University of Groningen

Morbidity after neck dissection in head and neck cancer patientsWilgen, Cornelis Paul van

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Publication date:2004

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Citation for published version (APA):Wilgen, C. P. V. (2004). Morbidity after neck dissection in head and neck cancer patients: a studydescribing shoulder and neck complaints, and quality of life. s.n.

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CHAPTER 1

INTRODUCTION

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A century after Crile (1906)

It is almost a century since Crile1 described the radical neck dissection forpatients with head and neck cancer. In that paper Crile complained about thelack of attention of other physicians concerning the surgical progress in thetreatment of head and neck cancer patients. Now, almost one hundred yearslater, many things have changed.In his historical paper Crile described, as one of the first, the importance ofremoving lymphatic structures of the neck (the complete lymphatic block orradical neck dissection) in head and neck cancer patients. In great detail hedescribed the anaesthesiology procedures, the surgical techniques, and thesacrificed structures, all illustrated with anatomical sketches. Additionally hedescribed complications like: infections, hemorrhage, shock and collapse. Inthis same paper an evaluation study was presented in which he comparedpatients operated with a radical neck dissection (n = 12) to patients in whichthe lymphatic structures were not removed (n = 48). Patients operated with aradical neck dissection had a survival rate that was four times higher thanpatients without a radical neck dissection. Crile’s paper is one of thekeystones of head and neck surgery, the radical neck dissection is still thesurgical standard against which various modifications are compared. Crile did not describe morbidity after surgery with radical neck dissection.Sacrificing the accessory nerve was not even mentioned in the text but onlyexplained in one of the sketches as one of the structures to be sacrificed.Almost 50 years after the paper of Crile, Ewing (1952) was one of the firstwho described morbidity after radical neck dissection.2 Several types ofmorbidity were mentioned: disfigurement, pain in the shoulder region, lossof strength, reduced range of motion, loss of function of the shoulder,sensory disturbance, and restrictions in daily activities. Up to 62 % of thepatients, operated with a radical neck dissection, had disfigurement of theshoulder and 46 % experienced shoulder pain. Other authors describedhigher incidences of shoulder complaints after radical neck dissection, evenup to 100 %.3 Shoulder complaints after radical neck dissection arecompletely attributed to sacrificing of the spinal accessory nerve. The high morbidity rates, and the gained insight in the biological behaviourof various cancer types, to estimate if a tumour has metastasised, led tomodifications on the classical radical neck dissection. Bocca (1980)

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described the functional neck dissection4, later to be called the modifiedradical neck dissection.5 In this modified radical neck dissection one or more of thefollowing non-lymphatic structures are preserved: spinal accessory nerve,sternocleidomastoideus muscle, and internal jugular vene. The spinalaccessory nerve seemed an important structure to preserve, in order toprevent shoulder morbidity. After modified radical neck dissections, withpreservation of the spinal accessory nerve, the prevalence of shouldercomplaints decreased, the prevalence rates were 18% to 61%.6,7 Furthermodifications in neckdissections were developed by removing only certainlevels of lymphatic structures, that are prone to metastasis, instead ofremoving all levels. Four selective neck dissections (figure 1) are described:supraomohyoid neckdissection (levels I, II, and III), lateral neckdissection(levels II,III, and IV) posterolateral neckdissection (levels II,III,IV,and V),and anterior neckdissection (level VI). 5 In these selective neckdissections allnon-lymphatic structures (spinal accessory nerve, sternocleidomastoideusmuscle, and internal jugular vene) are preserved. Supraomohyoid neckdissections are often performed in case of oropharyngeal squamous cellcarcinoma, with a N0 tumour status and possible sufficient in the treatmentof a selected group of patients with positive nodes at level I. 8,9

Figure 1 Classification of levels used for neck dissections (1a). Anatomical structures that cross the cervical lymphatic structures and lymph nodes (1b). Situation after a radical neck dissection (1c).

1 a 1 b 1c(pictures from Mondziekten & Kaakchirurgie, B. Stegenga, A. Vissink, LGM de Bont)

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Recently the classification of Robbins of 1991 has been updated. In this newclassification the levels have been further modified. The levels I, II and Vhave been split into two levels, and are to be called level I a/b, level II a/band level V a/b.10 (figure 2)

Figure 2 New classification described by Robbins et al. 2002 10

Morbidity after selective neck dissections has been described scarcely, andthe studies included relatively small samples.3,11,12 Pinsolle described a groupof 41 patients after supraomohyoid neckdissection of which 32% had minorproblems, 5 % moderate and 3 % severe shoulder problems. 13 Probablyshoulder morbidity rates have decreased further as a result of selectiveneckdissections, but the evidence is still limited.

