The accessory nerve, also known as the eleventh cranial nerve, cranial nerve XI, or simply CN XI, is a
cranial nerve
Cranial nerves are the nerves that emerge directly from the brain (including the brainstem), of which there are conventionally considered twelve pairs. Cranial nerves relay information between the brain and parts of the body, primarily to and ...
that supplies the
sternocleidomastoid
The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...
and
trapezius muscle
The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the ...
s. It is classified as the eleventh of twelve pairs of cranial nerves because part of it was formerly believed to originate in the brain. The sternocleidomastoid muscle tilts and rotates the head, whereas the trapezius muscle, connecting to the
scapula
The scapula (plural scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on eithe ...
, acts to shrug the shoulder.
Traditional descriptions of the accessory nerve divide it into a spinal part and a cranial part. The cranial component rapidly joins the
vagus nerve
The vagus nerve, also known as the tenth cranial nerve, cranial nerve X, or simply CN X, is a cranial nerve that interfaces with the parasympathetic control of the heart, lungs, and digestive tract. It comprises two nerves—the left and right ...
, and there is ongoing debate about whether the cranial part should be considered part of the accessory nerve proper.
Consequently, the term "accessory nerve" usually refers only to nerve supplying the sternocleidomastoid and trapezius muscles, also called the
spinal accessory nerve.
Strength testing of these muscles can be measured during a
neurological examination
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical hist ...
to assess function of the spinal accessory nerve. Poor strength or limited movement are suggestive of damage, 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.
Injury can cause wasting of the shoulder muscles,
winging of the scapula, and weakness of shoulder abduction and
external rotation
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
.
[
The accessory nerve is derived from the basal plate of the ]embryo
An embryo is an initial stage of development of a multicellular organism. In organisms that reproduce sexually, embryonic development is the part of the life cycle that begins just after fertilization of the female egg cell by the male spe ...
nic spinal segments C1–C6.
Structure
The fibres of the spinal accessory nerve originate solely in neuron
A neuron, neurone, or nerve cell is an electrically excitable cell that communicates with other cells via specialized connections called synapses. The neuron is the main component of nervous tissue in all animals except sponges and placozoa. N ...
s situated in the upper spinal cord
The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
, from where the spinal cord begins at the junction with the medulla oblongata
The medulla oblongata or simply medulla is a long stem-like structure which makes up the lower part of the brainstem. It is anterior and partially inferior to the cerebellum. It is a cone-shaped neuronal mass responsible for autonomic (involun ...
, to the level of about C6. These fibres join together to form rootlets, roots, and finally the spinal accessory nerve itself. The formed nerve enters the skull through the foramen magnum
The foramen magnum ( la, great hole) is a large, oval-shaped opening in the occipital bone of the skull. It is one of the several oval or circular openings (foramina) in the base of the skull. The spinal cord, an extension of the medulla oblon ...
, the large opening at the skull's base. The nerve travels along the inner wall of the skull towards the jugular foramen
A jugular foramen is one of the two (left and right) large foramina (openings) in the base of the skull, located behind the carotid canal. It is formed by the temporal bone and the occipital bone. It allows many structures to pass, including the i ...
. Leaving the skull, the nerve travels through the jugular foramen with the glossopharyngeal
The glossopharyngeal nerve (), also known as the ninth cranial nerve, cranial nerve IX, or simply CN IX, is a cranial nerve that exits the brainstem from the sides of the upper Medulla oblongata, medulla, just anterior (closer to the nose) to t ...
and vagus nerve
The vagus nerve, also known as the tenth cranial nerve, cranial nerve X, or simply CN X, is a cranial nerve that interfaces with the parasympathetic control of the heart, lungs, and digestive tract. It comprises two nerves—the left and right ...
s. The spinal accessory nerve is notable for being the only cranial nerve to both enter and exit the skull. This is due to it being unique among the cranial nerves in having neurons in the spinal cord.
After leaving the skull, the cranial component detaches from the spinal component. The spinal accessory nerve continues alone and heads backwards and downwards. In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of digastric muscle. As it courses downwards, the nerve pierces through the sternocleidomastoid muscle
The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...
while sending it motor
An engine or motor is a machine designed to convert one or more forms of energy into mechanical energy.
Available energy sources include potential energy (e.g. energy of the Earth's gravitational field as exploited in hydroelectric power g ...
branches, then continues down until it reaches the trapezius muscle
The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the ...
to provide motor innervation to its upper part.
Nucleus
The fibres that form the spinal accessory nerve are formed by lower motor neuron
Lower motor neurons (LMNs) are motor neurons located in either the anterior grey column, anterior nerve roots (spinal lower motor neurons) or the cranial nerve nuclei of the brainstem and cranial nerves with motor function (cranial nerve lower mo ...
s located in the upper segments of the spinal cord
The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
. This cluster of neurons, called the spinal accessory nucleus
The spinal accessory nucleus lies within the cervical spinal cord (C1-C5) in the posterolateral aspect of the anterior horn. The nucleus ambiguus is classically said to provide the "cranial component" of the accessory nerve. However, the very exist ...
