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Accessory nerve: anatomy and surgical identification

Published online by Cambridge University Press:  25 September 2007

S Lloyd
S Lloyd*
Affiliation:
Whipps Cross University Hospital, Whipps Cross Road, Leytonstone, London E11 1NR, UK
*
Address for correspondence: Mr S K Lloyd, C/o Mr G Kenyon, Whipps Cross University Hospital, London E11 1NR, UK. Fax: 020 7431 8897 E-mail: SKLloyd@blueyonder.co.uk
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Abstract

The XIth cranial nerve or accessory nerve provides the motor supply to the sternocleidomastoid and trapezius muscles. It is frequently encountered during neck surgery, and as such is at risk of iatrogenic injury, resulting in the ‘shoulder syndrome’. Historically, the nerve was sacrificed on oncological grounds during radical neck dissection. However, the basis for sacrifice is unfounded in the majority of cases, and accessory nerve sparing selective neck dissection has equal oncological efficacy. The path of the nerve in the neck is very variable, and there is not a wholly reliable landmark for its identification. However, there are a number of methods described in the literature to guide the surgeon in its identification. This paper provides a systematic review of all the methods available for identification of the accessory nerve, and comments on the reliability of each. In doing so, the detailed anatomy of the accessory nerve is also described.

Keywords

Accessory NerveEleventh Cranial NerveAnatomy
Type
Review Articles
Information
The Journal of Laryngology & Otology , Volume 121 , Issue 12 , December 2007 , pp. 1118 - 1125
Copyright
Copyright © JLO (1984) Limited 2007

