The X-pointer: A forgotten anatomical relationship of spinal accessory nerve and great auricular nerve.

INTRODUCTION: The preservation of the spinal accessory nerve cannot be overlooked in neck dissection. Injury to the nerve results in shoulder dysfunction and other related morbidities. In this article, we describe a unique constant relationship between spinal accessory nerve and great auricular nerve, at the junction of the anterior and posterior triangles of the neck, eponymously labelled the X- pointer. METHODOLOGY: This was an observational study conducted at a tertiary care cancer centre that runs a comprehensive surgical training program. A 100 cases of modified radical neck dissection performed for oral cavity squamous cell carcinoma from January 2017 to January 2019 in were included. The relationship was analyzed in 100 cases of neck dissection for its constancy. RESULT: In all the 100 cases, the X-pointer was demonstrated as a constant anatomical relationship between the spinal accessory nerve and great auricular nerve. The crossing over of the nerve on the undersurface of the sternocleidomastoid muscle is constant and independent of the patient's body proportions. CONCLUSIONS: The relationship between the spinal accessory nerve and great auricular nerve remains constant irrespective of the technique of neck dissection and body habitus of the patient. In our view, this relationship can be used as an additional confirmatory landmark to prevent inadvertent injury to the spinal accessory nerve.

Schwannoma of the extracranial portion of the accessory nerve presenting as spinal adenopathy.

Schwannomas are benign tumours arising from Schwann cells in the peripheral nerve. The schwannoma of the accessory nerve is a very rare entity. We report a case of Schwannoma of the extracranial accessory nerve. A 22-year-old man presented with a slow-growing mass, located on the right upper neck. The patient did not have any neurological deficit. CT scan showed a hypodense mass behind sternocleidomastoid muscle. The suspected diagnosis was an adenopathy of the accessory spinal chain. Surgery was done via transcervical approach. The histopathological analysis concluded with a diagnosis of schwannoma. No recurrence was noted at the follow-up examination 29 months after surgery.

Increased (18)F-FDG uptake in the trapezius muscle in patients with spinal accessory neuropathy.

UNLABELLED: To investigate (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) signal changes of denervated muscles in patients with electrophysiologically confirmed neuropathy. METHODS: This is a case series of three cancer patients who were referred to the electromyography laboratory in 2013 due to shoulder discomfort after surgery including neck dissection. Spinal accessory neuropathy was diagnosed based on electrophysiological studies. Patients' medical history, electrophysiological data, and FDG-PET images were reviewed retrospectively. Mean standard uptake values (SUV) of trapezius muscles were measured. RESULTS: The patients (3 men, aged 61-78years) showed spinal accessory neuropathy with different degrees of severity. In all patients, preoperative or postoperative FDG-PET showed increased FDG uptake in the ipsilateral trapezius muscle. These results were compatible with previously reported glucose hypermetabolism in denervated skeletal muscles. CONCLUSION: This is the first clinical report of increased FDG uptake by denervated muscles in electrophysiologically confirmed neuropathy.

MRI findings of spinal accessory neuropathy.

AIM: To characterise the magnetic resonance imaging (MRI) appearance of patients with spinal accessory nerve (SAN) denervation. MATERIAL AND METHODS: Twelve patients who had SAN denervation on electromyography (EMG) were included. The sternocleidomastoid and trapezius muscles and the SAN were assessed using MRI. RESULTS: Trapezius muscle atrophy was seen in 11 (92%), and of those patients, T2/short tau inversion recovery (STIR) signal hyperintensity was also demonstrated in seven (58%). All three patients with prior neck surgery had scarring around the SAN, and one of these patients demonstrated a neuroma, which was confirmed surgically. CONCLUSION: Features of SAN neuropathy on MRI include atrophy and T2/STIR signal hyperintensity of the trapezius, and in patients who have had posterior triangle neck surgery, scarring may be seen around the nerve.

Idiopathic cranial polyneuropathy with unilateral IX and X and contralateral XI nerve palsy in a 4-year-old boy.

A 4-year-old boy presented with a sudden onset of nasal escape of fluids, nasal speech, and difficulty placing his left arm through a sleeve. Neurologic examination indicated a unilateral cranial IX and X and contralateral XI nerve palsy that was considered idiopathic. Palsy of cranial nerves IX, X, and XI is rare in childhood, and few reports have described this condition. Our patient received prednisolone for 1 week and demonstrated complete recovery within several weeks. We suggest that aggressive therapy is unnecessary for patients with idiopathic cranial polyneuropathy. The pathogenesis of this condition may involve an immunologic mechanism.

[Spinal root of accessory nerve shwannoma: about a new case]. / Schwannome de la racine spinale du nerf accessoire : à propos d'une nouvelle observation.

