What is a Neck Dissection and Why is it Performed?

Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck.

Lymph nodes are small, bean shaped glands scattered throughout the body that filter and process lymph fluid from other organs. The immune cells in the lymph nodes help the body fight infection. When cancer cells spread from another part of the body, they may get caught in a lymph node where they grow. One may feel a lump in the neck. The cancer in the lymph node is known as a metastasis. When someone undergoes surgery for cancer that has spread to lymph nodes, both the primary cancer as well as the metastases must be removed.

Neck dissection refers to the removal of lymph nodes and surrounding tissue from the neck for the purpose of cancer treatment. The degree of tissue removal depends on many factors including the stage of disease, which reflects the extent of cancer, as well as the type of cancer. The most common cancers removed from lymph nodes in the neck include head and neck squamous cell carcinomas, skin cancers including melanoma, and thyroid cancers. In general, the goal of neck dissection is to remove all the lymph nodes within a predefined anatomic area. Many of the lymph nodes removed during surgery will not prove to have cancer in them.

A cancer may spread any number of cancer metastatic deposits that lodge in lymph nodes and grow. There are over 150 lymph nodes on each side of the neck. During an operation, a surgeon will not be able to tell if a lymph node is clean, or if it has cancer that will later grow in to a visible neck lump. The lymph nodes must be processed and tested; this takes time. For that reason, it is recommended that the lymph nodes in a pre-determined regions are removed, not just the lymph nodes that are obviously enlarged with cancer.

One cancer spreads differently than another. Skin cancers first spread to lymph nodes in different parts of the neck than thyroid cancers or oral cavity or larynx cancers. Squamous cell carcinomas that start in the lining or mucosa of the mouth, throat or larynx have a tendency to spread to lymph nodes early; cancer cells can often be detected in lymph nodes in the neck when examined by CT, MRI or PET/CT, even in the absence of visible or palpable neck lumps.

Lymph node metastasis reduces the survival of patients with squamous cell carcinoma by half. The survival rate is less than 5% in patients who previously underwent surgery and have a recurrent metastasis in the neck. Therefore, the control of cancer that has spread to the neck is one of the most important aspects in the successful management of these particular cancers. The neck dissection is a standardized procedure that was developed to ensure the complete removal of cancer that has spread to the lymph nodes of the neck.

Radical vs. Radical vs. Modified Neck Dissection

Radical Neck Dissection

• This operation has been used for almost 100 years anddescribes the removal of lateral neck nodes and tissues tosurgically remove cancer in the neck. Included in this tissue, which extends from the collarbone (clavicle) inferiorly to the jawbone (mandible) superiorly are dozens of lymph nodes. In addition to lymph nodes, this operation often includes removal of the submandibular gland (a saliva-producing gland in the upper neck), the sternocleidomastoid muscle, the jugular vein and the spinal accessory nerve (to the trapezius muscle).
• The radical neck dissection was designed to ensure completecancer removal in individuals with very advanced cancers inthe neck. The radical neck dissection is effective but producescharacteristic cosmetic changes. Because so much tissue isremoved, one side of the neck may appear flatter than theother. More importantly, sacrifice of the nerve to the trapeziusmuscle results in visible drooping of the shoulder and difficultyin raising the arm over-head. Some individuals develop painin the neck and collarbone. An intensive physical therapyprogram may diminish some of these problems, but somelong-term disability can be anticipated. Historically, radical neck dissections were the most commonlyperformed type of neck dissection performed by surgeons.This is no longer the case. Most patients are candidates for aless radical operation.

Modified Radical Neck Dissection

• This term describes a variety of neck dissections thatpreserve structures that are usually sacrificed in the radicalneck dissection such as the spinal accessory nerve, theinternal jugular vein or sternocleidomastoid muscle. Further,selective neck dissections are neck dissections that, inaddition to preserving these important structures, are used toremove specific groups of lymph nodes, rather than all the lumph nodes on the side of the neck, based on the probability that those lymph nodes contain cancer.
• While radical neck dissections produce the greatest changesin cosmetic appearance and shoulder function, selective neckdissections produce the least. In fact, selective neckdissections frequently produce no obvious cosmetic changes,yielding a nearly invisible scar. Nevertheless, strength andflexibility may be enhanced with adherence to neck andshoulder range of motion exercises after surgery. The bestresults can be expected with faithful adherence to an exerciseprogram over the long term.

The Procedure

Neck dissections are done under general anesthesia through an incision that runs along a skin crease in the neck, extending vertically on the side of the neck. Incisions are usually designed to enhance the visualization and protection of important structures in the neck, and enable the safe removal of lymph nodes that harbor cancer.

Beneath the skin, underlying fat, and a thin layer of muscle (the platysma), the dissection proceeds to identify and remove the tissue containing the lymph nodes. If the sternocleidomastoid muscle is removed as part of the operation, there may be some flattening of the neck, but removal of this muscle rarely results in significant weakness.

What are the risks of neck dissection?

Neck dissections are subject to numerous potential operative complications that are common to all operative procedures, as well as complications specific to this procedure. Some of these are described below, but do not include all potential complications associated with neck dissection. The risk of specific complications may be best determined for an individual by the nature and extent of their cancer, prior treatment and other circumstances.

• Bleeding-Patients may bleed after an operation. Bleedingunder the skin after a neck dissection is rare. Sometimes anoperative procedure to remove the blood is required. Rarely, ablood transfusion is also needed.
• Infection can occur after any surgical procedure includingneck dissection (uncommon)
• Chyle leak, which results in fluid accumulation in the neckfrom disruption of the thoracic duct (this problem is morecommon after left sided neck dissections) (rare)
• Wound healing problems requiring additional surgery (rare)

Several important nerves are found in the neck around the lymph nodes, and depending on the area of the neck to be operated, these nerves can be at risk for damage. The primary nerves of concern are-

• The marginal nerve, a small branch of the facial nerve whichcontrols lower lip movement
• The spinal accessory nerve which aids in shoulder mobilityand raising the arm over head
• The hypoglossal nerve, which controls movement of thetongue (uncommon
• The lingual nerve, which controls sensation on the side of thetongue (rare)
• The vagus nerve which controls movement of one vocal cord (rare)

Additional potential long-term problems include:

• Incision-Most incisions heal well, but some individualsdevelop scars.
• Numbness of the skin along the incision as well as over thecheek, ear and neck can be anticipated which improves withtime; long term is expected
• Neck stiffness or pain (common)
• Long term swelling in the neck or lymphedema, particularly ifyou have had radiation
• Shoulder weakness (uncommon)
• Changes in speech and swallowing (rare)

Some problems are attributable to nerve injury; more commonly, scarring under the skin from surgery and radiation contributes to disability. Some problems may be avoided with early and faithful adherence to a shoulder range of motion exercise program, lymphedema or speech therapy rehabilitation programs.

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