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References

1 Crile, G. Excision of cancer of the head and neck with special reference to the plan of dissection in 132 operations. J Am Med Assoc 1906;47:1780–6CrossRefGoogle Scholar
2 Dargent, M, Papillon, J. Motor complications of neck dissection: how to avoid them [in French]. Lyon Chir 1945;40:718Google Scholar
3 Suarez, O. The problem of distant lymphatic metastasis in cancer of the larynx and hypopharynx [in Spanish]. Rev Otorinolaryngol Santiago 1963;23:83–99Google Scholar
4 Bocca, E, Pignataro, O, Sasaki, CT. Functional neck dissection. A description of operative technique. Arch Otolaryngol 1980;106:524–7CrossRefGoogle ScholarPubMed
5 Bocca, E, Pignataro, O, Oldini, C, Cappa, C. Functional neck dissection: an evaluation and review of 843 cases. Laryngoscope 1984;94:942–5CrossRefGoogle ScholarPubMed
6 Brandenburg, JH, Lee, CY. The eleventh nerve in radical neck surgery. Laryngoscope 1981;91:1851–9CrossRefGoogle ScholarPubMed
7 Byer, RM. Modified neck dissection: a study of 967 cases from 1970 to 1980. Am J Surg 1985;150:414–21CrossRefGoogle Scholar
8 Brazilian Head and Neck Cancer Study Group. Results of a prospective trial on elective modified radical neck versus supraomohyoid neck dissection in management of squamous cell carcinoma. Am J Surg 1998;176:422–7CrossRefGoogle Scholar
9 Deutsch, EC, Skolnik, EM, Friedman, M, Hill, JH, Sharer, K. The conservation neck dissection. Laryngoscope 1985;95:561–5CrossRefGoogle ScholarPubMed
10 Molinari, R, Cantu, G, Chiesa, F, Grandi, C. Retrospective comparison of conservation and radical neck dissection in laryngeal cancer. Ann Otol Rhinol Laryngol 1980;89:578–81CrossRefGoogle ScholarPubMed
11 Lingeman, RE, Helmus, C, Stephens, R, Ulm, J. Neck dissection: radical or conservative. Ann Otol Rhinol Laryngol 1977;86:737–44CrossRefGoogle ScholarPubMed
12 Roy, PH, Beahrs, OH. Spinal accessory nerve in radical neck dissections. Am J Surg 1969;118:800–4Google ScholarPubMed
13 Schuller, DE, Platz, CE, Krause, CJ. Spinal accessory lymph nodes: a prospective study of metastatic involvement. Laryngoscope 1978;88:439–50CrossRefGoogle ScholarPubMed
14 Schuller, DE, Saunders, WH, Miglets, AW, Kelly, DR. Conservative neck dissection. Radical approach? Arch Otolaryngol 1981;107:642–5CrossRefGoogle ScholarPubMed
15 Saunders, JR Jr, Hirata, RM, Jaques, DA. Considering the spinal accessory nerve in head and neck surgery. Am J Surg 1985;150:491–4CrossRefGoogle ScholarPubMed
16 Skolnik, EM, Yee, KF, Friedman, M, Golden, TA. The posterior triangle in radical neck surgery. Arch Otolaryngol 1976;102:1–4CrossRefGoogle ScholarPubMed
17 Nahum, AM, Mullally, W, Marmor, L. A syndrome resulting from radical neck dissection. Arch Otolaryngol 1961;74:424–8CrossRefGoogle ScholarPubMed
18 Williams, PL, Dyson, M, Bannister, LH, Collins, P, Berry, MM, Ferguson, MWJ et al. eds. Gray's Anatomy: the Anatomical Basis of Medicine and Surgery, 38th edn. Edinburgh: Churchill Livingstone, 1999Google Scholar
19 McMinn, RMH. Last's Anatomy: Regional and Applied, 9th edn. Edinburgh: Churchill Livingstone, 1994Google Scholar
20 Rhoton, AL Jr, Buza, R. Microsurgical anatomy of the jugular foramen. J Neurosurg 1975;42:541–50CrossRefGoogle ScholarPubMed
21 Smith, CG. Basic Neuroanatomy, 1st edn. Toronto: University of Toronto Press, 1971Google Scholar
22 Soo, KC, Hamlyn, PJ, Pegington, J, Westbury, G. Anatomy of the accessory nerve and its cervical contributions in the neck. Head Neck Surg 1986;9:111–15CrossRefGoogle ScholarPubMed
23 Adetokunboh, A, Ohata, K, Tanaka, K, Hakuba, A. The microsurgical anatomy of the jugular foramen. J Neurosurg 1995;83:903–9Google Scholar
24 Levy, D, Vacher, C, Lezy, JP. Relations of the accessory nerve with the internal jugular vein: surgical implications in cervical lymph node clearances. Surg Radiol Anat 2001;23:155–7Google ScholarPubMed
25 Gardiner, KJ, Irvine, BW, Murray, A. Anomalous relationship of the spinal accessory nerve to the internal jugular vein. Clin Anat 2002;15:62–3CrossRefGoogle Scholar
26 Prades, JM, Timoshinko, A, Dumollard, JM, Durand, M, Merzougui, N, Martin, C. High duplication of the internal jugular vein: clinical incidence in the adult and surgical consequences, a report of 3 clinical cases. Surg Radiol Anat 2002;24:129–32CrossRefGoogle Scholar
27 Kierner, AC, Zelenka, I, Heller, S, Burian, M. Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Arch Surg 2000;135:1428–31CrossRefGoogle ScholarPubMed
28 Dailiana, ZH, Mehdian, H, Gilbert, A. Surgical anatomy of spinal accessory nerve: is trapezius functional deficit inevitable after division of the nerve? J Hand Surg 2001;26:137–41CrossRefGoogle ScholarPubMed
29 Hill, JH, Olson, NR. The surgical anatomy of the spinal accessory nerve and the internal branch of the superior laryngeal nerve. Laryngoscope 1979;89:1935–42CrossRefGoogle ScholarPubMed
30 Caliot, P, Bousquet, V, Midy, D, Cabanie, P. A contribution to the study of the accessory nerve: surgical implications. Surg Radiol Anat 1989;11:11–15CrossRefGoogle Scholar