, is located in the lateral aspect of the anterior horn of the spinal cord, and stretches from where the spinal cord begins (at the junction with the medulla) through to the level of about C6. The lateral horn of high cervical segments appears to be continuous with the nucleus ambiguus
The nucleus ambiguus ("ambiguous nucleus" in English) is a group of large motor neurons, situated deep in the medullary reticular formation named by Jacob Clarke. The nucleus ambiguus contains the cell bodies of neurons that innervate the muscle ...
of the medulla oblongata
The medulla oblongata or simply medulla is a long stem-like structure which makes up the lower part of the brainstem. It is anterior and partially inferior to the cerebellum. It is a cone-shaped neuronal mass responsible for autonomic (involun ...
, from which the cranial component of the accessory nerve is derived.
Variation
In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of digastric muscle
The digastric muscle (also digastricus) (named ''digastric'' as it has two 'bellies') is a small muscle located under the jaw. The term "digastric muscle" refers to this specific muscle. However, other muscles that have two separate muscle bellie ...
, in front of the vein in about 80% of people, and behind it in about 20%, and in one reported case, piercing the vein.
Traditionally, the accessory nerve is described as having a small cranial component that descends from the medulla
Medulla or Medullary may refer to:
Science
* Medulla oblongata, a part of the brain stem
* Renal medulla, a part of the kidney
* Adrenal medulla, a part of the adrenal gland
* Medulla of ovary, a stroma in the center of the ovary
* Medulla of t ...
and briefly connects with the spinal accessory component before branching off of the nerve to join the vagus nerve. A study, published in 2007, 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.
Development
The accessory nerve is derived from the basal plate of the embryonic spinal segments C1–C6.
Function
The spinal component of the accessory nerve provides motor control of the sternocleidomastoid
The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...
and trapezius
The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the ...
muscle
Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
s. The trapezius muscle controls the action of shrugging the shoulders, and the sternocleidomastoid the action of turning the head. Like most muscles, control of the trapezius muscle arises from the opposite side of the brain. Contraction of the upper part of the trapezius muscle elevates the scapula. The nerve fibres supplying sternocleidomastoid, however, are thought to change sides ( la, decussate) twice. This means that the sternocleidomastoid is controlled by the brain on the same side of the body. Contraction of the stenocleidomastoid fibres turns the head to the opposite side, the net effect meaning that the head is turned to the side of the brain receiving visual information from that area. The cranial component of the accessory nerve, on the other hand, provides motor control to the muscles of the soft palate, larynx and pharynx.
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 pharyngeal arch
The pharyngeal arches, also known as visceral arches'','' are structures seen in the embryonic development of vertebrates that are recognisable precursors for many structures. In fish, the arches are known as the branchial arches, or gill arch ...
es, some investigators believe the spinal accessory nerve that innervates them must carry specific special visceral efferent Special visceral efferent fibers (SVE) are the efferent nerve fibers that provide motor innervation to the muscles of the pharyngeal arches in humans, and the branchial arches in fish.
Some sources prefer the term "branchiomotor" or "branchial eff ...
(SVE) information. This is in line with the observation that the spinal accessory nucleus appears to be continuous with the nucleus ambiguus
The nucleus ambiguus ("ambiguous nucleus" in English) is a group of large motor neurons, situated deep in the medullary reticular formation named by Jacob Clarke. The nucleus ambiguus contains the cell bodies of neurons that innervate the muscle ...
of the medulla. Others consider the spinal accessory nerve to carry general somatic efferent
The general (spinal) somatic efferent neurons (GSE, somatomotor, or somatic motor fibers), arise from motor neuron cell bodies in the ventral horns of the gray matter within the spinal cord. They exit the spinal cord through the ventral roots, carr ...
(GSE) information. Still others believe it is reasonable to conclude that the spinal accessory nerve contains both SVE and GSE components.
Clinical significance
Examination
The accessory nerve is tested by evaluating the function of the trapezius
The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the ...
and sternocleidomastoid muscle
The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...
s. The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance. The sternocleidomastoid muscle is tested by asking the patient to turn their head to the left or right against resistance.
One-sided weakness of the trapezius may indicate injury to the nerve on the same side of an injury to the spinal accessory nerve on the same side ( la, ipsilateral, link=no) of the body being assessed. 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).
Hence, weakness of shrug on one side and head-turning on the other side may indicate damage to the accessory nerve on the side of the shrug weakness, or damage along the nerve pathway at the other side of the brain. Causes of damage may include trauma, surgery, tumours, and compression at the jugular foramen. Weakness in both muscles may point to a more general disease process such as amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or Lou Gehrig's disease, is a neurodegenerative disease that results in the progressive loss of motor neurons that control voluntary muscles. ALS is the most comm ...