Shoulder complains after neck dissection

Sacrificing the spinal accessory nerve

The spinal accessory nerve is a motor nerve, innervating thesternocleidomastoideus muscle and the trapezius muscle. Resection of thespinal accessory nerve leads to denervation of the trapezius muscle. Thetrapezius muscle exists of an upper, middle and lower part and has twomajor functions, shrugging the shoulder and stabilising the scapula on thethorax. Paralysis of the trapezius muscle will lead to a lateral gliding of thescapula and a lateral rotation.14 (figure 3)

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Figure 3 Lateral rotation of the scapula and changed shoulder joint position

As a consequence of the changed scapula position its possibility to moveduring shoulder movements decreases. As a consequence a reduced range ofmotion of the shoulder, abduction and forward flexion, appears. (figure 4) Areduced range of motion of the shoulder can cause dysfunction in activitiesin which the shoulder is needed like lifting heavy objects or reaching aboveshoulder level. 6,15 Several patients also complain about pain after head andneck cancer treatment. The exact cause of this pain is not properlyinvestigated. Several possible causes have been described like frozenshoulder16, sternoclavicular joint hypertrophy17, or myofascial pain as aconsequence of stretching of muscles due to the changed scapula position.18

But these hypothesised causes for shoulder pain have never beeninvestigated properly. Is some cases, after resection of the spinal accessory nerve, the trapeziusmuscle function remains (partly) intact. This is due to a double innervationby the cervical plexus of the musculus trapezius in about 18% of thepatients.14

Preservation of the spinal accessory nerve

Several patients after neck dissection with preservation of the spinalaccessory nerve still suffer from shoulder complaints. The mechanisms ofthe shoulder complaints after modified or selective procedures with sparringof the spinal accessory nerve are unclear.

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View from above

View from behind

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Figure 4 Scapula alata as a consequence of trapezius atrophy (4a) and a reduced abduction as a consequence of a changed scapula position (4b).

During neck dissection the spinal accessory nerve is lifted from itssurrounding structures, and its supplying blood vessels are dissected whichmay result in a neuropraxia or the nerve may be dissected accidentally whichresults in a neurotmesis (permanent deficit). In these cases preservation orpresumed preservation leads to spinal accessory nerve dysfunction and as aconsequence shoulder complaints. But with an intact spinal accessory nerveand trapezius muscle function still shoulder complaints may arise which areinterpreted as neuropathic pain or myofascial pain.19 Unfortunately littleresearch has been done to substantiate these hypothesis whereas it is of greatclinical importance for treatment possibilities.

More morbidity after head and neck cancer treatmentBeside shoulder complaints patients may suffer from other types ofmorbidity. Little is known about morbidity of the neck after head and neckcancer treatment. Clinically several patients complain about loss ofsensation, pain, or a reduced range of motion of the cervical spine. Inliterature only a few papers describe this morbidity.19,20,21 These studies areperformed on small samples, often without a physical examination.Consequences of neckdissection with or without radiation therapy on range

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4a 4b

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of motion of the cervical spine are only described in studies that usedquestionnaires without actually measuring range of motion.22 Loss ofsensation is thoroughly described in only one study by Saffold,23 althoughthat study was primarily aiming at the results of the preservation of cervicalroot branches in selective neck dissections. The influence of radiation therapy on loss of sensation, and range of motionis scarcely described, although clinically patients seem to suffer fromfibrosis of soft tissues which decreases range of motion. Pain is probably the most important type of morbidity of patients after headand neck cancer treatment. As mentioned before some hypotheses exist ashow to explain post cancer treatment pain. Pain can be explained asneuropathic pain, pain in the clavicular or acromio-clavicular joint (probablynociceptive) and myofacial pain. The causes of pain are still hardly studiedbut clinically important for treatment modalities. Treatment modalities mightbe medication, physical therapy, and informing patients.

