Last edited: 9/6/2021

59. ACCESSORY NERVE – CN XI

Accessory Nerve: Cranial Nerve XI Medical Editor: Dr. Sarah Abimhamed

OUTLINE Structures the pharyngeal plexus supplies

The pharynx, especially the superior, middle, inferior
I) ORIGIN OF THE NERVE pharyngeal constrictors.
II) COURSE OF CN XI
III) SPINAL NERVES THAT RUN WITH CN XI
Also supplies muscles of the soft palate
IV) CLINICAL CORRELATION
V) APPENDIX (salpingopharyngeus, the palatoglossus,
VI) REVIEW QUESTIONS palatopharyngeus, levator veli palatini, muscles of the
VII) REFERENCES uvula).

CN IX also picks up sensations from the oropharynx and

laryngopharynx (GVA fibers)
I) ORIGIN OF THE NERVE
Origin: Nucleus ambiguus (NA) in the medulla of the brain
stem.
This nucleus is the origin of many nerves like:
- Glossopharyngeal Nerve (CN IX)
- Vagus Nerve (CN X)
- Accessory nerve (CN XI - cranial part)

Figure 3. Structures the Nerve supply (CN IX in orange; CN X

in pink; CN XI (internal fibers) in blue)

(B) SPINAL PART OF THE ACCESSORY NERVE

In the cervical spinal cord:

Figure 1. Origin of Accessory Nerve
II) COURSE OF CN XI
Fibers come from the lateral funiculus  move outwards
and upwards then move posteriorly to the ventral root
and anteriorly to the dorsal root (run behind the denticulate
ligaments)

(A) CRANIAL PART OF THE ACCESSORY NERVE

From the NA  fibers of CN XI (these are called the
internal fibers of CN XI) enter through the jugular
foramen with the vagus nerve (CN X)

Figure 4. Origin of Spinal Part of CN XI

III) SPINAL NERVES THAT RUN WITH CN XI

From ventral ramus of C2-C3 to SCM

Fibers from C2-C3  ventral ramus runs with accessory
nerve to supply SCM

Figure 2. Course of Internal Fibers of CN XI

Accessory Nerve – CN XI NEURO PHYSIOLOGY: Note #59. 1 of 3

From ventral ramus of C3-C4 to trapezius
Fibers from C3-C4  ventral ramus  supplies trapezius
muscle
Origin
Primary
Somatomotor
Cortex
Figure 5. Origin of Spinal Nerves and Spinal part of CN XI
Figure 6. Course of Nerves of Cervical Spinal and Spinal Part
of CN XI
Fibers from cortex of the brain (corticobulbar fibers)
In the precentral gyrus, fibers emerge from the primary
somatomotor cortex  the motor neurons move down and
give connections to:
Figure 7. Fibers from Primary Somatomotor Cortex
Figure 8. Corticobulbar fibers at the spinal cord level
2 of 3 NEURO PHYSIOLOGY: Note #59.
Course of Corticobulbar Tract
Table 1. Summary of course of corticobulbar tract
IV) CLINICAL CORRELATION
Lesions can occur in any part of the pathway:
Lesion in precentral gyri that can affect the corticobulbar
fiber: e.g. an infarction.
Nucleus: e.g. tumor, abscess, infarction of vessels.
Spinal cord: e.g. ALS, polio, motor neuron disease.
Cranium: e.g. metastatic lesions can spread in that area
Neck: blunt force trauma can damage CN XI
Cervical Lymph Nodes: Infections / Lymphoma of
cervical lymph nodes  enlarge and compress on nerve.
o Cervical lymph nodes run close proximity to CN XI
If there is a tumor, any biopsy, radical neck dissection or
radiation therapy performed on the lymph nodes 
damage the accessory nerve
Demyelinating condition of CN XI (Guillain-Barré
syndrome)
ICA: e.g. aneurysm of the vessel can compress the nerve
CLINICAL PRESENTATION:
The posterior cervical triangle location is important, as
clinical effects differ depending on whether the lesion is
before the triangle or after. [See Figure 6. Course of Nerves
of Cervical Spinal and Spinal Part of CN XI]
(1) Lesion proximal to the triangle
- If there is a lesion proximal to the triangle (before
the posterior cervical triangle)  SCM weakness
Recall SCM function: flexion, ipsilateral movement of the
head. It also helps turn the head to the contralateral side.
Therefore if it is damaged on one side cannot move head
to the opposite side
(2) Lesion distal to the triangle
- If there is a lesion distal to the posterior triangle
(after the triangle)  trapezius is damaged
Recall Trapezius function: elevation of the scapula, and
retraction of scapula and stabilization of the shoulder joint
Therefore if trapezius is damaged:
o Drooping of shoulders, upper mild winging of the
scapula, laterally displaced scapula, difficulty in
abducting and elevating the arms above the
horizontal axis
o SCM is spared
Accessory Nerve – CN XI
 V) APPENDIX

Table 2. Summary of Accessory Nerve (CN XI)

Part Of CN XI Origin Foramen Nerves it runs with Structures It Supplies
Cranial Part Nucleus Ambiguus Jugular foramen CN X & CN IX Pharynx & Soft Palate

Foramen Magnum - Sternocleidomastoid

Spinal Part Lateral Funiculus C2-C3 spinal nerves Sternocleidomastoid

Intervertebral Foramina
C3-C4 spinal nerves Trapezius muscle

ABBREVIATIONS:
o NA: Nucleus Ambiguus
o SCM: Sternocleidomastoid
o ICA: Internal Carotid Artery
o IJV: Internal Jugular Vein
o ALS: Amyotrophic lateral sclerosis

VI) REVIEW QUESTIONS VII) REFERENCES

1) Which nucleus does the accessory nerve originate from?

a) Dorsal Nucleus of Vagus ● The Cervical Plexus - Spinal nerves - Branches. (2019, October
26). TeachMeAnatomy.
b) Nucleus Tractus Solitarius https://teachmeanatomy.info/neck/nerves/cervical-plexus/
c) Nucleus Ambiguus
d) Medulla Oblongata
2) Which nerve forms the pharyngeal plexus with CN XI
and CNX?
a) CN IX
b) CN V
c) CN VII
d) CN XII
3) Through which opening do the internal branches of
CN XI go through to exit the skull?
a) Foramen magnum
b) Foramen ovale
c) Jugular Foramen
d) Foramen SpinosumAt which level of the cervical
spinal cord do the ventral rami supply the SCM?
e) C1-C2
f) C2-C3
g) C3-C4
h) C4-C5
4) Which muscle is supplied by contralateral
corticobulbar fibers?
a) SCM
b) Pharyngeal Constrictors
c) Trapezieus
d) Levator Veli Palatini
5) Which triangle of the neck does CN XI go through?
a) Anterior Triangle
b) Posterior Triangle
c) Carotid Triangle
d) Submandibular Triangle
6) Which type of fibers of CN IX supplies the
oropharynx and laryngopharynx?
a) GVE
b) GVA
c) GSE
d) GSA
7) Which muscle is affected when the lesion occurs
after the triangle of the neck?
a) SCM
b) Trapezieus
c) Levator Scapulae Muscle
d) Levator Veli Palatini

CHECK YOUR ANSWERS

Accessory Nerve – CN XI NEURO PHYSIOLOGY: Note #59. 3 of 3