2b or not 2b? Shoulder function after level 2b neck dissection: A double-blind randomized controlled clinical trial

Peter T Dziegielewski, Margaret L McNeely, Nigel Ashworth, Daniel A O'Connell, Brittany Barber, Kerry S Courneya, Brock J Debenham, Hadi Seikaly, Peter T Dziegielewski, Margaret L McNeely, Nigel Ashworth, Daniel A O'Connell, Brittany Barber, Kerry S Courneya, Brock J Debenham, Hadi Seikaly

Abstract

Background: Selective neck dissection (SND) is a mainstay of head and neck cancer treatment. A common sequela is shoulder syndrome from spinal accessory nerve (SAN) trauma. Extensive dissection in neck levels 2 and 5 leads to SAN dysfunction. However, it is not known whether limited level 2 dissection reduces SAN injury. The purpose of this double-blind randomized controlled trial was to determine whether omitting level 2b dissection would improve shoulder-related quality of life and function.

Methods: Patients with head and neck cancers undergoing surgery were randomized 1:1 to SND without level 2b dissection (group 1) or with it (group 2) on their dominant-hand side. Patients, caregivers, and assessors were blinded. The primary outcome was the change in the Neck Dissection Impairment Index (NDII) score after 6 months. An a priori calculation of the minimally important clinical difference in the NDII score was determined to establish a sample size of 15 patients per group (power = 0.8). Secondary outcomes included shoulder strength and range of motion (ROM) and SAN nerve conduction. The trial was registered at ClinicalTrials.gov (NCT00765791).

Results: Forty patients were enrolled, and 30 were included (15 per group). Six months after the surgery, group 2 demonstrated a significant median decrease in the NDII from the baseline (30 points) and in comparison with group 1, whose NDII dropped 17.5 points (P = .02). Shoulder ROM and SAN conduction demonstrated significant declines in group 2 (P ≤ .05). No adverse events occurred.

Conclusions: Level 2b should be omitted in SND when this is oncologically safe and feasible. This allows for an optimal balance between function and cancer cure.

Keywords: head and neck cancer; neck dissection; quality of life; shoulder dysfunction; shoulder syndrome; spinal accessory nerve.

© 2019 American Cancer Society.

