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Neurological Rehabilitation

From Neck Mass to Shoulder Sass: The Unexpected Journey of a Spinal Accessory Nerve Injury.

Saturday, October 25, 2025
8:00 AM - 9:15 AM MT
Location: Kiosk 5

    Poster Presenter(s)

  • Asdrubal Rivera, MD

    Resident physician
    San Juan VAMC
    San Juan, Puerto Rico

    • Co-Author(s)

  • Joanne Gonzalez-Feliciano, MD

    Fellow of the American Board of Physical Medicine and Rehabilitation. Attending physician
    Veterans Affairs
    Ciales, Puerto Rico

Disclosure(s):
Joanne Gonzalez-Feliciano, MD: No financial relationships to disclose
Case Diagnosis: Left spinal accessory nerve injury.

Case Description or Program Description: Case of a 53-year-old male patient presented to PM&R clinics complaining of neck and left shoulder pain. He reports pain began after excision of left posterolateral neck 2.1 x 1.6 x 1.9 cm lipoma located deep to the posterior margin of the left sternomastoid muscle. Pain described as intermittent 5/10 in intensity with loss of motor strength in the left shoulder and trapezius muscles limiting shrug, abduction, and forward flexion. It is worsened by overhead activities, lying in affected side, physical effort, and dressing uppers. Improved by acetaminophen and rest. Denies radicular signs, and red flags. EDX requested to evaluate for suspected left spinal accessory neuropathy.

Setting: Outpatient clinics

Assessment/Results: Needle evaluation of the left trapezius muscle showed increased insertional activity, slightly increased spontaneous activity, increased motor unit amplitude, diminished recruitment, and very decreased interference pattern. Absent activity at left sternocleidomastoid muscle. Treatment included physical therapy. Pain diminishing in intensity and strength improving.

Discussion (relevance): Spinal accessory nerve injury is a common iatrogenic complication following posterior neck mass excision or biopsy. Almost 50% of patients present with injury to nerve with radical neck dissection and from 60% to 80% end up with severe dysfunction of upper extremity. This can lead to significant weakness in shoulder movements and pain as other muscles compensate for the deficit. As in this patient, early evaluation and diagnostic measures can identify and guide further management. Therefore, electrodiagnostic studies serve as a tool to determine rehabilitation goals and prognosis.

Conclusions: Electrodiagnostic studies provide valuable information of the severity of spinal accessory injury and the muscles affected by it. Prompt identification of symptoms such as weakness in shoulder range of motion, scapular dyskinesis, and pain in areas not associated to the procedure should warrant further workup to determine the extent of injury.