頸部淋巴結切片手術後脊副神經損傷引起肩頸部疼痛及疑似硬塊：病例報告

A Psuedo-Mass of Shoulder Girdle Due to Spinal Accessory Nerve Injury after Neck Lymph Node Biopsy: A Case Report

林硯農(Yen-Nung Lin) ； 魏靚華(Jing-Hwa Wey) ； 黃媺淳(Mei-Chun Huang) ； 張光華(Kwang-Hwa Chang) ； 邱俊傑(Chun-Chieh Chiu)

《台灣復健醫學雜誌》 35卷4期 (2007/12) Pp. 223-228

https://doi.org/10.6315/2007.35(4)05

摘要

肩膀疼痛無法抬舉、肩關節活動受限及肩頸部摸到硬塊等症狀都是在復健科門診經常會處理到的問題。常見的診斷包括棘上肌肌腱病變、頸神經根病變、五十肩、肩頸肌肉拉傷、或肩關節炎等等，但本個案報告將介紹一個較少見的狀況，即：因頸部淋巴節切片手術造成醫源性脊副神經損傷而導致病患主訴肩膀疼痛無法抬舉、肩頸部摸到硬塊、肩胛突出的案例。
本個案是一位49歲女性病患，於半年前因左頸部淋巴腫塊而接受淋巴節切片手術，之後便逐漸感到左肩疼痛、舉高無力及肩關節活動受限，雖曾因此多次就醫，但症狀仍持續。最後來到復健科求診時除左肩不適外，還主訴在肩背交界處發現一硬塊。理學檢查發現其左右兩肩的外觀不對稱，左肩有翼狀現象，主動外展運動無力但被動運動正常。超音波檢查發現其肩背交界處的硬塊，實際上是肩胛骨的上角，因左肩胛骨不正常下旋而突出，並不是組織腫瘤或腫塊。此外旋轉肌袖完整，沒有任何斷裂的跡象。肌電圖檢查結果爲斜方肌有明顯去神經現象。遂診斷爲「脊副神經損傷所引起的斜方肌功能失調及肩部失能」。
頸部淋巴節切片手術造成的醫源性脊副神經損傷的機率約爲百分之三至百分之八，病患症狀主要爲肩頸部疼痛，很容易被誤診，治療主要爲復健治療及早期接受神經修復手術。本報告除了討論此病症的診斷與治療外，同時也根據肩胛骨的生物力學，探討脊副神經受損後斜方肌無力所造成的影響。

關鍵字

脊副神經 ； 神經損傷 ； 斜方肌

並列摘要

Shoulder problems such as pain, weakness, limited range of motion and palpable mass are common complaints in PM&R clinic. This case report describes a less common but not rare condition: iatrogenic accessory nerve injury after neck lymph node biopsy. The patient in this study presented symptoms of shoulder girdle pain and weakness and also complained of a ”hard palpated mass” over her shoulder girdle.
A 49-year-old female complained of gradually worsening left shoulder pain accompanied by weakness and limited range of motion in her left shoulder for many months. She had sought medical advice for many times and rotator cuff pathology was diagnosed and treated, but her symptoms had no amelioration. She also complained of a hard immovable mass 2.5 cm in diameter palpated over her left shoulder girdle. She had received a lymph node biopsy six months previously at a different clinic. Physical examination revealed scapular asymmetry and winging. Active range of left shoulder abduction and flexion was reduced due to weakness. Passive range of motion was preserved. Musculoskeletal sonography confirmed the contour of her rotator cuff was intact, and no abnormal mass was observed. The nodule was actually the superior angle of the scapula. Downward rotation had caused protrusion and palpation of the superior angle under soft tissue. Electromyography demonstrated active denervation in the left accessory neuropathy. The final diagnosis was iatrogenic accessory nerve injury contributing to trapezius muscle dysfunction. This disorder is prone to misdiagnosis or delayed diagnosis. This article describes the clinical presentation, diagnosis and treatment of the disorder as well as the biomechanical impact on shoulder girdle and scapula of trapezius dysfunction.

並列關鍵字

spinal accessory nerve ； nerve injury ； trapezius muscle