided into at least four smaller triangles. The
injuries were responsible for 8.7% of medical malpractice first, and least complex, is the submental triangle. It is an
claims and that the majority of those were injuries to the unpaired triangle that is bounded by the mandibular sym-
nerves of the neck (Müller-Vahl, 1984). physis, the hyoid bone, and the anterior bellies of the

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© 2015 Elsevier Ltd. All rights reserved. 493
494 PART IV Injuries of the Peripheral Nerves

FIGURE 32.1 The triangles of the neck.

digastric muscles bilaterally. The mylohyoid muscles form neck as well as for their diagnosis and treatment. A detailed
the floor of the triangle. Its contents are largely veins and description of the surgical anatomy of the pertinent nerves
lymph nodes. is provided below in their individual sections.
The submandibular (or digastric triangle) is lateral to the
submental triangle. Its borders are the anterior and posterior
bellies of the digastric muscles inferiorly and laterally and
THE HYPOGLOSSAL NERVE
the inferior border of the mandible superiorly. The contents The extracranial anatomy of the hypoglossal nerve begins
of this triangle consist largely of the submandibular gland; as it exits the hypoglossal canal (Figure 32.2). The nerve
however, the hypoglossal nerve also crosses this triangle. emerges medially to the internal jugular vein and internal
The muscular triangle of the neck is the inferiormost tri- carotid artery (ICA). This is termed the descending portion
angle inside the anterior triangle. It is bounded superiorly of the nerve. Here the nerve travels at the posterior aspect of
by the superior belly of the digastric, inferiorly by the the vagus nerve in the carotid sheath. At this segment, it is
anterior border of the SCM and by the midline of the neck. joined by branches from the cervical plexus carrying fibers
It contains the viscera of the neck including the thyroid and from the C1 and C2 nerve roots. These fibers terminate in
parathyroid glands. This triangle also contains the inferior the three different branches of the hypoglossal nerve. Some
portion of the carotid sheath. C2 sensory fibers enter the hypoglossal canal and travel in a
Finally, the carotid triangle is located between the midline retrograde fashion to innervate the dura mater in the
of the neck medially, the superior belly of the omohyoid infe- posterior cranial fossa. C1 and C2 fibers travel with the
riorly, the posterior belly of the digastric superiorly, and the descending branch (or descendens hypoglossi—given off
anterior border of the SCM laterally. The carotid triangle con- from the descending segment) to form the superior branch
tains the carotid sheath and is the site where the common of the ansa cervicalis and innervate many of the infrahyoid
carotid bifurcates into the external and internal carotid muscles. Finally, some C1 fibers travel in the terminal
arteries. Several nerves also traverse the carotid triangle branch to innervate the thyrohyoid and geniohyoid muscles.
including the hypoglossal nerve as it exits the submandibular The vagus nerve also sends several communications to the
triangle. The glossopharyngeal and vagus nerves are also descending segment of the hypoglossal nerve. Some of
contained in the deep tissue of these two triangles. these fibers likely originate from the inferior vagal ganglion
A detailed understanding of the anatomy of the neck is a (nodose ganglion) and provide the afferent and efferent
necessary precursor to an evaluation of nerve injuries in the loops of intrinsic tongue reflexes (Saraswathi, 2003).
 Nerve Injuries of the Neck Chapter 32 495

FIGURE 32.2 The nerves of the neck. The branches of the cervical plexus and their anastomoses with the branches of the facial nerve, greater occipital
nerve (from the Cruveilhier plexus), and SAN (a) 1, Facial nerve trunk; 2, temporofacial (superior) division of the facial nerve; 3, cervicofacial (inferior)
division of the facial nerve; 4, posterior auricular branch of the facial nerve; 5, great auricular nerve; 6 and 7, duplicated lesser occipital nerve; 8, greater
occipital nerve; 9, lateral supraclavicular nerve; 10, medial supraclavicular nerve; 11, mental branch of the inferior alveolar nerve; 12, infraorbital branch
of the maxillary nerve; 13, supraorbital nerve (one of the terminal divisions of the frontal nerve); 14, auriculotemporal nerve; 15; the anastomosis between
the transverse cervical nerve and the cervical branch of the facial nerve; 16, the anastomosis between the great auricular nerve and the cervical branch of the
facial nerve; 17, SCM. (b) 1, Facial nerve; 2, SAN; 3, transverse cervical nerve; 4, great auricular nerve; 5 and 6, duplicated lesser occipital nerve;
7, supraclavicular nerves; 8, greater occipital nerve; 9, cervical branch of the facial nerve; 10; branches of the great auricular nerve; 11, posterior auricular
nerve and its branches; 12, branches of the transverse cervical nerve; 13, trapezius branches of the cervical plexus; 14, anastomosis between the transverse
cervical nerve and cervical branch of the facial nerve; 15, anastomosis between the great auricular and posterior auricular nerves; 16, a branch of the lesser
occipital nerve that anastomoses with the greater occipital nerve. Reproduced from Sappey (1872) with modifications. From Shoja et al. (2014).

