Anatomical evidence for the absence of a morphologically distinct cranial root of the accessory nerve in man

A detailed review of the spinal accessory nerve and its anatomical variations with cadaveric illustration

The spinal accessory nerve, considered part of the eleventh cranial nerve, provides motor innervation to sternocleidomastoid and trapezius. A comprehensive literature review and two cadaveric dissections were undertaken. The spinal accessory nerve originates from the spinal accessory nucleus. Its rootlets unite and ascend between the denticulate ligament and dorsal spinal rootlets. Thereafter, it can anastomose with spinal roots, such as the McKenzie branch, and/or cranial roots. The spinal accessory nerve courses intracranially via foramen magnum and exits via jugular foramen, within which it usually lies anteriorly. Extracranially, it usually crosses anterior to the internal jugular vein and lies lateral to internal jugular vein deep to posterior belly of digastric. The spinal accessory nerve innervates sternocleidomastoid, receives numerous contributions in the posterior triangle and terminates within trapezius. Its posterior triangle course approximates a perpendicular bisection of the mastoid-mandibular angle line. The spinal accessory nerve contains sensory nociceptive fibres. Its cranial nerve classification is debated due to occasional non-fusion with the cranial root. Surgeons should familiarize themselves with the variable course of the spinal accessory nerve to minimize risk of injury. Patients with spinal accessory nerve injuries might require specialist pain management.

El verdadero origen aparente de los nervios glosofaríngeo, vago y accesorio

Introducción. Existe un vacío conceptual asociado con los sitios precisos por donde emergen las raíces de los nervios glosofaríngeo, vago y accesorio, un conocimiento que es de suma importancia para los neurocirujanos.Objetivo. Determinar el sitio preciso por donde las raíces de los nervios glosofaríngeo, vago y accesorio emergen como origen aparente en la médula oblongada.Materiales y métodos. Se valoraron 67 troncos encefálicos humanos que con anterioridad habían sido fijados en solución de formalina al 10%. Mediante inspección directa, luego de retirar las meninges, se examinó y registró el sitio preciso por donde emergen las raíces de tales nervios y se comparó con lo registrado en la literatura.Resultados. En el 100% de los troncos encefálicos estudiados se encontró que las raíces nerviosas emergen entre 2mm a 3mm por detrás del surco retro-olivar, distinto a lo reportado en la literatura consultada.Conclusión. Hay disparidad de criterios en cuanto al origen aparente de los nervios glosofaríngeo, vago y accesorio, lo que amerita un estudio más amplio que permita llegar a un consenso generalizado sobre el sitio preciso por donde las raíces de tales nervios hacen su aparición.

Functional anatomy of the accessory nerve studied through intraoperative electrophysiological mapping

OBJECTIVE

Classically the 11th cranial nerve (CN XI, or accessory nerve) is described as having a cranial and a spinal root, the latter arising from the upper segments of the spinal cord through a number of very fine rootlets. According to classical knowledge, the cranial root gives motor innervation to the vocal cords, whereas the spinal root provides the motor innervation of the sternocleidomastoid muscle (SCM) and of the upper portions of the trapezius muscle (TZ). The specific function of each of the rootlets of the spinal component is not well known. Therefore the authors aimed to map, using intraoperative direct electrical stimulation and electromyographic (EMG) recordings, the innervation territory of these rootlets in relation to their exit level from the CNS.

METHODS

Forty-nine patients undergoing surgery with intradural exposure at the craniocervical junction were enrolled in the study. The EMG recordings included the sternal and clavicular parts of the SCM (SCM-S and SCM-C), the superior and middle parts of the TZ (TZ-S and TZ-M), and whenever possible the vocal cords. The main trunk of CN XI, its roots (both cranial and spinal), and when possible the fine cervical rootlets, were stimulated at predetermined locations, from the jugular foramen down to the lowest cervical level exposed. The EMG responses were collected, and a map of the responses was drawn up.

RESULTS

Monitoring and stimulation of the spinal root were performed in all cases, whereas for the cranial root this was possible in only 19 cases. A total of 262 stimulation sites were explored: 70 at the common trunk of the nerve, 19 at the cranial root, 136 at various levels on the spinal root, and 37 at the cervical rootlets. A vocal cord response was obtained by stimulation of the cranial root in 84.2% (16/19); absence of response was considered to have a technical origin. In no case did the vocal cords respond to the stimulation of the spinal root or rootlets. Stimulation of the cervical rootlets yielded responses that differed according to the level of stimulation: at C-1 the SCM-S responded 95.8% of the time (23/24); at C-2 the SCM-C responded 90.0% of the time (9/10); at C-3 the TZ-S responded 66.6% of the time (2/3); and below that level only the TZ-M responded. The spinal root stimulated at its various levels responded accordingly.

