Lupine Publishers | Otolaryngology Journal
Neck dissection is a complex surgical procedure which leaves multiple consequences on the person to whom it is made. The aim
was to measure the degree of damage to neck and shoulders motor function in patients who underwent neck dissection.
Materials and methods: 30 subjects divided into two groups
depending on the dissection made (16 (53.3%) of selective and
14 (46.6% radical) accounted for both sexes (3 (10% of women and 27
(90%) of men) in average age of 64.2 years who underwent
neck dissection. Digital goniometer was used to measure subject’s
maximum range of motion on 7 variables (4 variables for the neck
movements and 3 variables for the shoulder movements), of which 5 were
bilateral. The results are ranked with in the category of
a certain degree of damage depending on the standardized values of the
maximum amplitude at the non-operated population with
normal function of motion.
Results: Significant difference was found in the values of the amplitude of shoulder flexion, extension and abduction between
groups at a significance level of 5% and in the confidence interval of 95%.
Conclusion: Rehabilitation is necessary after neck dissection and kinesiotherapy can be an important rehabilitation method
for patients.
Keywords: Neck Dissection; Neck Motion Amplitude; Range of Motion; Rehabilitation; Shoulder Motion Amplitude.
Abbreviations: SND: Selective Neck Dissection; RND: Radical Neck Dissection; NF: Neck Flexion; NE: Neck Extension; NR: Neck
Rotation; NLF: Neck Lateral Flexion; SF: Shoulder Flexion; SE: Shoulder Extension; SA: Shoulder Abduction; N: Number of Samples;
x: Arithmetic Mean; SD: Standard Deviation; t: T value; df: Degree Of Freedom; F: F value; p: P value.
Dissection is a very complex surgical procedure on the neck
where the most of vital structures of the front and lateral sides
of the neck are and is carried out independently or with a basic
procedure in patients with malignant head and neck tumors. It is
done to treat regional metastases on neck lymph nodes. There are
several types of dissection, depending on the surgical approach.
Selective neck dissection includes one or more regions of the
lymph nodes, depending on the localization of primary tumors.
Radical dissection includes the lymph nodes within all five neck
regions, removal of internal jugular vein, sternocleidomastoid
muscle, and accessory nerve. Modified radical dissection involves
removing lymph nodes of all five neck regions with exemption of
one or more non lymphatic structures [1]. Preserving the nerve
does not necessarily imply its normal function. Dissection leads
to loss of motor strength, muscle volume and sensation. Some
of the consequences are painful and lowered shoulder, neck,
shoulder or upper chest insensitivity, neck pain, decreased neck
and shoulders mobility, inability or difficulty in raising hands above
the head, reduced arm strength, and Horner’s syndrome [2-4]. Such functional impairment is not uncommon, and out of the total
number, 5% of damage occurs by chance [5]. Dysfunction comes
to the fore in the later postoperative course which significantly
determines the physical and social functioning, reduces working
capacity and affects the quality of life [6]. Primary rehabilitation is
carried out directly after the surgical procedure in a hospital, the
secondary should be carried out after the release in order to further
improve and tertiary in order to maintain the achieved condition.
These patients have rarely been sent to a specialized facility after
hospitalization so few exercise by themselves at home, and most
do not exercise at all [6]. Normal values of the amplitude of neck
flexion range from 0–100°, extensions from 0 to 25°, lateral flexions
to the left and right sides from 0 to 40°, and neck rotation to both
sides from 40° to 45°. Normal values of the amplitude of shoulder
flexion are 100° and more, the shoulder extensions 60° or more, and
shoulder abduction from 160° to 180° [7]. Kinesiotherapy, which
uses movement to mobilize existing physiological mechanisms
and function, can be an important method for the rehabilitation
of certain pathological conditions arising as a result of a surgical
procedure. Exercising under the expert guidance and supervision
of a kinesiotherapists, allows patients the establishment of optimal
motor functions according to the anatomical and functional damage
and thus easier return to the life or work environment. According
to the current available data, within an interdisciplinary team for
treating head and neck cancers, as well as for the rehabilitation of
the consequences of surgical treatment of diseases, a specialist of
this profile is not detected.
Study design
This is a cross-sectional study which included the initial
measurement of the movement range of neck and shoulder after
neck dissection and before rehabilitation.
Ethical procedures
The procedures were performed according to the Declaration
of Helsinki and approved by the Ethics Committee of the University
Hospital Center Osijek on January 23th, 2017, under the protocol
number R2-10203/2017. The participants signed informed consent
to participate in the research.
Setting
The study was conducted at the Department of
Otorhinolaryngology and Head and Neck Surgery in University
Hospital Centre Osijek during 2017 on patients with head and neck
tumors.
Participants
A sample of 30 patients consisted of both sexes, 3 (10%) women
and 27 (90%) men, average age of 64.2 years. The study included
people who underwent neck dissection for malignant diseases of
the throat, and excluded people who preoperatively had reduced
mobility and / or soreness of neck and shoulder of different
etiology. Subjects were divided into two groups depending on the
type of dissection: the first group consisted of 16 (53.3%) subjects
who underwent selective dissection, and the other 14 (46.6%)
subjects who underwent radical dissection.
Measurement and variables
Digital goniometer (Warenhandel GmbH & Co., Germany)
was used to measure subject’s maximum amplitude of neck
and shoulders motions. Total of seven variables was measured:
4 variables for the neck movements - flexion, extension and
rotation and lateral flexion bilaterally and 3 variables for shoulder
movements - flexion, extension and abduction bilaterally. The
obtained data were compared to standardized values of maximum
amplitude in individuals with normal function, and between groups.
