J Reconstr Microsurg 2005; 21(1): 34
DOI: 10.1055/s-2005-862778
Copyright © 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Invited Discussion

Oskar Aszmann1
  • 1Division of Plastic Surgery, Department of Surgery, University of Vienna School of Medicine, Austria
Further Information

Publication History

Publication Date:
26 January 2005 (online)

The authors report two cases of iatrogenic spinal accessory nerve injury after diagnostic lymph-node biopsies in the posterior cervical triangle. Both patients had significant shoulder dysfunction with inability to abduct and lift the shoulder, and nerve injury was diagnosed with electrodiagnostic tests. Subsequently, both patients underwent nerve reconstruction at the appropriate time, one with a 2.5-cm autograft, the other with the use of a 2.5-cm PGA tube. The authors describe incomplete recovery in the autografted patient, and complete recovery in the PGA-treated patient. They now prefer the PGA tube for XIth nerve reconstruction.

Even though both patients are very well-documented, the mode of injury was similar and the reconstruction distance was the same, surely, the question of whether it is better to reconstruct the XIth cranial nerve with an autograft or PGA tube under these conditions cannot be answered on the basis of these two cases report. I would have been more satisfied if the title had been changed and the conclusion modified.

The argument of prolonged surgery time seems to be irrelevant since, in most of these patients, the greater auricular nerve will need to be exposed and identified for XIth nerve exploration. Furthermore the cost of the PGA tube should also be considerd (if this should, indeed, be an argument).

Since the authors end with an algorithm, they should also have stated that defects larger than 2.5 cm should still be reconstructed with an autograft. For defects less than 2.5 cm, it is question of preference. The fact that one patient here did better than the other seems to me to be totally irrelevant. Larger series on this specific nerve injury suggest that most will do very well, if reconstructed in a timely fashion.[1] [2]

Regarding cranial motor nerve reconstruction, I am surprised that the PGA tube has not been used, as yet, for facial nerve reconstruction. It would have been interesting had the authors commented on this in their discussion.

REFERENCES

  • 1 Williams W W, Twyman R S, Donell S T et al.. The posterior triangle and the painful shoulder: spinal accessory nerve injury.  Ann R Coll Surg Engl. 1996;  78 521-525
  • 2 Kline D G, Hudson A R. Nerve Injuries: Operative Result of Major Nerve Injuries, Entrapments and Tumors. Philadelphia; WB Saunders 1995: 448-451

Oskar AszmannM.D. 

Division of Plastic Surgery, Department of Surgery

University Clinics of Vienna, General Hospital and School of Medicine, Vienna, Austria

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