The vagus nerve also sends an anastomotic branch to the 41% of the cases. Other variations of this anatomic rela-
hypoglossal nerve near the point where it crosses the tionship exist as the hypoglossal nerve may also transition
occipital artery (OA). It is theorized that these fibers may from its descending segment by turning laterally to the
provide proprioceptive information from the tongue internal jugular vein rather than medially (Kim,
(Shoja et al., 2014). Caccamese, & Ord, 2003); it may be displaced inferiorly
The descending segment ends, and the lateral segment by the lingual artery (Weinstein & May, 1990). Further,
begins where the hypoglossal nerve leaves the carotid Curto et al. reported that 89% of hypoglossal nerves pass
sheath to run superficial laterally to and crosses the ICA, superior to the carotid bifurcation, 10% pass at the level
OA, and external carotid artery (ECA) in the carotid tri- of the carotid bifurcation, and 1% pass inferior to the level
angle. The point where the hypoglossal nerve crosses the of the carotid bifurcation (Curto, Suarez, & Kornblut,
vascular structures as it transitions from descending to 1980). Kim et al. also found this anatomy to be highly var-
lateral segments is a point of significant anatomic vari- iable (Kim, Chung, & Lanzino, 2009). The lateral segment
ability. Nathan and Levy described three main variations continues as the nerve runs anteromedially, deep to the pos-
in the way the hypoglossal nerve crosses the OA (Nathan terior belly of the digastric and deep to the intermediate
& Levy, 1982). In type I patients, the OA branched from tendon of the digastric muscle before finally turning ante-
the ECA superior to the nerve and coursed posteriorly, rosuperiorly to form the ascending segment and terminal
crossing the nerve superficially. This arrangement was seen branch.
in 37% of anatomic specimens. In type II patients, the OA The ascending segment forms the terminal branch of
branched at the same level the hypoglossal nerve crossed the hypoglossal nerve. This portion of the nerve runs
and coursed posteriorly to cross the hypoglossal nerve between the hyoglossus and mylohyoid muscles in the deep
superficially again. This arrangement was present 20% of tissue of the submental triangle. Here, the nerve is accom-
the time. Finally, in type III patients, the OA branched from panied by the lingual veins.
the ECA inferior to the hypoglossal nerve and then con- The syndrome of hypoglossal nerve injury is classically
tinued its common posterior course. This was reported in confined to the tongue. It consists of unilateral wasting of
496 PART IV Injuries of the Peripheral Nerves

