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PubMed2002

Anatomy of the spinal accessory nerve plexus: relevance to head and neck cancer and atherosclerosis.

The term spinal accessory nerve plexus may be defined as the spinal accessory nerve with all its intra- and extracranial connections to other nerves, principally cranial, cervical, and sympathetic. The term is not new. This review examines its applied anatomy in head and neck cancer and atherosclerosis. Over the centuries, general studies of neural and vascular anatomy and embryology formed a basis for the understanding upon which the plexus is described. During the past century, its anatomy and blood supply have come to be better understood. The importance of almost all of the plexus to head, neck, and upper extremity motor and sensory functions has come to be realized. Because of this understanding, surgical neck dissection has become progressively more conservative. This historical progression is traced. Even the most recent anatomic studies of the spinal accessory nerve plexus reveal configurations, new to many of us. They were probably known to classical anatomists, and not recorded in readily available literature, or not recorded at all. Human and comparative anatomic studies indicate that the composition of this plexus and its blood supply vary widely, even though within the same species their overall function is very nearly the same. Loss of any of these structures, then, may have very different consequences in different individuals. As a corollary to this statement, data are presented that the spinal accessory nerve itself need not be cut during surgical neck dissections for severe impairment to occur. In addition, data are presented supporting the theory that atherosclerosis by obstructing vessels to this plexus and its closely connected brachial plexus will very likely result in their ischemic dysfunction, often painful. Finally evidence, as well as theory, is stated concerning anatomic issues, methodology, outcome, and possible improvements in surgical procedures emphasizing conservatism.

Accessory Nerve↗
PubMed2007

Anatomical study of accessory nerve innervation relating to functional neck dissection.

PURPOSE: The present study sought to clarify correlations of accessory nerve innervation in the neck region and innervation of the sternocleidomastoid and trapezius muscles with postoperative dysfunction after functional neck dissection by macroscopic observation. MATERIALS AND METHODS: The materials used in this study were 35 cadavers provided for anatomical practice to the Department of Anatomy, Tokyo Dental College. The accessory nerve was identified at the anterior margin of the trapezius muscle, and its innervation in the posterior triangle of the neck was examined in detail. RESULTS: The superficial cervical vein vascularizes the anterior margin of the trapezius muscle near an area where the main trunk of the accessory nerve innervates the trapezius muscle. The results showed 3 types of accessory nerve innervation of the sternocleidomastoid muscle: Type A, the not penetrating type; Type B, the partially penetrating type; and Type C, the completely penetrating type. In addition, 5 types of innervation of the trapezius muscle by the main trunk and branches of the accessory nerve were apparent, with the number of branches innervating the muscle ranging from 0 to 4. CONCLUSIONS: Dysfunction after functional neck dissection can thus be avoided by paying attention to not only the main trunk of the accessory nerve, but also the branches. Moreover, when identifying accessory nerve innervation of the trapezius muscle, the superficial cervical vein may offer a useful surgical landmark.

Accessory Nerve↗
PubMed1985

Presence of unmyelinated axons in the spinal root of the feline accessory nerve.

The spinal root of the accessory nerve was studied electron microscopically at different levels in 3 adult cats. It was found that this nerve contains several unmyelinated axons. In the main nerve trunk the proportion of unmyelinated axon profiles was 27% at the level of the foramen magnum. In juxtamedullary root fascicles near the PNS/CNS transition the proportion of unmyelinated axons was lower and these axons tended to occupy superficial positions in the fascicles. No intrafascicular unmyelinated axons were found in the immediate vicinity of the PNS/CNS transition but bundles of unmyelinated axons occurred in the surrounding pia mater. The findings suggest that unmyelinated axons in the spinal accessory nerve contribute to the pial vasomotor and/or sensory innervation.

Accessory Nerve↗
PubMed2003

[Surgical anatomy and preservation of the accessory nerve in radical functional neck dissection].