, Guillain–Barré syndrome
Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system. Typically, both sides of the body are involved, and the initial symptoms are changes in sensation or pain often ...
or poliomyelitis
Poliomyelitis, commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 70% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe sym ...
.
Injury
Injury to the spinal accessory nerve commonly occurs during neck surgery, including neck dissection
The neck dissection is a surgical procedure for control of neck lymph node metastasis from squamous cell carcinoma (SCC) of the head and neck. The aim of the procedure is to remove lymph nodes from one side of the neck into which cancer cells may ...
and lymph node
A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that inclu ...
excision. It can also occur as a result of blunt or penetrating trauma, and in some causes spontaneously. Damage at any point along the nerve's course will affect the function of the nerve. The nerve is intentionally removed in "radical" neck dissections, which are attempts at exploring the neck surgically for the presence and extent of cancer. Attempts are made to spare it in other forms of less aggressive dissection.
Injury to the accessory nerve can result in neck pain and weakness of the trapezius muscle. Symptoms will depend on at what point along its length the nerve was severed. Injury to the nerve can result in shoulder girdle depression, atrophy, abnormal movement, a protruding scapula, and weakened abduction. Weakness of the shoulder girdle can lead to traction injury of the brachial plexus
The brachial plexus is a network () of nerves formed by the anterior rami of the lower four cervical nerves and first thoracic nerve ( C5, C6, C7, C8, and T1). This plexus extends from the spinal cord, through the cervicoaxillary canal in th ...
. Because diagnosis is difficult, electromyogram
Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyog ...
or nerve conduction studies
A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. These tests may be performed by medical spec ...
may be needed to confirm a suspected injury. Outcomes with surgical treatment appear to be better than conservative management, which entails physiotherapy and pain relief. Surgical management includes neurolysis Neurolysis is the application of physical or chemical agents to a nerve in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, it causes an interruption in the transmission of nerve signals. In the med ...
, nerve end-to-end suturing, and surgical replacement of affected trapezius muscle segments with other muscle groups, such as the Eden-Lange procedure
The Eden-Lange procedure is an orthopedic surgery, orthopedic procedure to alleviate the symptoms of Accessory nerve disorder, trapezius palsy when more conservative measures, such as spontaneous resolution and Neuroregeneration#Surgery, surgical ...
.[
Damage to the nerve can cause ]torticollis
Torticollis, also known as wry neck, is a dystonic condition defined by an abnormal, asymmetrical head or neck position, which may be due to a variety of causes. The term ''torticollis'' is derived from the Latin words ''tortus, meaning "twisted ...
.
History
English anatomist Thomas Willis
Thomas Willis FRS (27 January 1621 – 11 November 1675) was an English doctor who played an important part in the history of anatomy, neurology and psychiatry, and was a founding member of the Royal Society.
Life
Willis was born on his pare ...
in 1664 first described the accessory nerve, choosing to use "accessory" (described in Latin
Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power of the ...
as ''nervus accessorius'') meaning in association with the vagus nerve.
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 fibres originate in the spinal cord. In 1893 it was recognised that the heretofore named nerve fibres "accessory" to the vagus originated from the same nucleus in the medulla oblongata
The medulla oblongata or simply medulla is a long stem-like structure which makes up the lower part of the brainstem. It is anterior and partially inferior to the cerebellum. It is a cone-shaped neuronal mass responsible for autonomic (involun ...
, and it came to pass that these fibres were increasingly viewed as part of the vagus nerve itself. Consequently, the term "accessory nerve" was and is increasingly used to denote only fibres from the spinal cord; the fact that only the spinal portion could be tested clinically lent weight to this opinion.
Additional images
File:Gray793.png, Course and distribution of the glossopharyngeal
The glossopharyngeal nerve (), also known as the ninth cranial nerve, cranial nerve IX, or simply CN IX, is a cranial nerve that exits the brainstem from the sides of the upper Medulla oblongata, medulla, just anterior (closer to the nose) to t ...
, vagus
The vagus nerve, also known as the tenth cranial nerve, cranial nerve X, or simply CN X, is a cranial nerve that interfaces with the parasympathetic control of the heart, lungs, and digestive tract. It comprises two nerves—the left and right v ...
, and accessory nerves. The accessory nerve (top left) travels down through the jugular foramen with the other two nerves, and then passes down, usually over the internal jugular vein, to supply the sternocleidomastoid and trapezius muscles
File:Gray1210.png, Side of the neck, with accessory nerve seen between the sternocleidomastoid and trapezius muscles
File:Slide2ZEO.JPG, The brain and upper spinal cord in a cadaver
A cadaver or corpse is a dead human body that is used by medical students, physicians and other scientists to study anatomy, identify disease sites, determine causes of death, and provide tissue to repair a defect in a living human being. Stud ...
specimen. The accessory nerve can be seen as a number of rootlets arising from the medulla.
References
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External links
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