the tongue with deviation of the tongue toward the lesion from retractor placement, mobilization, and/or intubation.
when the patient is asked to protrude the tongue. Tongue Treatment for most hypoglossal nerve injuries should be
weakness can be quantified by having the patient press conservative including speech therapy and watchful waiting
on a pressure transducer with the tongue in a series of ste- (Cahill et al., 2004; Freixinet et al., 1996). If a transection
reotyped exercises supervised by a speech pathologist is identified during surgery, exploration, or imaging, or is
(Cahill et al., 2004; Goozée, Murdoch, & Theodoros, expected based on clinical history, direct reanastomosis
2001). Hypoglossal nerve syndrome is not limited to tongue has shown good results in limited case reports (Avitia &
weakness, however; the hyoid bone undergoes a compli- Osborne, 2008; Messner et al., 1995). Different surgical
cated series of stereotyped movements integral to the act approaches and strategies for carotid endarterectomy have
of swallowing that depend on the supra-, and infrahyoid been compared, but none have shown any benefit in
muscles as well as the oral cavity and pharynx for coordi- reducing the rate of cranial nerve palsies (Assadian et al.,
nation (Ishida, Palmer, & Hiiemae, 2002). Disruption to 2004; Beasley & Gibbons, 2008). As with most peripheral
these processes and the tongue likely contributes to the nerves, the general rules for the prevention of injury and
swallowing and vocal difficulties commonly seen with good long-term outcome remain gentle handling and direct
hypoglossal injury. Finally, because of the necessity of reanastomosis when appropriate.
tongue coordination for producing speech and effective
swallowing, bilateral hypoglossal nerve injuries have the
potential to be devastating, rendering patients unable to THE CERVICAL PLEXUS, PHRENIC NERVE,
feed themselves or speak. A rare syndrome involving the
AND ANSA CERVICALIS
extracranial hypoglossal nerve is Tapia’s syndrome. It is
composed of ipsilateral injury to the hypoglossal nerve The anatomy of the cervical plexus is variable (Shoja et al.,
and RLN and is thought to be a complication of anes- 2014) (Figure 32.3). In general, the ventral rami of C1-C4
thesia/airway management. It may present unilaterally or anastomose superiorly and inferiorly as well as with sympa-
bilaterally (Cinar, Seven, Cinar, & Turgut, 2005). thetic fibers from the gray rami communicantes of the
The major cause of hypoglossal nerve injury in the superior cervical ganglion to form several loops. These
developed world is iatrogenic. One of the most common sur- loops then form the cervical plexus. The cervical plexus lies
geries performed is carotid endarterectomy. In their series of deep to the superior attachment of the SCM and can be
6878 patients, Fokkema et al. reported a hypoglossal injury divided into posterior and anterior branches. The posterior
rate of 2.7% (Fokkema et al., 2014). This was the most fre- branches are chiefly concerned with cutaneous sensory
quent cranial nerve lesion following carotid endarterectomy. innervation of the lateral neck and upper thorax. There
The number of patients from this series that had permanent are four major nerves that are part of the posterior branches.
hypoglossal nerve damage was 0.7%. This risk was increased All of these nerves emerge from a relatively limited area on
if the surgery had been urgent or if the patient suffered a peri- the posterior border of the SCM known as the nerve point.
operative stroke. In a prospective series of 200 consecutive Three of these leave from the loop between C2 and C3. The
patients, Ballotta et al. found that the rate of hypoglossal lesser occipital nerve contains fibers from C2 and inner-
nerve injury was 5.5% (Ballotta et al., 1999). All of these vates the skin over the occiput posterior to the auricle.
injuries proved to be transient, but at least one injury took The great auricular nerve contains fibers from C2 and C3
37 months to resolve. Many other causes of hypoglossal nerve and innervates the skin over the auricle and between the
injury have been reported including blast injury (Shahzadi, angle of the mandible and the mastoid process. The trans-
Abouzari, & Rashidi, 2007), motor vehicle accident verse cervical nerve, also containing fibers from C2 and
(Freixinet, Lorenzo, Hernandez Gallego, Rodriguez Castro, C3, leaves the nerve point and turns anteriorly, superficial
& Sole, 1996), intubation with a laryngeal mask airway to the SCM and deep to the platysma to innervate the skin
or endotracheal tube (Cinar et al., 2005; Sommer, Schuldt, over the anterior triangle. The final posterior group is the
Runge, Gielen-Wijffels, & Marcus, 2004; Stewart & supraclavicular nerves. These branches contain fibers from
Lindsay, 2002), knife wound (Messner, McGuirt, & C3 and C4 and innervate the skin over the clavicle and
Blalock, 1995), other types of neck surgeries (Mukherjee supraclavicular fossa. Branches of C3 and C4 anastomose
et al., 2012), BP block (Johnson & Moore, 1999), with the SAN to aid in innervation of all portions of the tra-
cosmetic surgery (Bakhshaee, Bameshki, Foroughipour, & pezius muscle (Tubbs et al., 2011).
Zaringhalam, 2014), pseudoaneurysm (Hacein-Bey, Blazun, There are two important ventral branches of the cervical
& Jackson, 2013), internal jugular vein cannulation plexus. The first is the phrenic nerve. The phrenic nerve
(Briscoe, Bushman, & McDonald, 1974), and many others. receives its fibers chiefly from C4, but also receives contri-
The treatment of hypoglossal nerve injury is limited. As butions from C3 and C5. The phrenic nerve runs inferiorly
noted above, the majority of patients will recover spontane- with the internal jugular vein, but has a different course on
ously as the injury to the nerve is thought to be neuropraxic the left than the right. On the left, it crosses the anterior
 Nerve Injuries of the Neck Chapter 32 497

