Treatment of Right Trapezius Spasm After C3-T1 Decompression
For postoperative trapezius spasm following C3-T1 decompression, initiate cyclobenzaprine 5 mg three times daily as an adjunct to physical therapy, with close monitoring for neurologic deficits that may indicate Parsonage-Turner syndrome or C5 palsy requiring alternative management.
Immediate Pharmacologic Management
Cyclobenzaprine is FDA-approved specifically as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, making it the first-line pharmacologic choice for postoperative trapezius spasm 1.
Start with cyclobenzaprine 5 mg three times daily rather than the standard 10 mg dose, as clinical trials demonstrate statistically significant superiority over placebo for muscle spasm relief with the lower dose, reducing sedation risk 1.
Treatment duration should be limited to 2-3 weeks maximum, as adequate evidence for more prolonged use is not available and muscle spasm associated with acute musculoskeletal conditions is generally of short duration 1.
Concomitant use with NSAIDs (naproxen) is well-tolerated but associated with more drowsiness than NSAID therapy alone 1.
Critical Differential Diagnosis
You must immediately distinguish simple muscle spasm from Parsonage-Turner syndrome (PTS) or C5 palsy, as these conditions require fundamentally different management approaches:
PTS occurs in approximately 5% of cervical decompression cases and represents a subset of postoperative weakness unrelated to technical or structural surgical issues 2.
PTS typically presents with severe pain followed by weakness affecting the trapezius and other shoulder girdle muscles, distinguishing it from simple spasm 2.
If the patient exhibits progressive weakness, severe pain disproportionate to expected postoperative discomfort, or asymmetric shoulder drooping with scapular winging, obtain urgent EMG and nerve conduction studies 3, 2.
Physical Therapy Protocol
Initiate physical therapy immediately alongside pharmacologic treatment, as cyclobenzaprine is indicated specifically as an adjunct to physical therapy, not as monotherapy 1.
Focus on scapular stabilization exercises once acute spasm resolves, as the trapezius is a major scapular stabilizer contributing to scapulothoracic rhythm through elevation, rotation, and retraction 3.
Avoid aggressive stretching during the acute phase (first 2 weeks), as postoperative trapezius muscle shows reduced microcirculation and muscle tension that requires time to normalize 4.
Monitoring and Red Flags
Watch for these specific warning signs that indicate progression beyond simple muscle spasm:
Shoulder drooping with asymmetric neckline suggests trapezius dysfunction rather than simple spasm and requires EMG evaluation 3.
Weakness of forward elevation or scapular winging indicates nerve injury (spinal accessory nerve or C5 root) rather than muscle spasm alone 3, 2.
Pain persisting beyond 4 weeks or progressive weakness warrants electrodiagnostic examination to rule out PTS, as diagnosis within 1 year of injury allows consideration of microsurgical nerve reconstruction 3, 2.
Conservative Management Algorithm for PTS (If Diagnosed)
If EMG confirms PTS rather than simple spasm:
Pain management and physical therapy alone achieve eventual resolution in approximately 67% of cases (4 of 6 patients in one series) 2.
Continue conservative management for up to 1 year before considering surgical intervention, as most patients achieve resolution without surgery 2.
Surgical procedures (nerve releases, nerve reconstruction, or Eden-Lange tendon transfer) are reserved for active, healthy patients in whom 1 year of conservative treatment has failed 3, 2.
Common Pitfalls to Avoid
Do not assume all postoperative shoulder/neck pain is simple muscle spasm—approximately 5% represent PTS or C5 palsy requiring different management 2.
Do not continue cyclobenzaprine beyond 3 weeks without reassessing the diagnosis, as prolonged muscle spasm suggests an alternative etiology 1.
Do not ignore unilateral symptoms—simple bilateral muscle spasm is expected postoperatively, but unilateral trapezius dysfunction with weakness suggests nerve injury 3.
Do not delay EMG beyond 3-4 weeks if weakness is present, as early diagnosis of nerve injury (within 1 year) significantly impacts surgical reconstruction options 3, 2.