OBJECTIVE: The surgical anatomy and preservation of the accessory nerve in radical functional neck dissection were studied. METHODS: Thirty-three cN(0) patients with oral cancers were entered into the study. Radical functional neck dissection were performed and the relations between the accessory nerve and its surrounding structures were recorded. RESULTS: The accessory nerve going through or beneath the sternocleidomastoid muscle occurred in 82% (27/33) and 18% (6/33) of the patients respectively. Communicating branches between the accessory and the cervical nerves were found in 85% (28/33). There was 2 to 3 cm of the accessory nerve paralleled to the anterior border of the trapezius muscle before it entered the muscle in 70% (23/33). The dissection of the nerve needed 20 to 30 minutes. Twenty-seven percent of the patients had pathologically proved lymph node metastases. CONCLUSIONS: Looking for accessory nerve under the upper portion of the sternocleidomastoid muscle and above the middle point of the muscle posterior border is simple and safe. The point of the great auricular nerve going out the muscle is an important indicator for finding the accessory nerve.

Accessory Nerve↗
PubMedDate not supplied

Spinal accessory nerve function following neck dissection.

Spinal accessory nerve (SAN) function was evaluated by electromyography (EMG) and muscle testing in 36 patients who underwent neck dissection with SAN preservation. The results emphasized that SAN function was relatively good after conservative neck surgery. Muscle testing findings showed better function than did EMG findings. After surgery the trapezius muscle functioned more efficiently than the sternocleidomastoid (SCM) muscle probably because of the more traumatic surgical handling of both the SCM muscle and its SAN branch. In order to obtain the functional advantages of SAN preservation, the authors suggest that the conservative procedure in radical neck dissection be used whenever warranted by oncologic diagnosis.

Accessory Nerve↗
PubMed1999

[Iatrogenic lesion of the accessory nerve in cervical lymph node biopsy].

The majority of lesions of the spinal accessory nerve occur as an iatrogenic injury after lymph node biopsy in the posterior cervical triangle (trigonum colli laterale). In most cases the accessory nerve palsy is not recognised immediately after the injury. Therefore surgical repair is often performed too late to regain sufficient function of the paralytic trapezius muscle. Later than 6 months after the injury, reconstruction seems to be hopeless. However, "timely" reconstructions often have poor results. Exact knowledge of anatomy, postoperative check of the trapezius muscle and, if an accessory nerve injury has occurred, early reconstructive procedures (neurolysis, reconstruction of nerve continuity) may on the one hand prevent iatrogenic lesions of the nerve and on the other hand improve the reconstructive result. A series of 6 patients with an injury of the spinal accessory nerve after lymph node biopsy is reported. In 2 cases primary coaptation, in 3 cases interpositional nerve grafting and in 1 case neurotization was performed. Clinical recovery was achieved in 3 of the 6 cases.

Accessory Nerve↗
PubMedDate not supplied

Anatomy of the accessory nerve and its cervical contributions in the neck.

Details of the course of the accessory nerve and the pattern of the cervical contributions to the nerve are essential for planning neck dissection. Based on a recent anatomic description, a technique was devised to preserve the distal accessory nerve; the theory advanced was that the trapezius was supplied by motor fibers from the cervical plexus, which join the accessory nerve in the posterior triangle. Dissections were performed on 23 cadavers to test such a theory. The course of the accessory nerve in the neck was mapped in each dissection, and landmarks for use during surgery determined. Cervical contributions to the nerve usually joined deep to the sternocleidomastoid, and not in the posterior triangle. Branches from the cervical plexus, independent of the accessory nerve, entered the trapezius in the posterior triangle. None of the bilateral dissections showed symmetry of the cervical contributions.

Accessory Nerve↗
PubMed1998

Cable grafting of the spinal accessory nerve after radical neck dissection.

BACKGROUND: From January 1981 through March 1996, 20 patients with head and neck cancer underwent radical neck dissection with sacrifice of the spinal accessory nerve and immediate reconstruction of the nerve using a microsurgical technique and a cable graft of the great auricular nerve. METHODS: Postoperative shoulder function was assessed via a subjective questionnaire, objective strength testing, and/or postoperative electromyography. The latter was used to evaluate for the presence and amplitude of voluntary motor potentials, the presence of fibrillation potentials, and nerve conduction latency. The group of patients who underwent cable grafting of the spinal accessory nerve was compared with a group of patients who underwent modified radical neck dissection with preservation of the spinal accessory nerve and with another group of patients who underwent a classic neck dissection with sacrifice of the spinal accessory nerve and no reconstruction. RESULTS: In terms of shoulder function, the group of patients in whom the spinal accessory nerve was reconstructed occupied an intermediate position; ie, their postoperative shoulder function was better than that of the patients who underwent radical neck dissection without reconstruction but not as good as that of the patients who underwent modified neck dissection with preservation of the spinal accessory nerve. CONCLUSION: Cable grafting of the spinal accessory nerve that has been sacrificed during radical neck dissection results in improved shoulder function in the postoperative period.

