Download - Neuro clinics 24 - spinal accessory
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Neuro-clinics 24
Dr Pratyush Chaudhuri
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The Spinal Accessory nerve - XI nerve
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• It is called accessory because it is accessory to Vagus.
• Two components: 1.cranial part (ramus internus)2.Spinal part (ramus internus)
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• Eleventh nerve is entirely motor in function.
• Some element of proprioception
• We cannot assess the accessory segment independantly – along with vagus
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• Supplies two muscles
1.Sternocliedomastoid2.Trapezius (upper portion)
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• Action of sternocliedomastoid
Turns the head in the opposite direction and upwards.
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• Action of trapezius
1. Retracts the head and draws it to the corresponding side
2. Retracts and rotates the scapula – assists in abduction at the shoulder.
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• When both sternocliedomastoid work together – causes flexion of the cervical spine + brings the head forward and downward.
• When both trapezius work together – head is drawn backwards and face is deviated upwards.
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• Accessory nerve connects closely with the medial longitudinal fasciculus (MLF)
This is responsible for oculo-cephalic reflex (dolls eye reflex)
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Clinical examination
Sternocliedomastoid • Observe : muscle bulk, tone at rest and on
movement• Active examination – movement against
resistance.• Sternocleidomastoid reflex
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Trapezius examination
• Ask patient to shrug and retract the shoulder• Head tilting towards the side is affected.• Finds difficulty in elevating the arm above the rt
shoulder.
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Lesions
Supranuclear• Since central regulation is bilat- deficit expressed less
Paralytic• Notable as shoulder depression (often resulting in
painful shoulder in hemiplegics)
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Irritative – supra nuclear
• More common• Results in head turning with deviation of the eye in
seizures
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Dissociative paralysis• Trap on one side and sternocleidomastoid on the
other side: happens with lesions above the third nerve nuclei ipsilateral to the sterno.
Extra-pyramidal lesions: Oculogyric crisis
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• Nuclear palsy
• Rare- may occur with pseudo-bulbar palsy
• Note the presence of atrophy and fasciculations
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Infra-nuclear• Cervical adenitis• Meningitis• Neoplasms• Trauma, skull base fractures, cervical spine injuries.
Notable weakness and wasting
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Torticollis (Wryneck)
• Abnormal function of the inhibitory inter-neural network between the trigeminal and accessory has been suggested.
• By far lateral but retrocollis and anterocollis is known
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Etiology
Congenital• Hypertrophy, congenital fusion of the cervical
vertebrae, Klippel-feil syndrome, spina bifidaAcquired• Neonatal: trauma to the sterno at birth.• Post traumatic• Infection – meningitis, cervical adenitis• Reflex torticollis: secondary to occipital neuralgia
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Drug induced• Classical phenothiazines, metclopropamide
Neurogenic: Post encephalitic and dystonias
Psychogenic torticollis
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That all for today ….
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