Accessory nerve

Nerve: Accessory nerve
Plan of upper portions of glossopharyngeal, vagus, and accessory nerves.
Inferior view of the human brain, with the cranial nerves labelled.
Latin	nervus accessorius
Gray's	subject #206 913
Innervates	sternocleidomastoid muscle, trapezius muscle
MeSH	Accessory+Nerve

Cranial Nerves
CN I – Olfactory
CN II – Optic
CN III – Oculomotor
CN IV – Trochlear
CN V – Trigeminal
CN VI – Abducens
CN VII – Facial
CN VIII – Vestibulocochlear
CN IX – Glossopharyngeal
CN X – Vagus
CN XI – Spinal Accessory
CN XII – Hypoglossal
This box: view · talk · edit

In anatomy, the accessory nerve is a nerve that controls specific muscles of the shoulder and neck. As part of it was formerly believed to originate in the brain, it is considered a cranial nerve. Based on its location relative to other such nerves, it is designated the eleventh of twelve cranial nerves, and is thus abbreviated CN XI.

Traditional descriptions of the accessory nerve divide it into two parts: a spinal part and a cranial part.^[1] But because the cranial component rapidly joins the vagus nerve and serves the same function as other vagal nerve fibers, modern descriptions often consider the cranial component part of the vagus nerve and not part of the accessory nerve proper.^[2] Thus in contemporary discussions of the accessory nerve, the common practice is to dismiss the cranial part altogether, referring to the accessory nerve specifically as the spinal accessory nerve.

The spinal accessory nerve provides motor innervation from the central nervous system to two muscles of the neck: the sternocleidomastoid muscle and the trapezius muscle. The sternocleidomastoid muscle tilts and rotates the head, while the trapezius muscle has several actions on the scapula, including shoulder elevation and adduction of the scapula.

Range of motion and strength testing of the neck and shoulders can be measured during a neurological examination to assess function of the spinal accessory nerve. Limited range of motion or poor muscle strength are suggestive of damage to the spinal accessory nerve, which can result from a variety of causes. Injury to the spinal accessory nerve is most commonly caused by medical procedures that involve the head and neck.^[3]

The accesory nerve is derived from the basal plate of the embryonic spinal segments C1-C6.

Anatomy

Course

Upon exiting the skull via the jugular foramen, the spinal accessory nerve pierces the sternocleidomastoid muscle before terminating on the trapezius muscle.

Like other cranial nerves, the spinal accessory nerve begins in the central nervous system and exits the cranium through a specialized hole (or foramen). However, unlike all other cranial nerves, the spinal accessory nerve begins outside the skull rather than inside. In particular, in the majority of individuals, the fibers of the spinal accessory nerve originate solely in neurons situated in the upper spinal cord.^[4] These fibers coalesce to form spinal rootlets, roots, and finally the spinal accessory nerve itself, which enters the skull through the foramen magnum, the large opening at the base of the skull. The nerve courses along the inner wall of the skull towards the jugular foramen, through which it exits the skull with the glossopharyngeal (CN IX) and vagus nerves (CN X). Owing to its peculiar course, the spinal accessory nerve is notable for being the only cranial nerve to both enter and exit the skull.

Traditionally, the accessory nerve is described as having a small cranial component that descends from the medulla oblongata and briefly connects with the spinal accessory component before branching off of the nerve to join the vagus nerve. A recent study of twelve subjects suggests that in the majority of individuals, this cranial component does not make any distinct connection to the spinal component; the roots of these distinct components were separated by a fibrous sheath in all but one subject.^[4]

Once the cranial component has detached from the spinal component, the spinal accessory nerve continues alone and heads posteriorly (backwards) and inferiorly (downwards) upon exiting the skull. In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of digastric muscle. Masoud Saman et al. in a study of 84 necks ^[5] reported that in the anterior triangle of the neck the accessory nerve crossed the internal jugular vein anteriorly in 80% of necks, posteriorly in 19% and in the one case of internal jugular vein bifurcation, the nerve pierced the vein. The average distance traveled by nerve from base of skull to crossing the internal jugular vein was 2.38 cm. As it courses caudally, the nerve pierces the sternocleidomastoid muscle while sending it motor branches, then continues inferiorly until it reaches the trapezius muscle to provide motor innervation to its upper portion.