BACKGROUND: The accessory nerve schwannoma localized in spinal canal is extremely rare; only nine cases have been reported in the literature until now. We report a new case of schwannoma at the spinal root of accessory nerve. OBSERVATION: A young woman aged 30 had a high cervical spinal cord compression with respiratory problems. At admission, magnetic resonance imaging (MRI) showed a tumor compressing the spinal cord at C2 to the foramen magnum. The tumor was removed successfully and its origin from the left accessory nerve was confirmed peroperatively. CONCLUSION: Although schwannoma of the accessory nerve is exceptional, this entity should be considered as a differential diagnosis with the other tumors of the foramen magnum.

Multiple ancient schwannoma of the accessory nerve: a case report.

We are reporting a case of multiple ancient schwannoma of the accessory nerve in a 57 year old male. Accessory schwannomas are rare with only 19 cases reported in literature so far. Ancient schwannoma is even rarer in the head and neck region with no other cases associated with the accessory nerve being reported in literature so far.

Spinal accessory nerve cavernous malformation.

We present the first reported case of a spinal accessory nerve cavernous malformation. A 54-year-old Caucasian male presented with a several-year history of progressive, vague bilateral upper and lower extremity paresthesias and pain. MRI of the spine revealed a heterogenously enhancing mass in the dorsal aspect of the spinal canal at the level of the atlas with mild spinal cord compression. The lesion was resected and upon gross and histologic examination it was a cavernous malformation embedded within a branch of the spinal accessory nerve. Post-operatively, the patient had no complications and some improvement in his symptoms. To our knowledge, this is the first report of a patient with a spinal accessory nerve cavernous malformation, and this should be considered in the differential of lesions in the craniocervical region.

Spinal accessory nerve lesions.

The spinal accessory nerve, primarily a motor nerve, innervates the sternocleidomastoid and trapezius muscles. Proximally, lesions can occur intracranially at the skull base or just outside the jugular foramen producing ipsilateral weakness of trapezius and sternocleidomastoid muscles; or distally, in the posterior neck triangle causing trapezius muscle weakness.

An unusual presentation of whiplash injury: long thoracic and spinal accessory nerve injury.

Whiplash injuries from motor vehicle accidents are very common. The usual presentation and course of this condition normally results in resolution of symptoms within a few weeks. Brachial plexus traction injuries without any bone or joint lesion of the cervical spine have been reported before. We report a case where a gentleman was involved in a rear end vehicle collision, sustained a whiplash injury and was later found to have a long thoracic nerve palsy and spinal accessory nerve palsy. Although isolated injuries of both nerves following a whiplash injury have been reported, combined injury of the two nerves following a whiplash injury is very uncommon and is being reported for the first time.

Spinal accessory nerve meningioma in a paediatric patient: case report.

Accessory nerve meningiomas are exceedingly rare. We present a case of a nine-year-old patient with neurofibromatosis type 2 who had radiologic evidence of spinal cord compression from an upper cervical/foramen magnum lesion. He was asymptomatic from this lesion, but it progressed in size. The tumor was resected and histologic investigation revealed frequent tight whorls and psammoma bodies consistent with meningioma. To the authors' knowledge, this is the first reported spinal accessory nerve meningioma in a pediatric patient.

[Diagnostic complexities and anatomical surprises in a case of thyroid surgery for papillary carcinoma]. / Complessità diagnostiche e sorprese anatomiche in un caso di chirurgia tiroidea per carcinoma papillare.

We present the case of a male patient who needed surgery for a large undefined submandibular schwannoma and a small contralateral thyroid carcinoma associated with cervical lymph nodes of a dubious nature. During the operative procedure all the pathological conditions were resolved, with some remarkable surprises. A non-functioning parathyroid adenoma was found and removed. A fairly unusual anatomical complication was also detected with regard to the right inferior laryngeal nerve, i.e. an anastomotic branch connecting the main trunk to the vagus nerve.

Meningioma of the accessory nerve extending from the jugular foramen into the parapharyngeal space.

A 35-year-old man presented with pain in the right shoulder and neck for 18 months. The neurological examination revealed complete accessory nerve palsy on the right side without further deficits. Magnetic resonance imaging showed a right parapharyngeal tumour expanding into the posterior fossa through the jugular foramen without dural attachment and absence of invasion into the middle ear cavity or internal auditory meatus. Intraoperative inspection disclosed a tumour originating from the accessory nerve. Histological diagnosis revealed a meningothelial meningioma with invasion of the epineural space. To the knowledge of the authors this is the first report of an accessory nerve meningioma in the jugular foramen associated with a posterior fossa component and extension into the parapharyngeal space.

Surgical treatment of dumbbell-shaped jugular foramen schwannomas.

