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Aim: Chronic shoulder pain due to iatrogenic spinal accessory nerve (SAN) injury continues to be under-recognized, resulting in delayed time-to-diagnosis and poorer outcomes. Solutions are needed to improve the management of this condition, which can be challenging as care needs to be coordinated across pain management, neurophysiology, rehabilitation and reconstructive surgery.Cases: We present a series of six patients with shoulder pain refractory to conservative pain treatments to highlight how SAN injuries continued to be missed and treatment delayed, even at advanced care centers. The time to diagnosis of SAN palsy took an average of 21 months and treatment was inconsistent for all patients.Discussion: None of the six cases had initial suspicion of SAN palsy and only one patient received targeted SAN injury care. SAN treatment should be started as early as possible so that patients can be referred for prompt surgical evaluation if they fail conservative management. Integrated care pathways may be a solution for formalizing multidisciplinary team involvement and improving SAN injury outcomes.Conclusion: Systemic processes, such as integrated care pathways, are needed to optimize early recognition and targeted treatment of SAN injury and may be beneficial for other underdiagnosed and undertreated neuropathic pain conditions.
Neck dissection surgeries, which are done to treat various head and neck cancers, can often lead to shoulder pain. This pain commonly involves damage to a nerve called the spinal accessory nerve (SAN). Even though this nerve injury has been well-described by experts, many patients continue to experience delays in getting a correct diagnosis and treatment for this pain.This study describes six cases from a large cancer center where patients developed chronic shoulder pain after neck dissection. These patients waited an average of 21 months to reach a correct diagnosis of SAN injury. The pain and symptoms were often mistaken for other conditions. In one case, a patient received delayed treatment from a coordinated team of medical specialists, leading to improvements in her pain and shoulder function.The delay in diagnosing SAN injuries is likely due to two main challenges: a lack of awareness among providers and a tendency for healthcare to focus on specific areas rather than a team-based approach. Early diagnosis is crucial to prevent and minimize long-term pain and muscle loss.To improve patient care, this study suggests using an integrated care pathway approach and gives an example of how providers can adopt this approach. This method involves coordinating various medical specialists to ensure prompt diagnosis and treatment. By improving how SAN injuries are managed, patients can receive better care and avoid chronic pain and disability.
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INTRODUCTION/AIMS: Needle electromyography (EMG) is understood to be a relatively safe procedure based on clinical experience. There are no evidence-based guidelines for EMG procedures in thrombocytopenic patients. The purpose of this study was to determine whether there is an increased risk of bleeding complications associated with needle EMG in patients with thrombocytopenia. METHODS: This retrospective study included patients with a primary cancer and thrombocytopenia who underwent needle EMG between January 1, 2016 and October 30, 2020. Patients' medical records were reviewed for demographics; diagnoses; platelet counts within a 7-day period of EMG examination; concurrent use of anticoagulants or antiplatelet medications; number of sites sampled by needle EMG, including anatomical differentiation of paraspinal and both deep and superficial limb muscles; and associated complications not limited to bleeding within 30 days of EMG examination. RESULTS: The initial data search identified 198 patients with a documented diagnosis of thrombocytopenia; 124 met these criteria and were included in the study. A total of 1001 muscle sample sites were documented, with 111 sites in paraspinal muscles, 876 sites in superficial limb muscles, and 14 sites within deep limb muscles. Five patients were concurrently using therapeutic anticoagulation and 3 were using antiplatelet medications. There were no clinically significant complications, but five minor incidents were documented in the medical records within 30 days post-EMG examination. DISCUSSION: Our findings suggest that bleeding complications from standard needle EMG in oncology patients with documented thrombocytopenia are rare. Testing of high-risk muscles in this patient population appears to be safe.