For ease of processing, depending on the level of the maximum
amplitude, the results were scored and ranked in five groups
where 1 means complete function reduction, 2 heavy reduction, 3
moderate reductions, 4 light reduction, and 5 normal function. The
categorization of each individual movement was done in a way that
the maximum value of the amplitude was divided by five to obtain
the same class limits.
Statistical methods
Data were statistically analyzed using Statistical Package for
the Social Science for Windows (SPSS Inc. 16.0, Chicago, IL, SAD).
A descriptive analysis of the data was performed, resulting in
frequencies and percentages. From nominal and ordinal variables
the analysis of variance for independent samples was performed,
and the normality of distribution was tested with Kolmogorov-
Smirnov test.
On variables of neck flexion 10 subjects have a preserved
amplitude of movement (33.3%), 20 have a light dysfunction
(66.6%), and moderate/severe dysfunction or complete loss of
function is not recorded in any subjects. On the variables of neck
extension 4 (13.3%) subjects have a proper amplitude of movement,
17 (56.6%) have a light reduction in amplitude, 7 (23.3%) have
moderate, and 2 (6.6%) severe reduction in amplitude. Also, no
patients with complete inability of movement were recorded. On
the variable of neck rotation to both sides most subjects, 10 of them
(33.3%), have a moderate dysfunction of movement, 9 (30%) have
severe, and 7 (23.3%) light dysfunction (Table 1).
No patients with absolute impossibility of neck rotation were
recorded, and 4 of them (13.3%) have a preserved movement
function. In lateral neck flexion proper amplitude have 7 (23.3%)
of subjects, and 2 of them (6.6%) have a complete loss. 9 (30%)
subjects, most of them, have moderate deviation, 8 (26.6%) have
light deviation, and 4 (13.3%) have a severe deviation. On variables
of shoulder flexion most subjects have a light dysfunction, 14 of
them (46.6%), followed by 11 (36.6%) with moderate dysfunction
and 2 (6.6%) subjects with severe dysfunction. 3 (10%) subjects
have a proper shoulder flexion movement, and none of the subjects
has a complete loss of function. Regarding the shoulder extension,
proper movement, loss of function and severe dysfunction have 3
(10%) of subjects. Most of them have a moderate dysfunction, 11
of them (36.6%), followed by 10 (33.3%) with severe dysfunction.
None of the subjects has a preserved function of shoulder
abduction, as well as light dysfunction. 3 (10%) subjects have a
complete loss of function, 12 (40%) have a severe dysfunction,
and 15 (50%) a moderate dysfunction. All subjects had a constant
feeling of pain in the neck and a significant pain in shoulder, feeling
of tightness while initiating movement, and 7 (23.3%) of them, who
underwent radical dissection, had a significantly lowered shoulder
and spinal pain (Table 1). Analysis of variance, on the variables
of neck movement in all directions (flexion, extension, rotation
and lateral flexion) showed no statistically significant difference
between subjects with selective or radical neck dissection, while
on the variables of shoulder movement (bilateral flexion, extension
and abduction) a statistically significant difference between groups
was determined, at a significance level of 5% in the confidence
interval of 95%.
Table 1:
The results indicate a very frequent extensive reduction of
shoulder functions as confirmed by the results of previous studies
[8,9]. The study which included 65 subjects showed that 77% of
subjects had a shoulder dysfunction of different degree and 23%
of subjects had a preserved shoulder function [10]. Milenović et al.
[2] examined the loss of function of the brachial plexus on the basis
of the presence of pain and weakness in the shoulder, arm or hand,
and the possibility of shoulder abduction, and 14% of subjects
had a preserved function of the respected nerve. The cause of this
dysfunction is usually the manipulation of spinal nerves which
secondarily results in an atrophy of trapeziums [11,12]. Partially
there is always a preserved function of shoulder regardless of
nerve damage, because the lower part of the trapeziums muscle
is innervated by C2–C4 nerves. In a study by Spiro et al. [13]
13% of subjects with a resection of n. vagus after radical neck
dissection were recorded, and bilateral paralysis of the diaphragm
was recorded by Yaddanapudi et al. [14,15]. In 15% of cases with
preserved nerve dysfunction of movement occurs due to high
sensitivity and small dimensions of the nerve during preparation.
Milenović et al. [2] & Jong et al. [12] during their research found
no significant difference in motor nerves function depending on
the type of dissection made, but they examined nerve function
neurologically, without taking into account further motor function
of the muscle innervated by the examined nerve [10,11].
The main limiting factor is a small sample. There is also a
problem of additional homogenization of groups because each type
of neck dissection has subsets.
This study showed the highest or significant reduction in
amplitude in an attempt of shoulder abduction where the degree
of damage varied from moderate and severe to complete. This is
the only variable without subjects with completely normal function
or light dysfunction. Also, on the same variable statistically most
significant difference between subjects who underwent selective
or radical dissection was found. The best preserved amplitude
was measured during the neck flexion regardless of the type of
dissection made, where a statistically significant difference between
groups was not found. However, these results should be interpreted
with caution due to the relatively small sample size, the complexity
of neck dissection and a large number of dependent variables that
have a potential impact on the measured variable. Daily continuous
exercise can alleviate the consequences of this mutilating procedure
and the results of exercise would certainly be better if the exercises
for strengthening the neck muscles and shoulder area would be
performed individually under the supervision of a kinesiotherapist.
Back in the 1981 Tissot wrote that the movement can replace any
medical therapeutic remedy while the remedies cannot replace
movement.
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