(Kiosk 2) Insidious Asymmetric Shoulder Weakness After Hodgkin's Lymphoma Treatment: A Case Study

Case Diagnosis: A young patient, after lymph node excisional biopsy, elected to not be evaluated for treatment after increasing weakness in his right shoulder until neurorestorative window had passed and desired no surgical treatment for isolated spinal accessory nerve palsy.

Case Description or Program Description: A 29-year-old male with a history of Hodgkin's lymphoma was referred to the Physical Medicine and Rehabilitation (PM&R) clinic for evaluation of right shoulder pain and weakness of unknown etiology. Past surgical history was significant for an excisional cervical lymph node biopsy, for which the presenting scar overlies the course of the right spinal accessory nerve. Electromyography (EMG) of the right spinal accessory motor nerve revealed prolonged onset latency and 97% reduction in amplitude when compared to the left side. The patient’s lymph node biopsy occurred 29 months prior to presenting to our clinic, which placed him outside the window for attempting neurorestorative procedures. Rather than attempting more aggressive surgery, he opted to pursue rehabilitation and therapy to correct right shoulder muscle imbalances and improve postural support.

Setting: Outpatient setting

Assessment/Results: Patient was prescribed PT with plan to focus on synergistic muscles to preserve scapulothoracic moment in right upper extremity. Patient completed course with great reduction in pain, improved ROM, and more full participation in ADL's.

Discussion (relevance): Little research has been performed regarding conservative treatment and rehabilitation for isolated spinal accessory nerve palsies. Conservative treatment with physical therapy and compensatory movements can provide benefit to this population if other surgical intervention is not desired and neurorestorative window has passed.

Conclusions: We experienced a rare case of spinal accessory nerve palsy by iatrogenic cause that presented to our clinic for EMG evaluation 29 months after injury. PM&R can play a pivotal role in early identification of these injuries for prompt surgical intervention if indicated. There is room to identify ideal conservative treatment protocol for individuals who do not desire surgery after the neurorestorative window has passed.