References

    1. Crile G III. On the technique of operations upon the head and neck. Ann Surg. 1906;44:842-850.
    1. Schmitz S, Machiels JP, Weynand B, Gregoire V, Hamoir M. Results of selective neck dissection in the primary management of head and neck squamous cell carcinoma. Eur Arch Otorhinolaryngol. 2009;266:437-443.
    1. Gane EM, Michaleff ZA, Cottrell MA, et al. Prevalence, incidence, and risk factors for shoulder and neck dysfunction after neck dissection: a systematic review. Eur J Surg Oncol. 2017;43:1199-1218.
    1. Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Otolaryngol. 1961;74:424-428.
    1. Taylor RJ, Chepeha JC, Teknos TN, et al. Development and validation of the Neck Dissection Impairment Index: a quality of life measure. Arch Otolaryngol Head Neck Surg. 2002;128:44-49.
    1. Chepeha DB, Taylor RJ, Chepeha JC, et al. Functional assessment using Constant's Shoulder Scale after modified radical and selective neck dissection. Head Neck. 2002;24:432-436.
    1. Remmler D, Byers R, Scheetz J, et al. A prospective study of shoulder disability resulting from radical and modified neck dissections. Head Neck Surg. 1986;8:280-286.
    1. Parikh S, Tedman BM, Scott B, Lowe D, Rogers SN. A double blind randomised trial of IIb or not IIb neck dissections on electromyography, clinical examination, and questionnaire-based outcomes: a feasibility study. Br J Oral Maxillofac Surg. 2012;50:394-403.
    1. Koybasioglu A, Bora Tokcaer A, Inal E, Uslu S, Kocak T, Ural A. Accessory nerve function in lateral selective neck dissection with undissected level IIb. ORL J Otorhinolaryngol Relat Spec. 2006;68:88-92.
    1. Koybasioglu A, Tokcaer AB, Uslu S, Ileri F, Beder L, Ozbilen S. Accessory nerve function after modified radical and lateral neck dissections. Laryngoscope. 2000;110:73-77.
    1. Celik B, Coskun H, Kumas FF, et al. Accessory nerve function after level 2b-preserving selective neck dissection. Head Neck. 2009;31:1496-1501.
    1. Hoyt BJ, Smith R, Smith A, Trites J, Taylor SM. IIb or not IIb: oncologic role of submuscular recess inclusion in selective neck dissections. J Otolaryngol Head Neck Surg. 2008;37:689-693.
    1. Dziegielewski PT, O’Connell DA, Szudek J, et al. Neck metastases in oropharyngeal cancer: necessity and extent of bilateral treatment. Head Neck. 2013;35:1461-1467.
    1. Smith R, Taylor SM, Trites JR, Smith A. Patterns of lymph node metastases to the submuscular recess. J Otolaryngol. 2007;36:203-207.
    1. Rogers SN, Lowe D, Paleri V. A survey of head and neck surgical oncologists regarding the inclusion of level IIb in a neck dissection of the node negative neck. Br J Oral Maxillofac Surg. 2011;49:230-232.
    1. Cappiello J, Piazza C, Nicolai P. The spinal accessory nerve in head and neck surgery. Curr Opin Otolaryngol Head Neck Surg. 2007;15:107-111.
    1. Villaret AB, Piazza C, Peretti G, et al. Multicentric prospective study on the prevalence of sublevel IIb metastases in head and neck cancer. Arch Otolaryngol Head Neck Surg. 2007;133:897-903.
    1. Elsheikh MN, Rinaldo A, Ferlito A, et al. Elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma: is dissection of sublevel IIB necessary? Oral Oncol. 2008;44:216-219.
    1. Giordano L, Sarandria D, Fabiano B, Del Carro U, Bussi M. Shoulder function after selective and superselective neck dissections: clinical and functional outcomes. Acta Otorhinolaryngol Ital. 2012;32:376-379.
    1. Orhan KS, Demirel T, Baslo B, et al. Spinal accessory nerve function after neck dissections. J Laryngol Otol. 2007;121:44-48.
    1. Mendez A, Seikaly H, Ansari K, Murphy R, Cote D. High definition video teaching module for learning neck dissection. J Otolaryngol Head Neck Surg. 2014;43:7.
    1. O’Connell DA, Barber B, Klein MF, et al. Algorithm based patient care protocol to optimize patient care and inpatient stay in head and neck free flap patients. J Otolaryngol Head Neck Surg. 2015;44:45.
    1. McNeely ML, Parliament M, Courneya KS, et al. A pilot study of a randomized controlled trial to evaluate the effects of progressive resistance exercise training on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in head and neck cancer survivors. Head Neck. 2004;26:518-530.
    1. McNeely ML, Parliament MB, Seikaly H, et al. Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: a randomized controlled trial. Cancer. 2008;113:214-222.
    1. Goldstein DP, Ringash J, Bissada E, et al. Evaluation of shoulder disability questionnaires used for the assessment of shoulder disability after neck dissection for head and neck cancer. Head Neck. 2014;36:1453-1458.
    1. Buschbacher RM, Kumbhare DA, Robinson LR. Buschbacher's Manual of Nerve Conduction Studies. Demos Medical; 2016.
    1. Dumitru D, Amato AA, Zwarts MJ. Electrodiagnostic Medicine. Hanley & Belfus; 2002.
    1. Liveson JA, Ma DM. Laboratory Reference for Clinical Neurophysiology. FA Davis; 1992.
    1. McNeely ML, Parliament MB, Seikaly H, et al. Predictors of adherence to an exercise program for shoulder pain and dysfunction in head and neck cancer survivors. Support Care Cancer. 2012;20:515-522.
    1. McNeely ML, Parliament MB, Seikaly H, et al. Sustainability of outcomes after a randomized crossover trial of resistance exercise for shoulder dysfunction in survivors of head and neck cancer. Physiother Can. 2015;67:85-93.
    1. Revicki D, Hays RD, Cella D, Sloan J. Recommended methods for determining responsiveness and minimally important differences for patient-reported outcomes. J Clin Epidemiol. 2008;61:102-109.
    1. Rai SK, Yazdany J, Fortin PR, Avina-Zubieta JA. Approaches for estimating minimal clinically important differences in systemic lupus erythematosus. Arthritis Res Ther. 2015;17:143.
    1. Guldiken Y, Orhan KS, Demirel T, Ural HI, Yucel EA, Deger K. Assessment of shoulder impairment after functional neck dissection: long term results. Auris Nasus Larynx. 2005;32:387-391.
    1. Patel KN, Shah JP. Neck dissection: past, present, future. Surg Oncol Clin N Am. 2005;14:461-477, vi.
    1. Lima LP, Amar A, Lehn CN. Spinal accessory nerve neuropathy following neck dissection. Braz J Otorhinolaryngol. 2011;77:259-262.
    1. Laverick S, Lowe D, Brown JS, Vaughan ED, Rogers SN. The impact of neck dissection on health-related quality of life. Arch Otolaryngol Head Neck Surg. 2004;130:149-154.
    1. Selcuk A, Selcuk B, Bahar S, Dere H. Shoulder function in various types of neck dissection. Role of spinal accessory nerve and cervical plexus preservation. Tumori. 2008;94:36-39.
    1. Bhattacharya A, Adwani D, Adwani N, Sharma V. Is it worthy? Removal of level IIB nodes during selective neck dissection (I-III) for oral carcinomas. Ann Maxillofac Surg. 2015;5:20-25.
    1. Bartella AK, Kloss-Brandstatter A, Kamal M, et al. “IIb or not IIb”-the necessity of dissection in patients with oral squamous cell carcinoma. J Craniomaxillofac Surg. 2016;44:1733-1736.
    1. 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.
    1. Paleri V, Kumar Subramaniam S, Oozeer N, Rees G, Krishnan S. Dissection of the submuscular recess (sublevel IIb) in squamous cell cancer of the upper aerodigestive tract: prospective study and systematic review of the literature. Head Neck. 2008;30:194-200.

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