Accessory Nerve↗
PubMed2002

Accessory nerve monitoring and stimulation during neck surgery.

Iatrogenic injury to the spinal accessory nerve following surgical procdures in the neck is well recognized in causing significant morbidity to patients, with shoulder pain and loss of function being particularly problematic. We have used a Magstim Neurosign 100 peripheral nerve monitor, that is most often used in our practice to monitor the facial nerve during middle ear and parotid surgery, to monitor the accessory nerve during neck surgery. Ten patients undergoing accessory nerve-sparing neck dissection, or excision biopsy of neck mass had their accessory nerve monitored during the procedure. No patient suffered injury of the nerve. In several cases the nerve closely adhered to the tissue being resected, and in two cases, the nerve bifurcated or gave off branches. We found that the monitor aided identification and preservation of the nerve.

Accessory Nerve Injuries↗
PubMed1999

Reconstruction of accessory nerve defects with vascularized long thoracic vs. non-vascularized thoracodorsal nerve.

Modern techniques of lymph-node neck dissection aim at conserving the accessory nerve. However, its continuity cannot be retained in cases of tumor in its direct neighborhood. In these cases, the accessory nerve must be resected for oncologic reasons. This study reports on neuronal reconstruction with both a vascularized long thoracic nerve transfer and a free thoracodorsalis nerve transfer, and compares the two. Both nerve transfers were removed simultaneously with an osseo-myocutaneous scapula-latissimus dorsi transfer. In both cases, morphologic reconstruction in the face and a neuro-functional reconstruction of the shoulder-arm region is possible. The vascularized long thoracic nerve transfer was superior to the non-vascularized throacodorsalis transfer for patients who had undergone radiotherapy. It resulted in more rapid healing and an improved motor result in shoulder elevation and maximal arm abduction. The long thoracic nerve transfer should thus be favored in reconstruction of the accessory nerve following tumor resection.

Accessory Nerve↗
PubMed2001

Surgical landmarks of the spinal accessory nerve in modified radical neck dissection.

We designed a study to identify useful landmarks for the preservation of the spinal accessory nerve during modified radical neck dissection (MRND). Eighteen consecutive patients undergoing 23 MRNDs were enrolled in the study. The distance of the accessory nerve from the greater auricular nerve, where it crosses the posterior edge of the sternocleidomastoid muscle (greater auricular point), was noted. The vertical distance between the point of entrance of the accessory nerve into the trapezius muscle and the clavicle was also measured. The mean distance between the greater auricular point and the accessory nerve was 10.7 mm, SD +/- 6.3. In all cases the accessory nerve was above the greater auricular point. The mean distance between the point of entrance of the nerve into the trapezius and the clavicle was 51.3 mm, SD +/- 17. The greater auricular point is a reliable landmark for the identification of the accessory nerve during modified radical neck dissection. Distance above the clavicle was less helpful.

Accessory Nerve↗
PubMedDate not supplied

On the presence of ganglion cells in the intracranial portion of the accessory nerve (XI cranial nerve) in some mammals.

The intracranial tract of the accessory nerve (XI cranial nerve) was studied in some mammals (equines, domestic and wild ruminants, pig, carnivores, rabbit, nutria, guinea pig, hamster, hedgehog). The specimens were embedded in paraffin or paraplast, the sections were stained with cresyl violet, haematoxylin and eosin, or submitted to argentic impregnation. Pseudounipolar ganglion cells were found in all the mammals examined, with the exception of the cat. The number of cells and their variability in the different species and subjects were related. The topography and morphology of the cells were described. This comparative study has demonstrated that the accessory nerve is not a entirely motor nerve, but it is a mixed, motor and sensitive, nerve. Nevertheless, we think further studies are necessary in order to establish the peripheral distribution, the central pathway and the functional role of the pseudounipolar neurons found in the intracranial tract of the accessory nerve.

