XI Accessory Nerve

CASE HISTORY
Burt, a 55-year-old businessman, was having episodes of weakness involving his
right right face and arm. These were diagnosed as transient ischemic attacks
(TIAs) often referred to as reversible strokes. During investigation for his TIAs, he
was found to have 90 percent narrowing of his left internal carotid artery and
underwent left carotid endarterectomy.
Approximately two weeks postoperatively, Burt began to notice he was having
problems pulling a sweater off over his head and was unable to bring his left arm
over his head while swimming. He also developed a constant aching on the left side
of his neck and left ear and a dull pain in his left shoulder. The vascular surgeon
referred Burt to a neurologist. The neurologist noted that sensation Was intact over
Burt's face, neck, and shoulders, but he had weakness with shoulder elevation on
his left side and was unable to abduct (raise) his left arm above the level of his
shoulder. Electromyographic and nerve conduction studies showed that there had
been damage to the branch of the left accessory (spinal) nerve that supplies the
trapezius muscle, but that the branch to the sternomas-toid* muscle had been
spared.

ANATOMY OF THE ACCESSORY NERVE

Information from the premotor association cortex and other cortical areas is fed
into the motor cortex by association fibers. Axons of cortical neurons descend in
the cor-ticospinaF tract through the posterior limb of the internal capsule.
Cortical neurons destined to supply the sternomastoid muscle descend to the
ipsilateral accessory (spinal) nucleus located in the lateral part of the anterior
grey column of the upper five or six segments of the cervical spinal cord,
approximately in line with the nucleus ambiguus. Axons designated to supply
the trapezius muscle cross the mid-line in the pyramidal decussation to synapse
in the contralateral accessory nucleus (Figure XI-1 and Table XI-1).
From the accessory nucleus, postsynaptic fibers emerge from the lateral
white matter of the spinal cord as a series of rootlets to form the accessory nerve
(see Figure XI-1 and Chapter X, Figure X-2). The rootlets emerge posterior to
the ligamen-tum denticulatum, but anterior to the dorsal roots of the spinal cord
(Figure XI—2). The rootlets form a nerve trunk that ascends rostrally in the
subarachnoid space and parallel to the spinal cord as far as the foramen magnum.
At the foramen magnum

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Sternomastoid is a shortened form of sternocleidomastoid and will be used in this text.

†
The term corticospinal tract versus corticobulbar tract is used because the descending axons project to
the accessory nucleus in the spinal cord rather than to a nucleus in the brain stem.
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