Management of late presentation of a spinal accessory nerve injury.
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Accessory Nerve↗
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[Treatment of accessory nerve injuries].
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Accessory Nerve↗
A technique to identify and preserve the spinal accessory nerve during neck dissection.
INTRODUCTION: Preservation of the spinal accessory nerve during neck dissection should be the rule rather than the exception. Despite the presence of many described techniques to locate the nerve, a tedious dissection is often required; as a consequence, it remains vulnerable to damage. METHOD: We describe a novel method, not previously reported, based on identifying a constant vein which crosses the nerve. This aids in the nerve's early identification. CONCLUSION: Our method enables the surgeon to locate the nerve precisely and to avoid damage to it, thereby maximizing post-operative function.
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[Legal problems in surgical lesions of the accessory nerve].
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Cerebellopontine angle meningioma associated with cranial accessory nerve neurinoma--case report.
A 46-year-old female presented with a rare association of cerebellopontine (CP) angle meningioma with accessory nerve neurinoma manifesting as headache, occasional diplopia, speech disturbance, swallowing difficulty, and unsteady gait. Magnetic resonance imaging demonstrated a large tumor in the left CP angle. The tumor was totally removed through a lateral suboccipital approach. During the operation another smaller tumor was found originating from the cranial accessory nerve and was also totally removed. Histological examination found that the larger tumor was a meningotheliomatous meningioma and the smaller an Antoni type A neurinoma. The symptoms were apparently due to the larger tumor. Careful examination of neuroimages is necessary even after the main lesions responsible for the symptoms are identified.
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Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus.
The authors report their experience with 21 cases of neurotization via the spinal accessory nerve for multiple nerve root avulsion injuries of the brachial plexus associated with total paralysis of the upper limb. They performed microneuroanastomoses with interposed cable nerve grafts between the spinal accessory nerve taken in the supraclavicular fossa and the musculocutaneous nerve at its entrance into the biceps muscle. Surgical indications depend on the accurate diagnosis of spinal nerve root avulsion, especially C5. The anatomicosurgical basis of this technique is as precise as are the indications. As many as two-thirds of the patients with a neurotized musculocutaneous nerve can be expected to achieve strength of at least Grade 3 on late muscle testing. Nevertheless, these results are always inferior to those obtainable when grafting is performed with carefully selected unavulsed C5 or C6 spinal nerve root fibers in the intervertebral foramina. Therefore, neurotization via donor nerves extrinsic to the plexus should only be considered as a second-choice intervention.
Adult↗
Targeted disruption of the homeobox gene Nkx2.9 reveals a role in development of the spinal accessory nerve.
The homeodomain-containing transcription factor Nkx2.9 is expressed in the ventralmost neural progenitor domain of the neural tube together with the related protein Nkx2.2 during early mouse embryogenesis. Cells within this region give rise to V3 interneurons and visceral motoneurons in spinal cord and hindbrain, respectively. To investigate the role of the Nkx2.9 gene, we generated a mutant mouse by targeted gene disruption. Homozygous mutant animals lacking Nkx2.9 were viable and fertile with no apparent morphological or behavioral phenotype. The distribution of neuronal progenitor cells and differentiated neurons in spinal cord was unaffected in Nkx2.9-deficient animals. This finding is in contrast to Nkx2.2-null mutants, which have been shown to exhibit ventral to dorsal transformation of neuronal cell fates in spinal cord. Our results suggest that specification of V3 interneurons in the posterior CNS does not require Nkx2.9, most probably because of functional redundancy with the co-expressed Nkx2.2 protein. In hindbrain, however, absence of Nkx2.9 resulted in a significantly altered morphology of the spinal accessory nerve (XIth), which appeared considerably shorter and thinner than in wild-type animals. Consistent with this phenotype, immature branchial motoneurons of the spinal accessory nerve, which normally migrate from a ventromedial to a dorsolateral position within the neural tube, were markedly reduced in Nkx2.9-deficient embryos at E10.5, while ventromedial motor column cells were increased in numbers. In addition, the vagal and glossopharyngeal nerves appeared abnormal in approximately 50% of mutant embryos, which may be related to the observed reduction of Phox2b expression in the nucleus ambiguus of adult mutant mice. From these observations, we conclude that Nkx2.9 has a specific function in the hindbrain as determinant of the branchial motoneuron precursor cells for the spinal accessory nerve and possibly other nerves of the branchial-motor column. Like other Nkx genes expressed in the CNS, Nkx2.9 seems to be involved in converting positional information into cell fate decisions.
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Localisation of the spinal nucleus of the accessory nerve in the rabbit.
