Massage-Research.com

Spinal Accessory Neuropathy Associated With Deep Tissue Massage

Spinal Accessory Neuropathy Associated With Deep Tissue Massage: A Case Report
Aksoy, I.A., Schrader, S.L., Ali, M.S., Borovansky, J.A., Ross, M.A. 2009 Archives of Physical Medicine and Rehabilitation 90 (11), pp. 1969-1972 0

Spinal accessory neuropathy (SAN) causes impaired arm mobility and pain. The spinal accessory nerve is often injured during surgical procedures such as neck dissection for tumor resection or cervical lymph node biopsy. Other traumatic injuries may also occur. SAN causes weakness of the trapezius muscle and, less frequently, of the sternocleidomastoid muscle. The clinical consequence of trapezius muscle weakness includes impaired stability of the scapula leading to upper limb dysfunction and pain. We present a rare and illustrative case of SAN associated with deep tissue massage leading to scapular winging and droopy shoulder as a result of weakness of the trapezius muscle.

Case Description

A 38-year-old woman presented to our clinic with complaints of persistent right shoulder pain and limited ROM 10 days after a single session of deep tissue massage.

The patient had been feeling completely well prior to deep tissue massage and was working out with a personal trainer without any difficulty. There was no report of history of neck trauma or manipulation that would predispose the patient to injury. She underwent 1 session of deep tissue massage for relaxation without any particular musculoskeletal symptoms such as neck or shoulder pain. During performance of deep tissue massage along her neck and shoulders, she felt pain on the left side of her neck and at the top of her left shoulder radiating toward her arm. The pain continued afterward, and the patient noted that her left arm felt “long and heavy” while standing. Also, she had difficulty lifting her arm up and reaching back. There was no numbness or tingling during or after the deep tissue massage. She took over-the-counter nonsteroidal anti-inflammatory drugs to control the pain. After 10 days, the pain was reduced but not resolved, and shoulder dysfunction was unchanged.

Clinical evaluation revealed impaired left arm abduction with otherwise normal strength in the left upper limb muscles proximally and distally. Passive shoulder joint ROM was preserved, and there was no loss of sensation. The muscle stretch reflexes were normal in the upper and lower extremities. The impairment of left shoulder abduction led to scapular winging. During active shoulder ROM testing, impairment of shoulder elevation causing droopy shoulder with shoulder shrug motion was observed. There was mild diffuse tenderness to palpation along the trapezius muscle, but no atrophy in the shoulder girdle muscles including trapezius muscle was noted. Sternocleidomastoid muscle strength was tested, and no definite weakness was found. Based on the history and clinical examination findings, the differential diagnosis included cervical radiculopathy, brachial plexopathy, mononeuropathy, rotator cuff injury, and muscle contusion or strain. Further evaluation was undertaken with MRI of the left shoulder and EMG.

Discussion

Spinal accessory neuropathy associated with deep tissue massage is an unusual mechanism of nerve injury. Our literature search did not yield any reports of SAN associated with massage. Injuries to other nerves such as the posterior interosseous nerve9 and the recurrent motor branch of median nerve10 and to other structures in the neck such as vessels[11] and [12] resulting from massage have been reported. Further, various other types of injuries associated with massage including hematomas, pulmonary embolism, uterus rupture, and others are reported in the literature.13

Deep tissue massage applied to the neck was the possible inciting event in the case of our patient’s SAN. She started experiencing focal pain during massage and immediately after deep tissue massage; she noticed the impaired mobility of her arm, which she described as “my arm felt long and heavy.” This description of symptoms occurring immediately after the massage is consistent with SAN, which was subsequently identified by physical examination and confirmed by needle EMG.

In this case, the role of EMG in confirming the suspected clinical diagnosis was clearly demonstrated. Finding fibrillation potentials and reduced recruitment of MUPs in only the trapezius muscle confirmed the diagnosis. The role of EMG in predicting prognosis in this case was limited. The normal amplitude of the spinal accessory motor nerve response and the presence of MUPs in the upper trapezius muscle on needle examination at 3 weeks after onset confirmed nerve continuity and suggested limited axonal loss. These findings suggested a favorable prognosis for recovery. MRI of the shoulder served to rule out rotator cuff injury and muscle strain. Further, the MRI finding of diffuse edema in the trapezius muscle consistent with denervation confirmed probable SAN observed in EMG.