Lesser occipital
nerve Communicating branch from
C1 to hypoglossal nerve

C1 Greater auricular nerve

Communicating loop Transverse cervical

between the C1 and C2 nerve
C2 Hypoglossal
nerve
Communicating loop
between the C2 and C3
C3
Communicating loop
between the C3 and C4
C4 Superior and
inferior roots of
Ansa cervicalis
Branch to the
brachial plexus

C5 branch to the Trapezius branches

phrenic nerve

Phrenic nerve

Supraclavicular branches
FIGURE 32.3 The cervical plexus. From Shoja et al. (2014).

scalene anterior to the first part of the subclavian artery. On usually causes a syndrome of pain or sensory loss in the spe-
the right, this crossing occurs anterior to the second part of cific distribution of the affected nerve. The lesser occipital
the subclavian artery. The C5 fibers of the phrenic nerve nerve has also been implicated in the development of
may form an accessory phrenic nerve in the neck and go occipital neuralgia and headache syndromes. Ducic et al.
on to join the phrenic nerve proper in the root of the neck described this phenomenon in a series of patients following
or thorax. The role of the phrenic nerve is to innervate craniotomy, as well as their successful treatment with
the diaphragm. excision of the offending nerve (Ducic, Felder, & Endara,
The second major ventral branch of the cervical plexus 2012). Precipitating factors for lesser occipital nerve injury
forms the inferior root of the ansa cervicalis (or ansa hypo- other than craniotomy have been described as well. Sensory
glossi). The superior root is formed by C1 fibers (described disturbance of the ear is common after rhytidectomy and
above) and is termed the descedens hypoglossi. The fibers this is largely thought to be secondary to great auricular
comprising the inferior root are variable. Loukas et al. nerve injury, but the lesser occipital nerve may play an
reported that fibers came from C3 alone in 40% of cases, important role as well (Pantaloni & Sullivan, 1999; Rees
C2 and C3 in 38%, C2 alone in 12%, and C2, C3, and C4 & Aston, 1978). Other rarer causes of lesser occipital nerve
in 10% (Loukas et al., 2007). In 75% of cases, the ansa cer- injury have been described, including as a complication of
vicalis runs posterolaterally to the internal jugular vein; in posterior neck dissection (Hu et al., 2013) and shoulder
other cases, it runs anteromedially. The length of the ansa surgery (Tahir & Corbett, 2013).
cervicalis is said to have a long root when the union of The great auricular nerve is also prone to injury. As
the superior and inferior roots is inferior to the omohyoid. mentioned above, it is frequently the culprit in pain and
Seventy percent of patients have a long ansa cervicalis sensory disturbance after rhytidectomy. This injury is
(Loukas et al., 2007). The branches of the ansa cervicalis thought to be the result of inadequate release of the subauri-
innervate the infrahyoid muscles. These muscles are the cular membrane (Rohrich, Taylor, Ahmad, Lu, & Pessa,
omohyoid (both the superior and inferior bellies), the ster- 2011). Other causes of great auricular nerve injury have
nohyoid, and the sternothyroid. been reported in the literature, including hanging and other
Injury to the various nerves of the cervical plexus pre- neck surgeries (Arias, Arias-Rivas, Pérez, & Alende-Sixto,
sents with various clinical symptoms related to the specific 2005). When injury develops, treatment is based on the
function of the nerves. Injury to the posterior branch nerves specific anatomic diagnosis of the nerve. Often it is a
498 PART IV Injuries of the Peripheral Nerves