CONCLUSIONS

The function of each of the rootlets of CN XI appears to be specific. The cranial root contributes, independently of the spinal root, to the innervation of the vocal cords, which makes it a specific entity. The spinal root innervates the SCM and TZ with a cranio-caudal motor organization of its cervical rootlets.

Intraoperative Mapping and Monitoring for Rootlets of the Lower Cranial Nerves Related to Vocal Cord Movement

BACKGROUND

Damage to the motor division of the lower cranial nerves that run into the jugular foramen leads to hoarseness, dysphagia, and the risk of aspiration pneumonia; therefore, its functional preservation during surgical procedures is important. Intraoperative mapping and monitoring of the motor rootlets at the cerebellomedullary cistern using endotracheal tube electrodes is a safe and effective procedure to prevent its injury.

OBJECTIVE

To study the location of the somatic and autonomic motor fibers of the lower cranial nerves related to vocal cord movement.

METHODS

Twenty-four patients with pathologies at the cerebellopontine lesion were studied. General anesthesia was maintained with fentanyl and propofol. A monopolar stimulator was used at amplitudes of 0.05 to 0.1 mA. Both acoustic and visual signals were displayed as vocalis muscle electromyographic activity using endotracheal tube surface electrodes.

RESULTS

The average number of rootlets was 7.4 (range, 5-10); 75% of patients had 7 or 8 rootlets. As many as 6 rootlets (2-4 in most cases) were responsive in each patient. In 23 of the 24 patients, the responding rootlets congregated on the caudal side. The maximum electromyographic response was predominantly in the most caudal or second most caudal rootlet in 79%.

CONCLUSION

The majority of motor fibers of the lower cranial nerves run through the caudal part of the rootlets at the cerebellomedullary cistern, and the maximal electromyographic response was elicited at the most caudal or second most caudal rootlet.

ABBREVIATION

EMG, electromyographic.

Evolutionary and developmental understanding of the spinal accessory nerve

The vertebrate spinal accessory nerve (SAN) innervates the cucullaris muscle, the major muscle of the neck, and is recognized as a synapomorphy that defines living jawed vertebrates. Morphologically, the cucullaris muscle exists between the branchiomeric series of muscles innervated by special visceral efferent neurons and the rostral somitic muscles innervated by general somatic efferent neurons. The category to which the SAN belongs to both developmentally and evolutionarily has long been controversial. To clarify this, we assessed the innervation and cytoarchitecture of the spinal nerve plexus in the lamprey and reviewed studies of SAN in various species of vertebrates and their embryos. We then reconstructed an evolutionary sequence in which phylogenetic changes in developmental neuronal patterning led towards the gnathostome-specific SAN. We hypothesize that the SAN arose as part of a lamprey-like spinal nerve plexus that innervates the cyclostome-type infraoptic muscle, a candidate cucullaris precursor.

Morphological characteristics of the cranial root of the accessory nerve

There has been the controversy surrounding the cranial root (CR) of the accessory nerve. This study was performed to clarify the morphological characteristics of the CR in the cranial cavity. Fifty sides of 25 adult cadaver heads were used. The accessory nerve was easily distinguished from the vagus nerve by the dura mater in the jugular foramen in 80% of 50 specimens. The trunk of the accessory nerve from the spinal cord penetrated the dura mater at various distances before entering the jugular foramen. In 20% of the specimens there was no dural boundary. In these cases, the uppermost cranial rootlet of the accessory nerve could be identified by removing the dura mater around the jugular foramen where it joined to the trunk of the accessory nerve at the superior vagal ganglion. The cranial rootlet was formed by union of two to four short filaments emerging from the medulla oblongata (66%) and emerged single, without filament (34%), and usually joined the trunk of the accessory nerve directly before the jugular foramen. The mean number of rootlets of the CR was 4.9 (range 2-9) above the cervicomedullary junction. The CR of the accessory nerve was composed of two to nine rootlets, which were formed by the union of two to four short filaments and joined the spinal root of the accessory nerve. The CR is morphologically distinct from the vagus nerve, confirming its existence.

Adenoids in children: Advances in immunology, diagnosis, and surgery

Adenoids are strategically located for mediating local and regional immune functions as they are exposed to antigens from both the outside air and the alimentary tract. Recurrent or chronic respiratory infections can induce histomorphological and functional changes in the adenoidal immunological barrier, sometimes making surgical treatment necessary. Our aim in this review is to summarize the crucial points about not only the immunological histopathology of adenoidal tissue, especially in patients with adenoid hypertrophy, but also the most common and useful diagnostic techniques and surgical options.