Accessory Nerve↗
PubMed2001

Physical therapy for spinal accessory nerve injury complicated by adhesive capsulitis.

BACKGROUND AND PURPOSE: The authors found no literature describing adhesive capsulitis as a consequence of spinal accessory nerve injury and no exercise program or protocol for patients with spinal accessory nerve injury. The purpose of this case report is to describe the management of a patient with adhesive capsulitis and spinal accessory nerve injury following a carotid endarterectomy. CASE DESCRIPTION: The patient was a 67-year-old woman referred for physical therapy following manipulation of the left shoulder and a diagnosis of adhesive capsulitis by her orthopedist. Spinal accessory nerve injury was identified during the initial physical therapy examination, and a program of neuromuscular electrical stimulation was initiated. OUTCOMES: The patient had almost full restoration of the involved muscle function after 5 months of physical therapy. DISCUSSION: This case report illustrates the importance of accurate diagnosis and suggests physical therapy intervention to manage adhesive capsulitis as a consequence of spinal accessory nerve injury.

Accessory Nerve Diseases↗
PubMed1991

Accessory nerve injury: conservative or surgical treatment?

In order to clarify the functional prognosis of accessory nerve injury after nerve repair and nonsurgical treatment, 27 of our cases with accessory nerve injury were studied. 20 cases were followed up for more than 8 months. In ten cases treated conservatively, the dull feeling and hypaesthesia did not improve. However, pain and dysfunction of the shoulder improved in half of these cases. In ten cases treated surgically, nerve suture was performed in two cases, nerve graft in five cases and neurolysis in three cases. In the surgically treated group, subjective complaints disappeared in all cases, but hypaesthesia or contracture of the shoulder persisted in three cases. Surgical treatment of the accessory nerve is recommended in fresh cases with complete paralysis and in cases in which there is no sign of nerve recovery within one year after the original injury.

Accessory Nerve↗
PubMed1985

Accessory nerve latency to the middle and lower trapezius.

Trapezius muscle dysfunction occurs following injury to the spinal accessory nerve from a variety of causes. The trapezius consists of three distinct segments: upper, middle, and lower. Since previous studies of accessory nerve latency measure conduction to the upper trapezius segment only, this present study describes a standardized technique for determining accessory nerve latency to the middle and lower trapezius, a particularly important measurement for accurate examination for those who are in pain or unable to cooperate. Mean normal latency in 21 nerves to the middle trapezius is 3.0 +/- 0.2 msec and to the lower trapezius is 4.6 +/- 0.3 msec. Accessory nerve latency measurement of the middle and lower trapezius segments is valuable in a case of surgical injury in the posterior cervical triangle, especially during recovery from accessory nerve injury when reinnervation of the upper segment precedes the middle and lower segments.

Accessory Nerve↗
PubMed1996

[Evaluation of iatrogenic accessory nerve injury in forensic medical practice].

The authors give a survey of the clinical and medical-legal characteristics of the accessory nerve injury. In the past two decades the conception of the successfulness of the surgical treatment of the accessory nerve injury became prevailing. About the medical-legal aspects of the iatrogenic injury of the nerve reported in connection of the reconstructive surgery chiefly also departments of neurosurgery, orthopedics and traumatology. In the case of the authors a 70 year old patient suffered 10 years ago a iatrogenic accessory nerve injury. The mild trapezius palsy recovered spontaneously practically with cosmetic disadvantage. In connection with the development of extreme dorso-lumbal scoliosis associated with torsion the trapezius atrophy worsened. Physical therapy was partly successful. But the patient became unfit for manual work. Their observations sustain the data of authors who established that in the case of accessory nerve injury not only the surgical but also conservative treatment is usually successful. In opposite to certain data of the literature the authors establish that the iatrogenic injuries of the accessory nerve may lead to significant lifelong disability. The diagnosis is not always made in time with consequent delay in repair. This may be regarded as an unfavorable issue during medical-legal discussions. The authors recommend in interest to prevent nerve injury in the posterior triangle of the neck to perform operation in special department.

Accessory Nerve↗