Origin

Main article: Spinal accessory nucleus

The fibers that form the spinal accessory nerve are formed by lower motor neurons located in the upper segments of the spinal cord. This cluster of neurons, called the spinal accessory nucleus, is located in the lateral horn of the spinal cord. This is in contrast to most other motor neurons, whose cell bodies are found in the spinal cord's anterior horn. The lateral horn of high cervical segments appears to be continuous with the nucleus ambiguus of the medulla oblongata, from which the cranial component of the accessory nerve is derived.

Classification

Among investigators there is disagreement regarding the terminology used to describe the type of information carried by the accessory nerve. As the trapezius and sternocleidomastoid muscles are derived from the branchial arches, some investigators believe the spinal accessory nerve that innervates them must carry branchiomeric (special visceral efferent, SVE) information.^[6] This is in line with the observation that the spinal accessory nucleus appears to be continuous with the nucleus ambiguus of the medulla. Others, notably Haines, consider the spinal accessory nerve to carry general somatic efferent (GSE) information.^[7] Still others believe it is reasonable to conclude that the spinal accessory nerve contains both SVE and GSE components.^[8]

Function

The nerve functions to control the sternocleidomastoid and trapezius muscles. The thoracic branches of the spinal accessory nerve are matched to vagal innervation in early embyrologic development of the mammalian heart.

Clinical relevance

Injury

Main article: accessory nerve disorder

Injury to the spinal accessory nerve can cause an accessory nerve disorder or spinal accessory nerve palsy, which results in diminished or absent function of the sternocleidomastoid muscle and upper portion of the trapezius muscle.

The distal part of the spinal accessory nerve is most susceptible to injury. Throughout much of its course, the nerve is protected from injury by the muscles it innervates. It is in the interval between protection from these muscles, which corresponds to the distal part of the nerve, that the spinal accessory nerve is most vulnerable to injury.

Assessment of function

As physical examination cannot directly assess the functioning of nerves, assessment of spinal accessory nerve function is usually done indirectly. This is often accomplished through gross observation, range of motion testing, and strength testing, with specific attention to the trapezius and sternocleidomastoid muscles which are innervated by the spinal accessory nerve.

The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance. A one-sided weakness is indicative of an injury to the spinal accessory nerve on the same side (termed ipsilateral) of the body being assessed. The sternocleidomastoid muscle is tested by asking the patient to turn their head to the left or right against resistance. Weakness in head-turning suggests injury to the contralateral spinal accessory nerve: a weak leftward turn is indicative of a weak right sternocleidomastoid muscle (and thus right spinal accessory nerve injury), while a weak rightward turn is indicative of a weak left sternocleidomastoid muscle (and thus left spinal accessory nerve).

Gross observation may identify other findings associated with spinal accessory nerve injury. Patients with spinal accessory nerve palsy may exhibit signs of lower motor neuron disease such as diminished muscle mass (atrophy) and fasciculations of the sternocleidomastoid and trapezius muscles.

History and etymology

In 1848, Jones Quain described the nerve as the "spinal nerve accessory to the vagus", recognizing that while a minor component of the nerve joins with the larger vagus nerve, the majority of accessory nerve fibers originate in the spinal cord.^[9] Quain also suggested spinal accessory nerve as a shortened form of the term; this term, and its more abbreviated variant, accessory nerve, have persisted to modern times. Throughout this interval, the nerve has never had a consistent name among investigators and medical practitioners. Some use accessory nerve and spinal accessory nerve interchangeably; others distinguish between spinal accessory nerve and cranial accessory nerve; still others use accessory nerve to refer to both spinal and cranial components of the nerve.