Solitary fibrous tumour of the vagus nerve

We describe the complete removal of a foramen magnum solitary fibrous tumour in a 36-year-old woman. It originated on a caudal vagus nerve rootlet, classically described as the 'cranial' accessory nerve root. This ninth case of immunohistologically confirmed cranial or spinal nerve SFT is the first of the vagus nerve.

Transitional Nerve: A New and Original Classification of a Peripheral Nerve Supported by the Nature of the Accessory Nerve (CN XI)

Classically, the accessory nerve is described as having a cranial and a spinal root. Textbooks are inconsistent with regard to the modality of the spinal root of the accessory nerve. Some authors report the spinal root as general somatic efferent (GSE), while others list a special visceral efferent (SVE) modality. We investigated the comparative, anatomical, embryological, and molecular literature to determine which modality of the accessory nerve was accurate and why a discrepancy exists. We traced the origin of the incongruity to the writings of early comparative anatomists who believed the accessory nerve was either branchial or somatic depending on the origin of its target musculature. Both theories were supported entirely by empirical observations of anatomical and embryological dissections. We find ample evidence including very recent molecular experiments to show the cranial and spinal root are separate entities. Furthermore, we determined the modality of the spinal root is neither GSE or SVE, but a unique peripheral nerve with a distinct modality. We propose a new classification of the accessory nerve as a transitional nerve, which demonstrates characteristics of both spinal and cranial nerves.

Cisternal segments of the glossopharyngeal, vagus, and accessory nerves: detailed magnetic resonance imaging-demonstrated anatomy and neurovascular relationships

OBJECT

The aim of this study was to determine whether high-resolution MR imaging is suitable for identifying and differentiating among the nerve root bundles of the glossopharyngeal (cranial nerve [CN] IX), vagus (CN X), and accessory nerves (CN XI) as well as any adjacent vessels.

METHODS

Twenty-five patients (50 sides) underwent MR imaging using the 3D constructive interference in steady-state (CISS) sequence, as well as noncontrast and contrast-enhanced 3D time-of-flight (TOF) MR angiography. Two individuals scored these studies by consensus to determine how well these sequences displayed the neurovascular contacts and nerve root bundles of CNs IX and X and the cranial and spinal roots of CN XI. Landmarks useful for identifying each lower CN were specifically sought.

RESULTS

The 3D CISS sequence successfully depicted CNs IX and X in 100% of the sides. Nerve root bundles of the cranial segment of CN XI were identified in 88% of the sides and those of the spinal segment of CN XI were noted in 93% of the sides. Landmarks useful in identifying the lower CNs included the vagal trigone, the choroid plexus of the lateral recess, the glossopharyngeal and vagal meatus, the inferior petrosal sinus, and the vertebral artery. The combined use of 3D CISS and 3D TOF sequences demonstrated neurovascular contacts at the nerve root entry or exit zones in 19% of all nerves visualized.

CONCLUSIONS

The combined use of 3D CISS MR imaging and 3D TOF MR angiography (with or without contrast) successfully displays the detailed anatomy of the lower CNs and adjacent structures in vivo. These imaging sequences have the potential to aid the preoperative diagnosis of and the presurgical planning for pathology in this anatomical area.

The jugular foramen: imaging strategy and detailed anatomy at 3T

BACKGROUND AND PURPOSE

The purpose of this study was to assess how well the anatomy of the jugular foramen (JF) could be displayed by 3T MR imaging by using a 3D contrast-enhanced fast imaging employing steady-state acquisition sequence (CE-FIESTA) and a 3D contrast-enhanced MR angiographic sequence (CE-MRA).

MATERIALS AND METHODS

Twenty-five patients free of skull base lesions were imaged on a 3T MR imaging scanner using CE-FIESTA and CE-MRA. Two readers analyzed the images in collaboration, with the following objectives: 1) to score the success with which these sequences depicted the glossopharyngeal (CNIX) and vagus (CNX) nerves, their ganglia, and the spinal root of the accessory nerve (spCNXI) within the JF, and 2) to determine the value of anatomic landmarks for the in vivo identification of these structures.

RESULTS

CE-FIESTA and CE-MRA displayed CNIX in 90% and 100% of cases, respectively, CNX in 94% and 100%, and spCNXI in 51% and 0% of cases. The superior ganglion of CNIX was discernible in 89.8% and 87.8%; the inferior ganglion of CNIX, in 73% and 100%; and the superior ganglion of CNX, in 98% and 100% of cases. Landmarks useful for identifying these structures were the inferior petrosal sinus and the external opening of the cochlear aqueduct.