neuropractic injury that will recover spontaneously. In other disproving this hypothesis (Davies, 2010; Sauvageau,
cases it may require surgical decompression (Barbour, 2012). Wherever possible, injury to the phrenic nerve
Iorio, & Halpern, 2014), or amputation/neurolysis of a should be treated with decompression or direct repair
painful neuroma (de Chalain & Nahai, 1995). When the (Kaufman et al., 2012). Many patients with phrenic nerve
nerve is severed, direct repair should be attempted if pos- injury will recover spontaneously, so a course of obser-
sible (de Chalain & Nahai, 1995). Due to its nature as a pure vation is usually warranted (Iverson, Mittal, Dugan, &
sensory nerve, the great auricular nerve may serve as a Samson, 1976). For patients with primary hypoventilation,
donor for nerve grafting/repair (Messner et al., 1995). direct phrenic nerve stimulation can be carried out,
The sensory nerves are gathered closely together at the regardless of the primary diagnosis (Judson & Glenn,
nerve point. For this reason, it is a popular choice for anes- 1967). This is usually not possible for patients with asymp-
thetic nerve blocks. There have been numerous reports of tomatic phrenic nerve paralysis. For them, when surgical
both BP and cervical plexus injuries associated with these intervention is necessary, a diaphragmatic plication is indi-
procedures (Christ, Rindfleisch, & Friederich, 2009). cated (Versteegh & Jouk Tjien, 2007).
Because of this risk, several techniques exist to avoid the
nervous structures while providing anesthesia, including
THE SPINAL ACCESSORY NERVE
ultrasound guidance (Herring, Stone, Frenkel, Chipman,
& Nagdev, 2012) and infiltrating in the subcutaneous The SAN exits the jugular foramen and descends inferiorly
tissue only, along the posterior border of the SCM, which deep to the SCM. It is initially composed of cranial roots
appears to be equally effective as a directed nerve block (from the nucleus ambiguus) as well as spinal roots (from
(Ramachandran, Picton, Shanks, Dorje, & Pandit, 2011). the upper cervical spine), but the cranial root leaves the nerve
There is no specific defined syndrome of ansa cervicalis early in its extracranial course and joins the vagus nerve. The
injury. The muscular targets of the ansa cervicalis are the spinal root continues deep to the SCM but superficial to the
infrahyoid muscles. The motion of the hyoid bone is investing deep cervical fascia. It gives off branches to
involved in swallowing and mastication, but this motion the SCM prior to entering the posterior triangle on its pos-
is largely dependent on the muscles of oropharynx and pha- terolateral course toward the trapezius muscle. In their study
ryngeal constrictors and will continue to function appropri- of the surgical anatomy of the SAN, Kierner et al. described
ately even with infrahyoid muscle denervation (Ishida et al., multiple configurations of the entrance to the posterior tri-
2002). This makes it an excellent donor for reinnervation angle. It entered the posterior triangle an average of
procedures for injuries to the RLN. Another factor that 8.3 cm superior to the clavicle. In 67% of posterior triangles
makes the ansa cervicalis ideal for this purpose is that it dissected, the SAN entered deep to the SCM, while in 37% it
is normally activated during phonation and swallowing entered the posterior triangle surrounded by muscle fibers
(Loukas et al., 2007; van Lith-Bijl & Stolk, 1997). (Kierner, Zelenka, Heller, & Burian, 2000). As far as its
Finally, the syndrome of phrenic nerve injury is relation to vascular structures, the SAN passes ventrally to
described as a paresis of the ipsilateral hemidiaphragm. the internal jugular vein in 56% of cases and dorsally in
The diagnosis is usually suspected based on clinical exam 44% (Kierner et al., 2000), and the SAN can penetrate the
findings of decreased breath sounds on the affected side internal jugular vein (Hashimoto, Otsuki, Morimoto,
with decreased chest expansion and dullness to percussion. Saito, & Nibu, 2012). The number and course of the trapezius
The classic radiographic finding is paradoxical movement branches in the SAN were reported to be considerably
of the affected diaphragm on fluroroscopy; nonfluroscopic variable as well, with one, two, and multiple branches
radiographs will typically show an elevated diaphragm on reported with variations in branching points as well as length
the affected side (Subramanyam & Palaniswamy, 2013). of branches (Kierner et al., 2000).
This can be a desired effect, as with a surgically induced The course of the accessory nerve through the posterior
neuropraxia, which is intended to allow recovery from a triangle is posterolateral in general, with its straight orien-
diaphragmatic hernia repair. Other common causes of tation in the proximal segment giving way to a coiled con-
phrenic nerve palsy in the neck include arterial compression figuration in the triangle itself (Tubbs et al., 2006). This
(Kaufman et al., 2012), blunt neck trauma (Bell & coiled configuration is thought to protect the nerve from
Siriwardena, 2000), neck dissection (which may carry a risk traction injury secondary to routine range of motion in
of up to 8%) (McCaul & Hislop, 2001), and large cat attacks the upper extremity (Tubbs et al., 2010). During this
(Anderson et al., 2008; Kadesky et al., 1998), among others. portion, it runs between the superficial cervical fascia and
Interestingly, it was proposed that a mechanism of death in deep investing fascia and is in close proximity to the cer-
hanging was phrenic nerve injury and asphyxiation from vical lymph node chain. Here is where the trapezius
diaphragmatic paralysis, but a review of video evidence branches are given off.
of multiple judicial hangings revealed continued deep, The accessory nerve receives a communication from the
rhythmic breathing after the initiation of the hanging, cervical plexus, specifically fibers from C2 and C3 for the
 Nerve Injuries of the Neck Chapter 32 499