The spinal nucleus of the accessory nerve (SNA) was localised in eight adult rabbits by a retrograde degeneration technique using thionine as a stain for the Nissl substance. The SNA was found to extend from the caudal one fifth of the medulla oblongata to the cranial one fourth of the sixth cervical segment. In the caudal part of the medulla oblongata, the SNA was located in the dorsal part of the detached ventral grey column. In the first cervical segment, the SNA was dorsolateral to the dorsomedial column and dorsal to the ventromedial column of the ventral grey column. In the cranial part of the second cervical segment, the SNA shifted laterally to the lateral margin of the ventral grey column. After this lateral shift, the SNA was located in the lateral part of the ventral grey column of the second, third and fourth cervical segments. In the fifth and cranial one fourth of the sixth cervical segments, the SNA was not a well defined column of cells but was represented by isolated cells scattered in the ventral part of the ventral grey column between the phrenic nucleus and the ventral border of the grey matter. The total number of chromatolysed cells found in the SNA of the right experimental side varied from 2723 to 3210.
Accessory Nerve↗
Gross anatomy of the accessory nerve and vagus nerve of the head and cranial neck region in the Bactrian camel.
Seven heads and necks of Bactrian camels were dissected to investigate the origin, course, branches and distribution of the accessory nerve and vagus nerve in the cranial cervical region. The spinal root and external branch of the accessory nerve were not present, but there was a delicate communicating branch between the dorsal root of the first cervical nerve and the root of the vagus nerve. The sternocephalic muscle was innervated by the second cervical nerve while the brachiocephalic and trapezius muscles were supplied by the sixth and seventh cervical nerves. In the head and cranial cervical region of the Bactrian camel the vagus nerve gave off the auricular branch, pharyngeal branch, cranial laryngeal nerve, a common trunk to the larynx, oesophagus and trachea, and some communicating branches connecting with the glossopharyngeal, hypoglossal, first cervical nerves and the cranial cervical ganglion.
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Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion.
OBJECT: Between 1994 and 1998, 44 nerve transfers were performed using a graft between a branch of the accessory nerve and musculocutaneous nerve to restore the flexion of the arm in patients with traumatic brachial plexus injuries. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 39 patients: 1) time interval between injury and surgery; and 2) length of the nerve graft used to connect the accessory and musculocutaneous nerves. METHODS: The postoperative follow-up interval ranged from 23 to 84 months, with a mean +/- standard deviation of 36 +/- 13 months. Reinnervation of the biceps muscle was achieved in 72% of the patients. Reinnervation of the musculocutaneous nerve was demonstrated in 86% of the patients who had undergone surgery within the first 6 months after injury, in 65% of the patients who had undergone surgery between 7 and 12 months after injury, and in only 50% of the patients who had undergone surgery 12 months after injury. A statistical comparison of the different preoperative time intervals (0-6 months compared with 7-12 months) showed a significantly better outcome in patients treated with early surgery (p < 0.05). An analysis of the impact of the length of the interposed nerve grafts revealed a statistically significant better outcome in patients with grafts 12 cm or shorter compared with that in patients with grafts longer than 12 cm (p < 0.005). CONCLUSIONS: Together, these results demonstrated that outcome in patients who undergo accessory to musculocutaneous nerve neurotization for restoration of elbow flexion following brachial plexus injury is greatly dependent on the time interval between trauma and surgery and on the length of the nerve graft used.
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Ansa cervicalis as a variant of spinal accessory nerve plexus: a case report.
The ansa cervicalis is a neural loop in the neck formed by the union of two main nerve roots, namely superior and inferior roots, derived from ventral rami of the cervical nerves. With the expanding use of the ansa cervicalis for reinnervation procedures and the fact that it is located in the vicinity of major nerves and vessels of the neck, knowledge of the topography and morphology of this loop is quite necessary in the modern era. Any variation in the course, contributing roots or branching pattern of the ansa cervicalis, potentially alters and perhaps complicates the course of the procedures involving this nerve such as neurorrhaphy, skull base surgery, neck dissection, and anterior cervical spinal approach. Here, we present an unusual case of an ansa cervicalis encountered upon routine dissection of an adult male cadaver. In this case, the inferior root of the ansa cervicalis was formed by the joining of two rootlets, one originating from spinal accessory nerve and the other from a branch of the cervical plexus to the sternocleidomastoid muscle. The fibers traversing the branch of spinal accessory nerve were derived from the first segments of the cervical spinal cord. This case demonstrates a variant of the spinal accessory nerve plexus that contributed to the formation of the ansa cervicalis. Review of the literature was performed to reveal the possible clinical aspects of this anatomical variation.
Adult↗
Tumor above the spinal accessory nerve in papillary thyroid cancer that involves lateral neck nodes: a common occurrence.
