Studies Involving Surgery of the Spinal Accessory Nerve Plexus and Related Structures in the 20th Century Leading to the Present Conservative Approach
The best surgical minds of the 20th century were divided on the need to leave the spinal accessory nerve undamaged in surgical neck dissections for cancer. Perhaps some of the divergence of opinion was due to a spectrum of impairments seen by different observers from loss of that nerve. These impairments vary from minor to severe, depending on the composition of the spinal accessory nerve excised. In 1900, little had been published in the surgical literature about this varying composition, now known to be an important determinant of impairment (1).Early on, however, Crile in 1906 advocated leaving the nerve (24). Later, in 1944 Brown and McDowell (25) published their view that that nerve may need excision, but often it was unnecessary in an area not expected to be involved in cancer. Unfortunately, they did not state criteria for determining whether an area could be expected to be involved in cancer. They did add that the mandibular branch of the facial nerve should be removed in lip and tongue cancers. This latter procedure unhappily is not only disfiguring because it causes the corner of the mouth to droop, but also it is socially unacceptable because of constant drooling from inability to close the lips abetted by sensory loss. By 1951, Martin et al. (26) had again reversed course, writing that removal of the mandibular branch of the facial nerve need not be done, but that it was essential to remove the spinal accessory nerve. In 1976, Beahrs (27) did not advocate removal of the spinal accessory nerve without very good cause, but he also stated words to the effect that removal of the spinal accessory nerve was a small price to pay for a curative cancer operation. Patients losing that nerve, however, know the pain and disability that may accompany that loss, so that in their minds, its loss may not be a small price particularly because it may not be necessary to pay that price at all. Evidence published from a study of 967 patients (28) and confirmed a few years later (29) strongly suggested that removal of the spinal accessory nerve need not be done. Leaving it apparently had no adverse effect on outcome even if the nerve were involved with the cancer. The studies of Byers et al. (28) also gave good indication that in doing neck dissections, structures as the internal jugular vein, the sternocleidomastoid muscle and some of the lymph nodes very often could be left intact without influencing outcome.