OBJECT: Schwannomas of the jugular foramen are rare, comprising between 2 and 4% of intracranial schwannomas. The authors retrospectively analyzed their surgical experience with schwannomas of the lower cranial nerves that presented with intra- and extracranial extensions through an enlarged jugular foramen. The transcondylar suprajugular approach was used without sacrificing the labyrinth or the integrity of the jugular bulb. In this report the clinical and radiological features are discussed and complications are analyzed. METHODS: This retrospective study includes six patients (three women and three men, mean age 31.6 years) with dumbbell-shaped jugular foramen schwannomas that were surgically treated by the senior author during a 5.5-year period. One patient had undergone previous surgery elsewhere. Glossopharyngeal and vagal nerve deficits were the most common signs (appearing in all patients), followed by hypoglossal and accessory nerve deficits (66.6%). Two or more signs or symptoms were present in every patient. Three tumors presented with cystic degeneration. In four patients the jugular bulb was not patent on neuroimaging studies. The suprajugular approach was used in five patients; the origin of the tumor from the 10th cranial nerve could be defined in three of them. All lesions were completely resected. No death or additional postoperative cranial nerve deficits occurred in this series. Aspiration pneumonia developed in one patient. Preoperative deficits of the ninth and 10th cranial nerves improved in one third of the patients and half recovered mobility of the tongue. No recurrence was discovered during the mean follow-up period of 32.8 months. CONCLUSIONS: With careful, extensive preoperative evaluation and appropriate planning of the surgical approach, dumbbell-shaped jugular foramen schwannomas can be radically and safely resected without creating additional neurological deficits. Furthermore, recovery of function in the affected cranial nerves can be expected.

Glomus jugulare tumour presenting with isolated accessory nerve palsy.

Glomus tumours of the skull base are rare, and most frequently present with symptoms of hearing loss and tinnitus. Diagnosis is often delayed due to the slow growth of the tumour. We describe the previously unreported occurrence of a glomus tumour presenting with a unilateral accessory nerve palsy.

Spinal accessory schwannoma mimicking a tumor of the fourth ventricle: case report.

OBJECTIVE AND IMPORTANCE: Spinal accessory schwannomas unassociated with neurofibromatosis are very rare, and only 30 cases have been reported in the literature. To our knowledge, this is the first report of a spinal accessory schwannoma mimicking a tumor of the fourth ventricle. CLINICAL PRESENTATION: A 50-year-old man presented with neck pain after being involved in a motor vehicle accident. There were no neurological deficits, but a computed tomographic scan revealed a large hypodense mass with punctuate calcifications in the fourth ventricle. The tumor exhibited low intensity on the T1-weighted magnetic resonance imaging scan and high intensity on the T2-weighted scan, and it showed inhomogeneous contrast enhancement. INTERVENTION: The tumor was totally removed by a bilateral suboccipital craniectomy and C1 laminectomy. Dissection of the surgical specimen revealed that the tumor had originated from the left spinal accessory nerve. Histopathological examination confirmed the diagnosis of schwannoma. The patient experienced transient postoperative cerebellar ataxia but recovered completely. CONCLUSION: Intracisternal-type spinal accessory schwannomas sometimes mimic a tumor of the fourth ventricle. Total surgical resection can be achieved with good outcome.

Bilateral meningiomatous lesions of the spinal accessory nerves.

BACKGROUND: Meningiomas arising from cranial nerves with no dural attachment are exceedingly rare. The authors present a patient with bilateral meningiomatous lesions originating symmetrically from both spinal accessory nerves. CASE REPORT: A 61-year old woman presented with a one-year history of spinal ataxia and minimal left-sided motor impairment. Magnetic resonance imaging demonstrated two extrinsic lesions dorsolaterally of the medulla. Surgical exposure via a midline suboccipital approach with C1 laminectomy revealed the lesions arising from the spinal accessory nerves and in direct contact with the vertebral arteries. Histological investigation showed hypocellular fibrous lesions with proliferating meningothelial cells, psammoma bodies and immunoreactivity for vimentin, S-100 protein and epithelial membrane antigen. INTERPRETATION: To the authors' knowledge this is the first report of intradural tumours of the spinal accessory nerves not derived from Schwann cells and the first report of bilateral intracranial meningiomatous lesions without dural attachment.

Schwannoma of the spinal accessory nerve in the cisterna magna.

BACKGROUND: Intracranial schwannoma of the accessory nerve can be divided into two types. One is a jugular foramen type arising from the accessory nerve of the jugular foramen, while the other is an intracisternal type, which arises from the spinal root of the accessory nerve and is separate from the jugular foramen. The latter type is rare, and only 9 cases have been reported previously. CASE DESCRIPTION: A 46-year-old female presented with a large, midline mass lesion in the posterior fossa manifesting as foramen magnum syndrome. Magnetic resonance imaging (MRI) revealed a huge tumor with cystic lesion located in the cisterna magna with extension to the C1 spinal level. The tumor was totally removed by a suboccipital craniectomy and C1 laminectomy. It originated from the spinal root of the right accessory nerve. Temporary slight atrophy of the right sternocleidomastoid muscle was observed, but the patient was free of disease 2 years after treatment. CONCLUSIONS: We report a schwannoma of the spinal accessory nerve in the cisterna magna. The clinical and neuroradiological findings are discussed with a review of the literature. The initial symptoms were variable without loss of function of the cranial nerve, and the tumor tended to grow in the cisterna magna without laterality. Because of the absence of typical neurologic symptoms, early neuroradiological investigation by MRI is recommended for accurate diagnosis of these tumors.