title: Surgical challenges associated with the morphology of the spinal accessory nerve in the posterior cervical triangle: functional or structural?
abstract: OBJECTIVE
  The spinal accessory nerve (SAN) has been reported to have a distinctly coiled appearance in its course through the posterior cervical triangle of the neck. As this is unusual compared with other peripheral nerves including the cranial nerves, the present histological analysis was performed to further elucidate the reason for this anatomy with potential application in nerve injury and repair.
  
  
  METHODS
  Ten adult cadavers underwent dissection of the neck. The SAN was harvested proximally and within the posterior cervical triangle. For comparison with other cranial nerves within the neck, the cervical vagus and hypoglossal nerves were also harvested. All nerves underwent histological analysis. Additionally, 2 human fetuses (11 and 20 weeks' gestation) underwent examination of the SAN in the posterior cervical triangle, and 3 randomly selected specimens were submitted for electromicroscopy.
  
  
  RESULTS
  All SANs were found to have a straight gross configuration proximal to the posterior triangle and a coiled appearance within this geometrical area. Histologically, no differences were identified for the SAN in these 2 locations (that is, proximal to and within the posterior cervical triangle). The histology of the SAN both with routine analysis and electron microscopy was similar in both regions and to nerves used as controls (for example, vagus and hypoglossal nerves). Interestingly, both fetal specimens were found to have coiled SANs in the posterior cervical triangle.
  
  
  CONCLUSIONS
  Based on this study, it appears that the tortuous course of the SAN in the posterior triangle arises from functional as opposed to structural forces. It is hoped that this analysis will provide some insight into the nature behind the morphology observed in the SAN within the posterior cervical triangle and aid in future investigations regarding its injury. Moreover, such a coiled nature of this nerve may assist the neurosurgeon in identifying it during, for example, neurotization procedures.
authors.affiliation: Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA. rstubbs@uab.edu.
authors.forename: R Shane
authors.initials: RS
authors.lastname: Tubbs
authors.forename: William
authors.initials: W
authors.lastname: Stetler
authors.forename: Robert G
authors.initials: RG
authors.lastname: Louis
authors.forename: Ankmalika A
authors.initials: AA
authors.lastname: Gupta
authors.forename: Marios
authors.initials: M
authors.lastname: Loukas
authors.forename: David R
authors.initials: DR
authors.lastname: Kelly
authors.forename: Mohammadali M
authors.initials: MM
authors.lastname: Shoja
authors.forename: Aaron A
authors.initials: AA
authors.lastname: Cohen-Gadol
mesh_terms: D000055:Accessory Nerve / Q000196:embryology / Q000473:pathology* / Q000601:surgery*; D061227:Accessory Nerve Injuries; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005865:Gestational Age; D006801:Humans; D007002:Hypoglossal Nerve / Q000473:pathology / Q000601:surgery; D008297:Male; D008854:Microscopy, Electron; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D009333:Neck / Q000196:embryology / Q000294:innervation* / Q000601:surgery*; D016067:Nerve Transfer / Q000379:methods; D011247:Pregnancy; D014630:Vagus Nerve / Q000473:pathology / Q000601:surgery