SCM and C3 and C4 fibers for the trapezius (Brown, 2002). or suspected it may be assessed further with electromyog-
This innervation from the cervical plexus is likely what raphy and physical therapy. Both modalities have shown
allows some trapezius function even with a complete benefit in following the progress of spontaneously
SAN palsy. improving SAN function. Physical therapy in particular
The syndrome of SAN injury is classically described as has been proven to be effective at aiding in the diagnosis
weakness of the ipsilateral SCM and trapezius muscle. This of accessory nerve palsy and improving in the symptoms
is clinically evident by weakness turning the head to the of shoulder syndrome, and all patients with a SAN injury
opposite side of the lesion, an ipsilateral shoulder droop, should be referred to physical therapy for an evaluation
and difficulty elevating the arm above the horizontal. This (Brown & Stickler, 2011; Mcgarvey et al., 2011; Petrera
is because the main function of the trapezius muscle is to & Trojaborg, 1984). In their series of 20 patients, Ogino
elevate and retract the scapula. A more specific physical et al. describe a rate of success with conservative therapy
exam finding, the “triangle sign,” has been proposed by of 50%. Of the patients treated surgically in this report,
Levy et al. This sign is demonstrated by having the patient shoulder syndrome remained significant in 30% (Ogino,
lie prone on the examination table and attempt to straighten Sugawara, Minami, Kato, & Ohnishi, 1991). These authors
their arms as much as possible. A triangle sign is when the recommend surgical treatment in cases with immediate
affected limb cannot elevate and a triangle is formed of the complete paralysis of the SAN or failure to improve 1 year
table, chest wall, and posterior upper arm. Levy et al. after the injury.
reported a sensitivity of 100% and specificity of 95% for There are myriad surgical techniques available for the
SAN injury when using this test in the clinic (Levy, treatment of SAN palsy. Most straightforward is a simple
Relwani, Mullett, Haddo, & Even, 2009). Injury to the suturing of a severed nerve, advocated for in settings of
SAN has also been described as “shoulder syndrome,” char- sharp trauma. Nerve grafts have also been reported with
acterized by pain, weakness, and deformity of the affected donor sites from the sural nerve as well as the cervical
shoulder (Remmler et al., 1986). plexus (Bertelli & Ghizoni, 2006; Novak & Mackinnon,
As with the other nerves examined in this chapter, the 2002; Ogino et al., 1991). Neurolysis can also be considered
most frequent cause of accessory nerve injury is iatrogenic, where appropriate. Reinnervation with donor nerves has
and it is the most common iatrogenically injured nerve also been described. Novack and Mackinnon utilized a
(Kretschmer et al., 2001). Also, SAN injury is a major medial pectoral nerve to SAN transfer with good result
source of malpractice litigation. In a review of SAN injury (Novak & Mackinnon, 2004), and Bertelli and Ghizoni
malpractice cases, it was discovered that the rate of plaintiff have reported the use of the motor branch to the platysma
compensation was 84% (Morris, Ziff, & Delacure, 2008). as the donor nerve during a complex accessory, phrenic,
Most of the injuries from that series were the result of lymph and BP repair, also with good result (Bertelli & Ghizoni,
node biopsies. Further, studies that compare radical neck 2011). Finally, if reinnervation of the SAN fails, the
dissection with nerve sparing neck dissections have demon- Eden-Lange procedure is a muscle transposition surgery
strated that the rate of SAN dysfunction is essentially that can correct the scapular winging and glenohumeral
100%, with the only difference noted when the nerve was instability that may result in severe cases of SAN palsy.
actually sacrificed (Erisen et al., 2004; Giordano, This procedure involves the transfer of the levator scapulae
Sarandria, Fabiano, Del Carro, & Bussi, 2012; Remmler to the spine of the scapula and the rhomboid major and
et al., 1986). If the injury is incomplete, the weakness asso- minor to the supra- and infraspinous fossae of the scapula,
ciated with the nerve injury usually gradually recovers respectively (Bigliani, Compito, Duralde, & Wolfe, 1996;
(Remmler et al., 1986). Although iatrogenesis is the most Skedros & Knight, 2012).
common cause of SAN morbidity, there are other relatively
common causes. Trauma, especially by ligature, is a risk
factor (Barkhaus, Means, & Sawaya, 1987; Harris, 1958), THE VAGUS NERVE, THE SUPERIOR
as well as more traditional trauma such as gunshot wounds LARYNGEAL NERVE, AND THE RECURRENT
and motor vehicle accidents (Kabatas, Bayrak, Civelek,
LARYNGEAL NERVE
Imer, & Hepgül, 2008; Tekİn & Ege, 2012).
The treatment of SAN injuries in general begins with The anatomy of the vagus nerve in the neck is complex,
avoidance. Because surface anatomy is unreliable for iden- with numerous branches, plexuses, and anastomoses. It ini-
tification of the nerve, ultrasound identification of the SAN tially arises from a series of rootlets from the medulla, then
has been considered as a way to avoid nerve trauma during leaves the skull through the jugular foramen. In the foramen
biopsies, but this has yet to be tested, other than a demon- lies the superior ganglion of the vagus nerve (or jugular gan-
stration that the nerve can be visualized consistently with glion) containing the general sensory afferents. Just inferior
currently available equipment (Mirjalili, Muirhead, & to the jugular foramen lies the inferior ganglion of the vagus
Stringer, 2012). If an accessory nerve injury is diagnosed nerve (or nodose ganglion) containing the visceral afferents
500 PART IV Injuries of the Peripheral Nerves