Psychological consequences after head and neck cancer therapyAfter head and neck cancer treatment also psychological consequences aredescribed. Beside the physical morbidity, psychological as well as socialproblems have their effect on well being and quality of life. 24 Psychologicalconsequences may be depression,25 distress,26 fear of recurrence,27

inadequate coping strategies28 problems in reintegration in work and lack ofsocial support.29 After cancer treatment depression is, with a prevalence of24 % (range 1.5 % - 50 %), an important psychological morbidity.30

Depression has a construct in which physical and psychological domains arecombined. Depression effects survival, recovery, treatment compliance, painand quality of life.31,32 Therefor depression should be assessed adequately inthe post treatment phase.33 Most studies describe psychological morbiditywithout taking physical morbidity into account. Especially in head and neckcancer patients both factors seem to be related. Therefor more studies areneeded in which psychological as well as physical morbidity are analysed. Head and neck cancer and rehabilitationIn the Netherlands 60.000 new patients are yearly diagnosed with cancer.34

About 10 % of these patients, mostly man, are diagnosed with head and neckcancer.35Although mortality rates for head and neck cancer patients are still

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high, through early diagnosis and better treatment possibilities more patientswill survive cancer.36 In the last decade attention has been given to postcancer treatment rehabilitation.37,38 The last year’s treatments are more oftenmultidimensional, aiming on physical and psychological problems. Theseprograms are executed in groups to gain from peer support of fellow cancerpatients.39

Specific physical therapy programs for patients with shoulder complaintsafter neck dissections are proposed since 1976. (appendix 2) Only one studyis performed as a controlled trial.40 Physical therapy programs differ incontent and aims. Most programs aim at gaining a full, active and passive,range of motion, strengthening of shoulder muscles to stabilise the shoulder,and training shoulder function in activities in daily life. Besides exercises aphysical therapy progam may contain, relaxation or massage. Most programsare developed because of assumed spinal accessory nerve dysfunction.Several authors claim good results, but only the study of Salerno used acontrol group.40 She showed that physical therapy can be helpful in therehabilitation after neck dissection for shoulder complaints. Neverthelessbefore setting up a program more insight in the exact morbidity after headand neck cancer treatment should be achieved to known where the programshould focus on.

Aim of our studyIn this thesis we are aiming at more insight in morbidity after head and neckcancer treatment (resection of the primary tumour, neck dissection and pre-or post-operative radiation therapy). We will study shoulder complaints andthe role of the spinal accessory nerve, pain and the underlying painmechanisms, range of motion, and loss of sensation. The consequences ofdysfunction such as shoulder disability and activities of daily living, but alsopsychological problems (depression) and quality of life will be analysed.This thesis aims at a better understanding of consequences of type of neckdissection, especially the supraomohyoid neck dissection and the influenceof radiation therapy. A better understanding of morbidity after cancertreatment must lead to specific rehabilitation treatment options in the nearfuture.

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References1. Crile G. Excision of cancer of the head and neck. JAMA 1906;47:1780-

1786.2. Ewing MRMH. Disability following radical neck dissection. Cancer

1952;5:873-883.3 Cheng PT, Hao SP, Lin YH, Yeh AR. Objective comparison of shoulder

dysfunction after three neck dissection techniques. Ann. Otol. Rhinol.Laryngol. 2000;109:761-766.

4. Bocca E, Pignataro O, Sasaki CT. Functional neck dissection. A descriptionof operative technique. Arch.Otolaryngol. 1980;106:524-527.

5. Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW.Standardizing neck dissection terminology. Official report of theAcademy's Committee for Head and Neck Surgery and Oncology.Arch.Otolaryngol.Head Neck Surg. 1991;117:601-605.

6. Short SO, Kaplan JN, Laramore GE, Cummings CW. Shoulder pain andfunction after neck dissection with or without preservation of the spinalaccessory nerve. Am.J.Surg. 1984;148:478-482.

7. Carenfelt C, Eliasson K. Occurrence, duration and prognosis of unexpectedaccessory nerve paresis in radical neck dissection. Acta Otolaryngol.1980;90:470-473.

8. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale,indications, and surgical technique. Head Neck 1989;11:111-122.

9. Kowalski LP, Magrin J, Waksman G, Santo GF, Lopes ME, de Paula RP,Pereira RN, Torloni H. Supraomohyoid neck dissection in the treatment ofhead and neck tumors. Survival results in 212 cases.Arch.Otolaryngol.Head Neck Surg. 1993;119:958-963.

10. Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, SomP, Wolf GT. Neck dissection classification update: revisions proposed bythe American Head and Neck Society and the American Academy ofOtolaryngology-Head and Neck Surgery. Arch.Otolaryngol.Head NeckSurg. 2002;128:751-758.