OBJECTIVE: To describe the nature and extent of lateral neck node metastases from papillary thyroid cancer in relation to presenting physical examination and staging radiologic studies. DESIGN: Retrospective study. SETTING: Tertiary referral cancer center. PATIENTS: Consecutive patients who underwent comprehensive neck dissection with or without concurrent thyroidectomy for well-differentiated thyroid cancer between 1991 and 2001. Excluded were patients with well-differentiated thyroid cancer diagnosed incidentally at the time of treatment of other primary head and neck cancer, those with previous neck dissection for nonthyroid malignancies, and those undergoing surgery for medullary thyroid cancer. INTERVENTIONS: All pathology and operative and preoperative radiology reports for patients undergoing comprehensive neck dissection for well-differentiated thyroid malignancy were reviewed. Data were collected on previous procedures, preoperative evaluation, operative details, and pathologic findings. MAIN OUTCOME MEASURE: Identification of metastatic thyroid cancer in one or more nodes in anatomically defined drainage basins of the central and lateral neck. RESULTS: A total of 51 neck dissections were performed. All patients had preoperative evidence of metastatic disease. In addition to the usual comprehensive node dissection encompassing all lymphatic tissue in levels II through V, level I nodes and level II nodes above the spinal accessory nerve were labeled as distinct regions in 16 (31%) and 34 (67%) specimens, respectively. Disease was confined to a single nodal level in 20 (39%) of 51 specimens and was present in 4 or more levels in 7 (14%) of 50 neck dissections. There was cancer at 2 or 3 levels in 16 (31%) and 15 (29%) cases, respectively. Seven (21%) of the 34 patients undergoing separate analysis of nodes from above the spinal accessory nerve had cancer there. In 3 of the 34 it was the sole disease in level II. CONCLUSIONS: Tumor involvement at multiple nodal levels occurs in most cases when patients have lateral cervical node metastases. "Skip" metastases and cancer above the spinal accessory nerve are common. Neck dissections should include all node stations likely to be involved because selective node excision is likely to leave metastatic disease in situ.
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Schmidt syndrome due to idiopathic accessory nerve paralysis.
A patient with Schmidt syndrome due to idiopathic accessory neuropathy has had paralysis of soft palate and larynx as well as trapezius and sternocleidomastoid muscles, reflecting involvement of cranial and spinal roots, respectively. In addition to vocal cord paralysis on the laryngoscopy, videofluoroscopy confirmed diminished mobility of the soft palate. Electrodiagnosis showed accessory neuropathy at the proximal segment. Furthermore, the accessory nerve innervated not only upper but also middle and lower portions of the trapezius muscles.
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Spinal accessory nerve palsy due to neurovascular compression. Report of a case diagnosed by magnetic resonance imaging and magnetic resonance angiography.
The case of a young patient with left accessory nerve paralysis is reported. He had slight tilting of the head to the right side, developed over a period of about 6 months. On neurological examination hypotrophy of the left sternocleidomastoid and trapezius muscles was observed. MRI and MR-angiography imaged the presence of a neurovascular compression between the medulla oblungata, at the level of the nerve entry zone, and a vessel loop of an elongated left vertebral artery. In spite of the absence of a surgical demonstration it is our opinion that the neurovascular conflict is the cause of the accessory nerve palsy.
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High division of the accessory nerve: a rare anatomical variation as a possible pitfall during neck dissection surgery.
A rare clinical variant found during neck dissection surgery is reported in which the spinal accessory nerve divided at a high level in the neck, before entering the sternocleidomastoid muscle. This case documents the need for meticulous technique in identification and dissection of the spinal accessory nerve in order to reduce the risk of postoperative morbidity.
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Nerve cells in the spinal part of the accessory nerve in the dog.
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Perineural spread of squamous cell carcinoma involving the spinal accessory nerve in an immunocompromised organ transplant recipient.
BACKGROUND: Squamous cell carcinoma is the second most common cutaneous malignancy in humans, affecting approximately 200,000 people in the United States each year. In immunocompromised patients, squamous cell carcinoma is the most common skin cancer, and it also tends to behave more aggressively than in immunocompetent patients. OBJECTIVE: We describe an immunocompromised patient, previously treated for a squamous cell carcinoma of the left posterior shoulder, who subsequently developed a cord-like, intraneural metastasis of the spinal accessory nerve. RESULTS: The patient presented with a 3-month history of lancinating pain of the left neck and shoulder. He had been treated previously for a squamous cell carcinoma of the left posterior shoulder, which subsequently recurred twice. On examination, a cord-like mass was palpable along the path of the spinal accessory nerve. Given the aggressive nature of this patient's squamous cell carcinoma, surgical exploration was performed. Frozen-section analysis of the spinal accessory nerve and of the multiple supraclavicular nerves revealed perineural and intraneural squamous cell carcinoma. CONCLUSION: To our knowledge, this is the first reported case of a primary cutaneous squamous cell carcinoma of the trunk or extremity metastasizing to a cranial nerve.
Carcinoma, Squamous Cell↗
Stretch palsy of the spinal accessory nerve. Case report.
Although sharp and blunt injury to the spinal accessory nerve has been well-documented, stretch or traction-type injury has not been reported previously. Such a case, treated successfully with nerve grafting, is described.
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