Scapular Winging after total thyroidectomy for Pappillary Ca

[seema70]

Dear Doctor,

This is my first visit to this site. In May 09, I was diagnosed with Pappillary Ca with multiple nodes (likely Ca) on left side of neck. Histopathology confirmed Pappillary Ca in thyroid and ONLY ONE neck node with Ca growth. I underwent complete thyroidectomy and left neck lymph nodes removal on 25 May 09. Post surgery, I have difficulty in moving my left arm upwards above shoulder level and am unable to do even simple tasks with this hand. Occasionally, there is shooting pain across the entire arm. From 2 July onwards, I have been undergoing physiotherapy with IFT, stretching exercises and ultrasound. The physiotherapist says I have Scapular Dyskinesis (which is apparent to me too !) and I also have winged scapula of left shoulder. I read online that radical neck dissection has the added risk of damage to Long Thoracic Nerve and Spinal Accessory Nerve which in turn may cause winged scapula and shoulder dysfunction. However, when I consulted my operating surgeon, he confirmed that none of the above nerves have been damaged during surgery. Even after 6 weeks of physiotherapy, there has been no improvement to my shoulder and left arm.

1.  What could be the cause ? Is it damage to SAN or Long Thoracic Nerve ?
2.  Should we opt for EMG to confirm the nerve damage ?
3.  If the EMG shows damage to a nerve, what then ?
4.  Does the nerve heal itself ?
5. Is nerve graft a viable option and how much delay is acceptable ? I cant get it done before Nov 09 which would be 6 months from (likely) trauma.
6.  In the meantime, should I start exercises for strengthening of muscles related to shoulder movement, as advised for scapular winging  ?  

Thank you.

[seema70]

Dear Doctor,

Thanks for your reply. As you mentioned, the affeted nerves are nowhere near the thyroid but in my case, the left lymph nodes of the neck were also removed upto level II & IV. And instead of a radical dissection, it was a SELECTIVE NECK DISSECTION (as mentioned by operating surgeon).

However, my fear is that the nerves could still be stressed/damaged during such a neck dissection.

During my little online research to find the links between scapular winging and neck dissection, I came upon the foll article which depicts my injuries very accurately.

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2502542&blobtype=pdf

I do intend to see  a neurologist asap, maybe get an EMG done.

I would be grateful for any feedback.    

[Archibald S Miller III, MD,FACS]

Well, it is a rare occurrence to have the problems you describe with a radical neck dissection, but it does happen. It would behoove you to be checked by a neurologist to see what has happened because these do not occur after a thyroidectomy. The nerves are nowhere near the thyroid. I would be inclined to get worked up for a metastatic tumor, or a problem that has occurred in a lymph node.

                  arch s miller ms md facs