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13. Pinsolle V, Michelet V, Majoufre C, Caix P, Siberchicot F, Pinsolle J.[Spinal accessory nerve and lymphatic neck dissection.Rev.Stomatol.Chir.Maxillofac. 1997;98:138-142.

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15. Shone GR, Yardley MP. An audit into the incidence of handicap afterunilateral radical neck dissection. J.Laryngol.Otol. 1991;105:760-762.

16. Patten C, Hillel AD. The 11th nerve syndrome. Accessory nerve palsy oradhesive capsulitis? Arch.Otolaryngol.Head Neck Surg. 1993;119:215-220.

17. Cantlon GE, Gluckman JL. Sternoclavicular joint hypertrophy followingradical neck dissection. Head Neck Surg. 1983;5:218-221.

18. Nori S, Soo KC, Green RF, Strong EW, Miodownik S. Utilization ofintraoperative electroneurography to understand the innervation of thetrapezius muscle. Muscle Nerve 1997;20:279-285.

19. Sist T, Miner M, Lema M. Characteristics of postradical neck painsyndrome: a report of 25 cases. J.Pain Symptom.Manage. 1999;18:95-102.

20. Chaplin JM, Morton RP. A prospective, longitudinal study of pain in headand neck cancer patients. Head Neck 1999;21:531-537.

21. Shah S, Har-El G, Rosenfeld RM. Short-term and long-term quality of lifeafter neck dissection. Head Neck 2001;23:954-961.

22. Schuller DE, Reiches NA, Hamaker RC, Lingeman RE, Weisberger EC,Suen JY, Conley JJ, Kelly DR, Miglets AW. Analysis of disability resultingfrom treatment including radical neck dissection or modified neckdissection. Head Neck Surg. 1983;6:551-558.

23. Saffold SH, Wax MK, Nguyen A, Caro JE, Andersen PE, Everts EC, CohenJI. Sensory changes associated with selective neck dissection.Arch.Otolaryngol.Head Neck Surg. 2000;126:425-428.

24. White CA, Macleod U. Cancer. BMJ 2002;325:377-380.25. de Leeuw JR, de Graeff A, Ros WJ, Blijham GH, Hordijk GJ, Winnubst

JA. Prediction of depressive symptomatology after treatment of head andneck cancer: the influence of pre-treatment physical and depressivesymptoms, coping, and social support. Head Neck 2000;22:799-807.

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28. Petticrew M, Bell R, Hunter D. Influence of psychological coping onsurvival and recurrence in people with cancer; systematic review. BMJ2002;325:1066-1076.

29. Hassanein KA, Musgrove BT, Bradbury E. Functional status of patientswith oral cancer and its relation to style of coping, social support andpsychological status. Br.J.Oral Maxillofac.Surg. 2001;39:340-345.

30. Hann D, Winter K, Jacobsen P. Measurement of depressive symptoms incancer patients: evaluation of the Center for Epidemiological StudiesDepression Scale (CES-D). J.Psychosom.Res. 1999;46:437-443.

31. Hjerl K, Andersen EW, Keiding N, Mouridsen HT, Mortensen PB,Jorgensen T. Depression as a prognostic factor for breast cancer mortality.Psychosomatics 2003;44:24-30.

32. Krishnan KR, Delong M, Kraemer H, Carney R, Spiegel D, Gordon C,McDonald WI, Dew MA, Alexopoulos G, Buckwalter K, Cohen PD, EvansD, Kaufmann PG, Olin J, Otey E, Wainscott C. Comorbidity of depressionwith other medical diseases in the elderly. Biological Psychiatry 2002;Vol52:559-588.

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35. Netherlands Cancer Registry. Head and Neck tumours in the Netherlands1989-1995. Lulof Almelo, 1998.

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curative therapy. Support.Care Cancer 2002;10:281-291.39. Weert van E, Hoeksta-Weebers JEHM, Grol BMF, Otter R, Arendzen JH,

Postema K, Schans van der CP. Physical functioning and quality of lifeafter cancer rehabilitation Int. J. Rehab.Res. 2004;27: 27-35.

40. Salerno G, Cavaliere M, Foglia A, Pellicoro DP, Mottola G, Nardone M,Galli V. The 11th nerve syndrome in functional neck dissection.Laryngoscope 2002;112:1299-1307.

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