CONCLUSIONS

This study protocol is excellent for displaying the complex anatomy of the JF and related structures. It is expected to aid in detecting small pathologies affecting the JF and in planning the best surgical approach to lesions affecting the JF.

Neuroanatomical basis of Sandifer's syndrome: a new vagal reflex?

Sandifer's syndrome is a gastrointestinal disorder with neurological features. It is characterized by reflex torticollis following deglutition in patients with gastroesophageal reflux and/or hiatal hernia. The authors believe that neurological manifestations of the syndrome are the consequence of vagal reflex with the reflex center in nucleus tractus solitarii (NTS). Three models for the neuroanatomical basis of the hypothetic reflex arc are presented. In the first one the hypothetic reflex arc is based on the classic hypothesis of two components nervus accessorius (n.XI) - radix cranialis (RC) and radix spinalis (RS) The nervous impulses are transmitted by nervus vagus (n.X) general visceral afferent (GVA) fibers to NTS situated in medulla oblongata, then by interneuronal connections on nucleus ambiguus (NA) and nucleus dorsalis nervi vagi (NDX). Special visceral efferent fibers (SVE) impulses from NA are in part transferred to n.XI ramus externus (RE) (carrying the majority of general somatic efferent (GSE) fibers) via hypothetic anastomoses in the region of foramen jugulare. This leads to contraction of trapezius and sternocleidomastoideus muscles, and the occurrence of intermittent torticollis. In the second suggested neuroanatomical model the hypothetic reflex arc is organized in the absence of n.XI RC, the efferent part of the reflex arc continues as NA, which is motor nucleus of nervus glossopharyngeus (n.IX) and n.X in this case while distal roots of n.XI that appear at the level of the olivary nucleus lower edge represent n.X roots. In the third presented model the hypothetic reflex arc includes no jugular transfer and could be realized via interneuronal connections directly from NTS to the spinal motoneurons within nucleus radicis spinalis nervi accessorii (NRS n.XI) or from NA to NRS n.XI. The afferent segment of the postulated reflex arc in all three models is mediated via n.X. We conclude that Sandifer's syndrome is a clinical manifestation of another vagal reflex that could be termed a "vagocervical" or "esophagocervical" reflex, based on the neuroanatomical hypotheses elaborated in this paper.

Is the cranial accessory nerve really a portion of the accessory nerve? Anatomy of the cranial nerves in the jugular foramen

The accessory nerve is traditionally described as having both spinal and cranial roots, with the spinal root originating from the upper cervical segments of the spinal cord and the cranial root originating from the dorsolateral surface of the medulla oblongata. The spinal rootlets and cranial rootlets converge either before entering the jugular foramen or within it. In a recent report, this conventional view has been challenged by finding no cranial contribution to the accessory nerve. The present study was undertaken to re-examine the accessory and vagus nerves within the cranium and jugular foramen, with particular emphasis on the components of the accessory nerve. These nerves were traced from their rootlets attaching to the spinal cord and the medulla and then through the jugular foramen. The jugular foramen was exposed by removing the dural covering and surrounding bone. A surgical dissecting microscope was used to trace the roots of the glossopharyngeal nerve (CN IX), vagus nerve (CN X) and accessory nerve (CN XI) before they entered the jugular foramen and during their travel through it. The present study demonstrates that the accessory nerve exists in two forms within the cranial cavity. In the majority of cases (11 of 12), CN XI originated from the spinal cord with no distinct contribution from the medulla. However, in one of 12 cases, a small but distinct connection was seen between the vagus and the spinal accessory nerves within the jugular foramen.

Localization of motoneurons that extend axons through the ventral rami of cervical nerves to innervate the trapezius muscle: A study using fluorescent dyes and 3D reconstruction method

It has been suggested that in addition to motor axons, which extend directly into the spinal accessory nerve (SAN), ventral rami-associated motor fibers of cervical nerves also innervate the trapezius muscle. Using fluorescent dye labeling and 3D reconstruction in adult rats, this study clarifies the localization of motoneurons, which extend axons either directly through the SAN or through the ventral rami of cervical nerves to innervate the trapezius. DiI or DiI and DiO were used to label the ventral rami of cervical nerves entering the SAN, as well as branches of the SAN. We show that motoneurons whose axons pass through the ventral rami of cervical nerves and then enter the SAN, and those extending axons directly through the SAN are distributed within the same area. The neurons that extend axons through the SAN had a greater diameter than those axons that pass through the cervical nerves en route to the trapezius muscle. In addition, the axons that ultimately extend through the SAN exit the spinal cord dorsolaterally, while those that pass through the cervical nerves extend out the spinal cord through the ventral roots. We presume that the neurons that extend axons through the SAN are mainly alpha-motoneurons and that those projecting axons through the cervical nerves to the trapezius are mainly gamma-motoneurons. Taken together, these results could explain why patients in whom the SAN was used to treat brachial plexus injury retain some control of the trapezius muscle.

