A novel method of lengthening the accessory nerve for direct coaptation during nerve repair and nerve transfer procedures

OBJECTIVEThe accessory nerve is frequently repaired or used for nerve transfer. The length of accessory nerve available is often insufficient or marginal (under tension) for allowing direct coaptation during nerve repair or nerve transfer (neurotization), necessitating an interpositional graft. An attractive maneuver would facilitate lengthening of the accessory nerve for direct coaptation. The aim of the present study was to identify an anatomical method for such lengthening.METHODSIn 20 adult cadavers, the C-2 or C-3 connections to the accessory nerve were identified medial to the sternocleidomastoid (SCM) muscle and the anatomy of the accessory nerve/cervical nerve fibers within the SCM was documented. The cervical nerve connections were cut. Lengths of the accessory nerve were measured. Samples of the cut C-2 and C-3 nerves were examined using immunohistochemistry.RESULTSThe anatomy and adjacent neural connections within the SCM are complicated. However, after the accessory nerve was “detethered” from within the SCM and following transection, the additional length of the accessory nerve increased from a mean of 6 cm to a mean of 10.5 cm (increase of 4.5 cm) after cutting the C-2 connections, and from a mean of 6 cm to a mean length of 9 cm (increase of 3.5 cm) after cutting the C-3 connections. The additional length of accessory nerve even allowed direct repair of an infraclavicular target (i.e., the proximal musculocutaneous nerve). The cervical nerve connections were shown not to contain motor fibers.CONCLUSIONSAn additional length of the accessory nerve made available in the posterior cervical triangle can facilitate direct repair or neurotization procedures, thus eliminating the need for an interpositional nerve graft, decreasing the time/distance for regeneration and potentially improving clinical outcomes.

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Study of the cervical plexus innervation of the trapezius muscle

Journal of Neurosurgery Spine ◽

10.3171/2011.1.spine10717 ◽

2011 ◽

Vol 14 (5) ◽

pp. 626-629 ◽

Cited By ~ 29

Author(s):

R. Shane Tubbs ◽

Mohammadali M. Shoja ◽

Marios Loukas ◽

Jeffrey Lancaster ◽

Martin M. Mortazavi ◽

...

Keyword(s):

Fiber Type ◽

Trapezius Muscle ◽

Immunohistochemical Analysis ◽

Nerve Transfer ◽

Nerve Fibers ◽

Spinal Accessory Nerve ◽

Accessory Nerve ◽

Type I ◽

Cervical Nerve ◽

Spinal Accessory

Object There is conflicting and often anecdotal evidence regarding the potential motor innervation of the trapezius muscle by cervical nerves, with most authors attributing such fibers to proprioception. As knowledge of such potential motor innervations may prove useful to the neurosurgeon, the present study aimed to elucidate this anatomy further. Methods Fifteen adult cadavers (30 sides) underwent dissection of the posterior triangle of the neck and harvesting of cervical nerve fibers found to enter the trapezius muscle. Random fibers were evaluated histologically to determine fiber type (that is, motor vs sensory axons). Results In addition to an innervation from the spinal accessory nerve, the authors also identified cervical nerve innervations of all trapezius muscles. For these innervations, 3 sides were found to have fibers derived from C-2 to C-4, 2 sides had fibers derived from C-2 to C-3, and 25 sides had fibers derived from C-3 to C-4. Fibers derived from C-2 to C-4 were classified as a Type I innervation, those from C-2 to C-3 were classified as a Type II innervation, and those from C-3 to C-4 were classified as a Type III innervation. Immunohistochemical analysis of fibers from each of these types confirmed the presence of motor axons. Conclusions Based on the authors' study, cervical nerves innervate the trapezius muscle with motor fibers. These findings support surgical and clinical experiences in which partial or complete trapezius function is maintained after injury to the spinal accessory nerve. The degree to which these nerves innervate this muscle, however, necessitates further study. Such information may be useful following nerve transfer procedures, denervation techniques for cervical dystonia, or sacrifice of the spinal accessory nerve due to pathological entities.

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Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk

Journal of Neurosurgery Spine ◽

10.3171/2018.12.spine18498 ◽

2019 ◽

Vol 31 (1) ◽

pp. 133-138 ◽

Cited By ~ 3

Author(s):

Johannes A. Mayer ◽

Laura A. Hruby ◽

Stefan Salminger ◽

Gerd Bodner ◽

Oskar C. Aszmann

Keyword(s):

Brachial Plexus ◽

Nerve Repair ◽

Nerve Transfer ◽

Axillary Nerve ◽

Spinal Accessory Nerve ◽

Accessory Nerve ◽

Nerve Function ◽

Analog Scale ◽

Spinal Accessory ◽

Active Range Of Motion

OBJECTIVESpinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.METHODSFive cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.RESULTSAll 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.CONCLUSIONSRestoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.