In Neuroanatomy and the Neurologic Exam, Terence R. Anthoney provides a historical account of the usage of the terms accessory nerve, spinal accessory nerve, and cranial accessory nerve, summarized in the following excerpt:

To summarize, then, the eleventh cranial nerve was called both the "accessory nerve" and the "spinal accessory nerve" as early as 1848—"accessory" referring to its fibers which became accessory to the vagus nerve and "spinal" referring to its largely spinal origin. When it became recognized, as early as 1893, that the "accessory" fibers to the vagus nerve came from the same medullary nuclei as the rest of the vagal efferent fibers, people began to view the "accessory" fibers as part of the vagus nerve proper, leaving the eleventh cranial nerve to originate solely from its spinal nucleus. This shift was reinforced by the neuroclinicians, who could only test the integrity of the spinal portion of the nerve separately anyway. Because of the shift to just a spinal origin for the nerve, the word "accessory" came to be associated with the "true"—i.e., spinal—component of the nerve, no longer being considered in the context of "accessory to the vagus." This association has been reinforced by referring to the spinal nucleus of origin as the "(spinal) accessory nucleus."^[10]

Additional images

• 

  Dura mater and its processes exposed by removing part of the right half of the skull, and the brain.

• 

  Hind- and mid-brains; postero-lateral view.

• 

  The nerves of the scalp, face, and side of neck.

• 

  Upper part of medulla spinalis and hind- and mid-brains; posterior aspect, exposed in situ.

• 

  Course and distribution of the glossopharyngeal, vagus, and accessory nerves.

• 

  Plan of the cervical plexus.

• 

  Side of neck, showing chief surface markings.

References

1. ^ "The Accessory Nerve". Gray's Anatomy of the Human Body. http://education.yahoo.com/reference/gray/subjects/subject/206. 
2. ^ "Spinal Accessory Nerve". Structure of the Human body, Loyola University Medical Education Network. http://www.meddean.luc.edu/lumen/MedED/grossanatomy/h_n/cn/cn1/cn11.htm. Retrieved 2007-06-17. 
3. ^ London J, London NJ, Kay SP (1996). "Iatrogenic accessory nerve injury". Annals of the Royal College of Surgeons of England 78 (2): 146–50. PMC 2502542. PMID 8678450. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2502542. 
4. ^ ^{a b} Ryan S, Blyth P, Duggan N, Wild M, Al-Ali S (2007). "Is the cranial accessory nerve really a portion of the accessory nerve? Anatomy of the cranial nerves in the jugular foramen". Anatomical science international / Japanese Association of Anatomists 82 (1): 1–7. doi:10.1111/j.1447-073X.2006.00154.x. PMID 17370444. 
5. ^ Saman M, Etebari P, Pakdaman MN, Urken ML (2010). "Anatomic relationship between the spinal accessory nerve and the jugular vein: a cadaveric study". Surgical and Radiologic Anatomy 33 (2): 175–179. doi:10.1007/s00276-010-0737-y. PMID 20959982. 
6. ^ William T. Mosenthal (1995). A Textbook of Neuroanatomy: With Atlas and Dissection Guide. Washington, DC: Taylor & Francis. pp. 12. ISBN 1-85070-587-9. 
7. ^ Duane E. Haines (2004). Neuroanatomy: an atlas of structures, sections, and systems. Hagerstown, MD: Lippincott Williams & Wilkins. ISBN 0-7817-4677-9. 
8. ^ Joshi SS, Joshi SD (2001). "Muscle Dorso-Fascialis — A Case Report". Journal of the Anatomical Society of India 50 (2): 159–160. 
9. ^ Jones Quain (1848). Richard Quain, William Sharpey. ed. Elements of Anatomy. 2 (5th ed.). London: Taylor, Walton, and Maberly. pp. 812. http://books.google.com/?id=wSAEAAAAQAAJ&printsec=titlepage. 
10. ^ Terence R. Anthoney (1993). Neuroanatomy and the Neurologic Exam: A Thesaurus of Synonyms, Similar-Sounding Non-Synonyms, and Terms of Variable Meanings. Boca Raton: CRC-Press. pp. 69–73. ISBN 0-8493-8631-4. 

External links

• MedEd at Loyola GrossAnatomy/h_n/cn/cn1/cn11.htm
• lesson6 at The Anatomy Lesson by Wesley Norman (Georgetown University)
• cranialnerves at The Anatomy Lesson by Wesley Norman (Georgetown University) (XI)
• SUNY Labs 28:13-0115
• Cranial Nerves at Yale 11-1