of the vagus nerve. After leaving the skull, the vagus nerve secondary to iatrogenic causes. The largest risk for RLN
enters the carotid sheath and makes multiple anastomoses to injury is surgery on the thyroid. Normally the RLN leaves
form the pharyngeal plexus in the space between the the vagus nerve and loops from superficial to deep over the
internal and ECA. Here, the vagus nerve participates in a aortic arch at the level of the ligamentum arteriosum on the
complex plexus of nerves with cervical sympathetics and right and subclavian artery on the left to its final course in
glossopharyngeal nerves to innervate the carotid body. This the tracheoesophageal groove. The right RLN has a slightly
plexus of nerves will give off a descending carotid sinus more anterior course in the tracheoesophageal groove and a
nerve that will innervate the carotid body (chemoreceptor) shorter course due to its loop under the subclavian artery.
and carotid sinus (mechanoreceptor). The innervation over Despite these differences between the right and left side,
the carotid bifurcation itself is complex and can be the RLN enters the tracheoesophageal fascia at C7 or below
described as a plexus in its own right, termed the inter- in 100% of dissections (Haller, Iwanik, & Shen, 2012). The
carotid plexus (Shoja et al., 2014; Toorop, Scheltinga, surgical anatomy of the RLN has been described in great
Moll, & Bleys, 2009). The portion of the vagus nerve within detail because of its extreme clinical importance. First, its
the carotid sheath is also responsible for giving off the pha- relation to Zuckerandl’s tubercle has been described to
ryngeal nerves, the superior laryngeal nerves, the cardiac facilitate the identification of the nerve during surgery.
nerves, and the RLN on the right (the left nerve leaves in Zuckerandl’s tubercle is a lateral projection from the lateral
the thoracic portion of the nerve). thyroid lobe. In their study of the relation of Zuckerandl’s
The superior laryngeal nerve runs lateral to the pharynx tubercle to the RLN, Yalçin and Ozan found that 64% of
and gives off both internal and external laryngeal nerves. hemithyroids contained an appreciable Zuckerandl’s
The external laryngeal nerve runs lateral to the larynx deep tubercle and among those it indicated the location of the
to the sternothyroid muscle and innervates the cricothyroid RLN in 55% of the hemithyroids explored (Yalçin &
and superior pharyngeal muscles. The internal laryngeal Ozan, 2007).
nerve enters the larynx with the superior laryngeal artery Another important anatomic landmark important to the
and supplies sensation to the pharynx from the epiglottis RLN is the ligament of Berry (or lateral thyrohyoid
and base of the tongue inferiorly to the vocal cords. Just ligament). It has been proposed that the RLN consistently
as in RLN injury (discussed below), the major risk for injury lies posterolateral to this ligament, but anatomic studies
is thyroid surgery. Superior laryngeal nerve injury is subtle, are still in disagreement, with some authors claiming that
often overlooked, and more difficult to diagnose than RLN the RLN is embedded within the ligament of Berry (John
palsy (Teitelbaum & Wenig, 1995). That being said, inci- et al., 2012).
dence of injury reported in thyroid surgery ranges from There are other important anatomic variations as well. A
0% to 28%. Symptoms are subtle and usually are subtle nonrecurrent pattern of branching is a rare but reported
quality changes in the voice including a weak voice and dif- pattern. Because of the intimate developmental nature of
ficulty producing a high pitch (Teitelbaum & Wenig, 1995). the RLN with its vascular loops and course, a non-RLN
Objective signs include bowing of the ipsilateral cord as is almost invariably accompanied by a vascular abnor-
well as posterior rotation of the glottis toward the injured mality, usually an aberrant right retroesophageal or retrotra-
side. Currently, no effective treatments exist for superior cheal subclavian artery or situs inversus. Non-RLNs often
laryngeal nerve palsy. Even with a careful evaluation, are accompanied by RLNs or are thought to be branches
superior laryngeal nerve palsy may be confused with ary- of the superior laryngeal nerve with aberrant innervation
tenoid subluxation, especially in the setting of trauma, patterns and anatomic courses (Kobayashi, Yuta,
and a high index of suspicion is necessary (Schroeder, Okamoto, & Majima, 2007; Tateda et al., 2008).
Motzko, Wittekindt, & Eckel, 2003). As mentioned above, the major cause of RLN injury is
Injuries to the vagus nerve in the neck are rare. When iatrogenic and the result of injury during thyroid surgery
they do occur their symptoms are usually similar to RLN (Hayward, Grodski, Yeung, Johnson, & Serpell, 2013;
palsy (adduction and paresis of the ipsilateral cord and Steurer et al., 2002). The current estimated risk of per-
hoarse voice). Autonomic symptoms are rare, but are theo- manent RLN palsy after thyroid surgery is 0.3% to 3%
retically possible. For this reason, vagal nerve stimulators and transient palsies range from 3% to 8% (Hayward
are placed on the left side preferentially. A common side et al., 2013). There are some clear risks associated with
effect of vagal nerve stimulation is hoarseness, but this is thyroid surgery and RLN palsy. Cancer surgery, reo-
related to stimulation intensity (Handforth et al., 1998). peration, and total resection all increase the risk of RLN
At least one case has been reported of permanent hoarse palsy (Hayward et al., 2013). Some studies have shown a
voice after vagus nerve stimulator removal, but this was decrease in RLN palsy with increasing surgeon experience,
attributed to RLN palsy (Srinivasan, Hall, & Leo, 2009). while others have failed to demonstrate this effect
The RLN is the most commonly injured branch of the (Hayward et al., 2013). Finally, side of operation, diabetes
vagus nerve and one of the most common nerve injuries mellitus, Graves’ disease (Basedow-Graves’ disease), and
 Nerve Injuries of the Neck Chapter 32 501