31 Becker, GD, Parell, GJ. Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 1979;89:827–31CrossRefGoogle ScholarPubMed
32 Bater, MC, Dufty, J, Brennan, PA. High division of the accessory nerve: a rare anatomical variation as a possible pitfall during neck dissection surgery. J Craniomaxillofac Surg 2005;33:340–1CrossRefGoogle ScholarPubMed
33 Brown, H, Burns, SK, Kaiser, CN. The spinal accessory nerve plexus, the trapezius muscle and shoulder stabilization after radical neck cancer surgery. Ann Surg 1988;296:654–61CrossRefGoogle Scholar
34 Lu, L, Haman, SP, Ebraheim, NA. Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study. Orthopedics 2002;25:71–4CrossRefGoogle ScholarPubMed
35 Tubbs, RS, Salter, EG, Wellons, JC 3rd, Blount, JP, Oakes, WJ. Superficial landmarks for the spinal accessory nerve within the posterior cervical triangle. J Neurosurg Spine 2005;3:375–8CrossRefGoogle ScholarPubMed
36 Landau, SI. International Dictionary Of Medicine And Biology. London: John Wiley, 1986;3Google Scholar
37 Hone, SW, Ridha, H, Rowley, H, Timon, CI. Surgical landmarks of the spinal accessory nerve in modified radical neck dissection. Clin Otolaryngol Allied Sci 2001;26:16–18CrossRefGoogle ScholarPubMed
38 Kierner, AC, Zelenka, I, Burian, M. How do the cervical plexus and the spinal accessory nerve contribute to the innervation of the trapezius muscle? As seen from within using Sihler's stain. Arch Otolaryngol Head Neck Surg 2001;127:1230–2CrossRefGoogle Scholar
39 Hattori, Y, Doi, K, Toh, S, Baliarsing, AS. Surgical approach to the spinal accessory nerve for brachial plexus reconstruction. J Hand Surg 2001;26:1073–6CrossRefGoogle Scholar
40 Al-Qattan, MM, El-Shayeb, A. Identification of the spinal accessory nerve within the surgical field during primary exploration of the brachial plexus in infants with obstetric palsy. J Hand Surg 2005;30:808–11CrossRefGoogle ScholarPubMed
41 Kierner, AC, Burian, M, Bentzien, S, Gstoettner, W. Intraoperative electromyography for identification of the trapezius muscle innervation: clinical proof of a new anatomical concept. Laryngoscope 2002;112:1853–6CrossRefGoogle ScholarPubMed
42 Weitz, JW, Weitz, SL, McElhinney, AJ. A technique for preservation of spinal accessory nerve function in radical neck dissection. Head Neck Surg 1982;5:75–8CrossRefGoogle ScholarPubMed
43 Stacy, RJ, O'Leary, ST, Hamlyn, PJ. The innervation of the trapezius muscle: a cervical motor supply. J Craniomaxillofac Surg 1995;23:250–1CrossRefGoogle Scholar
44 Soo, KC, Guiloff, RJ, Oh, A, Della Rovere, GQ, Westbury, G. Innervation of the trapezius muscle: a study in patients undergoing neck dissections. Head Neck 1990;12:488–95CrossRefGoogle ScholarPubMed
45 Eisele, DW, Weymuller, EA Jr, Price, JC. Spinal accessory nerve preservation during neck dissection. Laryngoscope 1991;101:433–5CrossRefGoogle ScholarPubMed
46 Pereira, MT, Williams, WW. The spinal accessory nerve distal to the posterior triangle. J Hand Surg 1999;24:368–9CrossRefGoogle Scholar
47 Jobe, CM, Kropp, WE, Wood, VE. Spinal accessory nerve in a trapezius-splitting surgical approach. J Shoulder Elbow Surg 1996;5:206–8CrossRefGoogle Scholar
48 Bertelli, JA, Ghizoni, MF. Improved technique for harvesting the accessory nerve for transfer in brachial plexus injuries. Neurosurgery 2006;58(suppl 2):366–70Google ScholarPubMed
49 Leung, MK, Dieu, T, Cleland, H. Surgical approach to the accessory nerve in the posterior triangle of the neck. Plast Reconstr Surg 2004;113:2067–70CrossRefGoogle Scholar
50 Baring, DE, Johnston, A, O'Reilly, BF. The identification of the accessory nerve by its relationship to the great auricular nerve. J Laryngol Otol 2007 (In press)CrossRefGoogle Scholar
51 King, RJ, Mott, AG. Iatrogenic accessory nerve palsy. Ann R Coll Surg Engl 1983;65:35Google Scholar
52 Salasche, SJ, Bernstein, G, Senkarik, M. Surgical Anatomy of the Skin. Norwalk, Connecticutt: Appleton and Lange, 1988;12, 116–17, 263–5Google Scholar
53 Rafferty, MA, Goldstein, DP, Brown, DH, Irish, JC. The sternomastoid branch of the occipital artery: a surgical landmark for the spinal accessory nerve in selective neck dissections. Otolaryngol Head Neck Surg 2005;133:874–6CrossRefGoogle ScholarPubMed
54 Tatla, T, Kanagalingam, J, Majithia, A, Clarke, PM. Upper neck spinal accessory nerve identification during neck dissection. J Laryngol Otol 2005;119:906–8CrossRefGoogle ScholarPubMed
55 Chaukar, DA, Pai, A, D'Cruz, AK. A technique to identify and preserve the spinal accessory nerve during neck dissection. J Laryngol Otol 2006;120:494–6CrossRefGoogle ScholarPubMed
56 Deschler, DG, Singer, MI. Preservation of spinal accessory nerve in modified neck dissections. Laryngoscope 1996;106:664–6CrossRefGoogle ScholarPubMed
57 Stearns, MP, Shaheen, OH. Preservation of the accessory nerve in block dissection of the neck. J Laryngol Otol 1981;95:1141–8CrossRefGoogle ScholarPubMed
58 Fisher, DA. A simple method of identifying the spinal accessory nerve. Dermatol Surg 2000;26:384–6CrossRefGoogle ScholarPubMed
59 Midwinter, K, Willatt, D. Accessory nerve monitoring and stimulation during neck surgery. J Laryngol Otol 2002;116:272–4CrossRefGoogle ScholarPubMed