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Surgical Anatomy of Spinal Accessory Nerve: Is Trapezius Functional Deficit Inevitable after Division of the Nerve?

Journal of Hand Surgery (European Volume) ◽

10.1054/jhsb.2000.0487 ◽

2001 ◽

Vol 26 (2) ◽

pp. 137-141 ◽

Cited By ~ 59

Author(s):

Z. H. DAILIANA ◽

H. MEHDIAN ◽

A. GILBERT

Keyword(s):

Nerve Transfer ◽

Surgical Anatomy ◽

Spinal Accessory Nerve ◽

Accessory Nerve ◽

Cervical Plexus ◽

Spinal Accessory ◽

Iatrogenic Injuries ◽

Functional Deficit ◽

Posterior Triangle ◽

Transfer Procedures

The course of spinal accessory nerve in the posterior triangle, the innervation of the sternocleidomastoid and trapezius muscles and the contributions from the cervical plexus were studied in 20 cadaveric dissections. The nerve was most vulnerable to iatrogenic injuries after leaving the sternocleidomastoid. Direct innervation of trapezius by cervical plexus branches was noted in five dissections, whereas connections between the cervical plexus and the spinal accessory nerve were observed in 19 dissections. These were usually under the sternocleidomastoid (proximal to the level of division of the nerve in nerve transfer procedures). Although the contribution from the cervical plexus to trapezius innervation is considered minimal, trapezius function can be protected in neurotization procedures by transecting the spinal accessory nerve distal to its branches to the upper position of trapezius.

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Improved white matter integrity after contralateral seventh cervical nerve transfer measured by tractographic representation

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2021.106715 ◽

2021 ◽

pp. 106715

Author(s):

Hyun-Joo Lee ◽

Hyun-Sil Cha ◽

Myong-Hun Hahm ◽

Huijoong Lee ◽

Sang Soo Kim ◽

...

Keyword(s):

White Matter ◽

Nerve Transfer ◽

White Matter Integrity ◽

Cervical Nerve

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STUDIES ON ENTRY AND EGRESS OF POLIOMYELITIS INFECTION

Journal of Experimental Medicine ◽

10.1084/jem.92.6.571 ◽

1950 ◽

Vol 92 (6) ◽

pp. 571-589 ◽

Cited By ~ 1

Author(s):

Harold K. Faber ◽

Rosalie J. Silverberg ◽

Lester A. Luz ◽

Luther Dong

Keyword(s):

Alimentary Tract ◽

Secondary Phase ◽

Blood Stream ◽

Nerve Fibers ◽

The Body ◽

Infraorbital Nerve ◽

Gasserian Ganglion ◽

Neural Connections ◽

Axonal Conduction ◽

Initial Stage

Excretion of poliomyelitis virus has been demonstrated in monkeys after four different parenteral routes of inoculation. Virus has been found in both the pharyngeal secretions and the stools after infraorbital nerve dip and after inoculation of the Gasserian ganglion; in the pharyngeal secretions after intrathalamic inoculation; and in the stools after inoculation of the celiac ganglion. Excretion began as early as the 2nd and as late as the 7th day after inoculation, in all instances before the onset of symptoms. The immediate source of the excreted virus appeared to be infected peripheral ganglia with neural connections to the mucous membranes of the upper and lower portions of the alimentary tract, notably the pharynx. Primary infection of the body surfaces was excluded in the experiments and therefore could not account for the excretion of virus. The mode of elimination was probably by centrifugal spread through axons of peripheral nerve fibers and not by way of the blood stream or lymphatics. Evidence was obtained that when excretion of virus has once occurred, reinvasion from the implicated surface to other, previously uninfected peripheral ganglia ensues, thus providing new sources for excretion and other potential pathways for invasion of the CNS. It is suggested that such reinvasion may occur serially until the immunological defenses come into play. Our experiments lend support to the view that during the initial stage of poliomyelitis, and perhaps throughout its course in some cases, e.g. the asymptomatic and the mild cases without central nervous symptoms, infection is confined to the peripheral nervous system. Involvement of the CNS when it occurs is a secondary phase of the infective process and is not a necessary prelude to elimination of the virus. Excretion is explainable on the basis of the established neurocytotropism and axonal conduction of the virus without resort to the hypothesis of extraneural infection.

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