retrosternal goiter have all been shown to have no effect on symptomatic outcomes, while having the advantages of
the rate of postoperative RLN palsy (Hayward et al., 2013; restoring neural innervation to muscle and allowing it to
Schlosser et al., 2008). Two major techniques are currently maintain its natural bulk and tension, although outcomes
utilized to minimize the risk of RLN palsy in thyroid are best if performed within 2 years of the initial injury
surgery. The first, and current gold standard, is intra- (Li et al., 2014; Zheng, Li, Zhou, Cuan, & Wen, 1996).
operative dissection and visualization of the RLN. In a The reason for choosing the inferior root ansa cervicalis
large, prospectively gathered registry investigating risk as the donor nerve is that it is close in anatomical rela-
factors for RLN palsy in thyroid surgery, Dralle et al. tionship, is physiologically active during phonation, and
reported an odds ratio for RLN palsy of 1.4 for no nerve weakness of the infrahyoid muscles is not clinically
dissection compared with dissection and visualization, important to either phonation or swallowing. When
and this result has been confirmed by other studies examined in patients with vocal paralysis lasting 6-12
(Dralle et al., 2004; Hayward et al., 2013). The other major months, 12-24 months, or more than 24 months, Li et al.
technique utilized to prevent RLN palsy is intraoperative reported that all patient groups had significant improvement
neuromonitoring (IONM) of the vagus nerve/RLN. Current in all categories of vocal cord function (Li et al., 2014). If
reports are conflicting about the success of IONM to reduce reinnervation and direct anastomosis are not treatment
the risk of RLN palsy. The best evidence currently indicates options, other treatment options exist for vocal cord
that it is as effective as dissection and visualization alone, paralysis including thyroplasty and vocal cord injection.
but not superior to it; although, it may prove effective at
limiting neuropraxic injuries (Calò et al., 2013; Hayward
et al., 2013; Phelan et al., 2013).
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