Re-examination of the medullary rootlets of the accessory and vagus nerves

The vagus (X) and cranial root of the accessory nerve (crXI) are traditionally described as arising from a series of rootlets from the medulla oblongata. Descriptions of the number of rootlets vary, and the existence of the crXI is contested. Here we report the results of dissections in six embalmed adult human specimens (11 sides). The rootlets forming the vagus were counted at three positions. At emergence from the brainstem there were between 12 and 21 rootlets, at the jugular foramen the range was 12-17, and midway between these two points it was 6-12. In addition, the origin of the most caudal X rootlet (cX) and the most rostral XI rootlet (rXI) was recorded in relation to the spino-medullary junction, defined as the caudal border of the olivary eminence. The position of the cX varied between -1 and +8 mm (median = +2 mm on left, +3.75 mm on right). The rXI varied between -5 and +7 mm (median = -0.5 mm on left, +1.75 mm on right). In five sides, rXI was above the caudal border of the olivary eminence and as such can be defined as being of cranial origin. These observations show the arrangement of rootlets contributing to the vagus to be more complex than what was described previously and provide evidence for the variable existence of a cranial root of the accessory nerve.

Superficial landmarks for the spinal accessory nerve within the posterior cervical triangle

OBJECT

The spinal accessory nerve (SAN) within the posterior cervical triangle (PCT) is the most commonly iatrogenically injured nerve in the body. Nevertheless, there is a paucity of published information regarding superficial landmarks for the SAN in this region. Additional identifiable landmarks of this nerve may assist the surgeon in identifying it for repair, use of it in peripheral nerve neurotization, or avoiding it as in proximal brachial plexus repair. The present study was undertaken to provide reliable superficial landmarks for the identification of the SAN within the PCT.

METHODS

The PCT was dissected in 30 cadaveric sides. Measurements were made between the SAN and surrounding landmarks. The mean distances between the entry site of the SAN into the trapezius and a midpoint of the clavicle, mastoid process, acromion process, and lateral aspect of the sternocleidomastoid (SCM) muscle were 6, 7, 5.5, and 3.5 cm, respectively. The mean distances between the angle of the mandible and the mastoid process and the exit point of the SAN from the posterior border of the SCM muscle were 6 and 5 cm, respectively. The mean width and length of the SAN were 3 and 3.5 cm, respectively.

CONCLUSIONS

It is the authors' hope that these data will aid those who may need to locate or avoid the SAN while undertaking surgery in the PCT and thus decrease morbidity that may follow manipulation of this region.

Forces necessary for the disruption of the cisternal segments of cranial nerves II through XII

Manipulation of the cisternal segment of cranial nerves is often performed by the neurosurgeon. To date, attempts at quantifying the forces necessary to disrupt these nerves in situ, to our knowledge, has not been performed. The present study seeks to further elucidate the forces necessary to disrupt the cranial nerves while within the subarachnoid space. The cisternal segments of cranial nerves II through XII were exposed in six unfixed cadavers, all less than 6 hr postmortem. Forces to failure were then measured. Mean forces necessary to disrupt nerves for left sides in increasing order were found for cranial nerves IX, VII, IV, X, XII, III, VIII, XI, VI, V, and II, respectively. Mean forces for right-sided cranial nerves in increasing order were found for cranial nerves IX, VII, IV, X, XII, VIII, V, VI, XI, III, and II, respectively. Overall, cranial nerves requiring the least amount of force prior to failure included cranial nerves IV, VII, and IX. Those requiring the highest amount of force included cranial nerves II, V, VI, and XI. There was an approximately ten-fold difference between the least and greatest forces required to failure. Cranial nerve III was found to require significantly (P < 0.05) greater forces to failure for right versus left sides. To date, the neurosurgeon has had no experimentally derived data from humans for the in situ forces necessary to disrupt the cisternal segment of cranial nerves II through XII. We found that cranial nerve IX consistently took the least amount of force until its failure and cranial nerve II took the greatest. Other cranial nerves that took relatively small amount of force prior to failure included cranial nerves IV and VII. Although in vivo damage can occur prior to failure of a cranial nerve, our data may serve to provide a rough estimation for the maximal amount of tension that can be applied to a cranial nerve that is manipulated while within its cistern.

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.