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The Effects of Somatic Dysfunction on the Spinal Accessory Nerve (CN XI) with Subsequent Distal Dysfunctions by Sherman Gorbis, DO, FAAO

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The Effects of Somatic Dysfunction on the Spinal Accessory Nerve (CN XI) with Subsequent Distal Dysfunctions by Sherman Gorbis, DO, FAAO The Effects of Somatic Dysfunction on the Spinal Accessory Nerve (CN XI) with Subsequent Distal Dysfunctions by Sherman Gorbis, DO, FAAO Abstract This paper will explore how bony and soft tissue dysfunctions, at various Motor codes (head region) locations, can affect The Spinal Accessory Nerve (CN XI). The resultant possible neuromusculoskeletal abnor- Posterior limb of internal capsule malities will be discussed, including specific descriptions of the dysfunctions, along with various types of osteopathic DBOUSSFigon In pyramids manipulative medicine (OMM) as Nucleus amblguus treatment measures. IX Lateral X corticospinal tract The Spinal Root of CN XI is derived XI Jugular from motor cells in the lateral ventral foramen Accessory nucleus columns of the gray matter of the first five or six segments of the spinal cord (1-Page 944). They are approximately in line with nucleus ambiguus. These Flgure XI-I Branchtal Motot Component of Accessory Nerve (Elevated Brain Sterol cells are called the spinal nuclei of the accessory nerve (2-Page 105). Laterally, the motor roots exit the spinal cord about midway between the dorsal and ventral roots. Each inferior root joins with the one above until a trunk is formed that extends superiorly and laterally through the foramen magnum posterior to the Jugular lor•men vertebral artery, bilaterally (XI in Figure Accessory (spinal XI-1). The Cranial Root of CN XI consists nucleus CI-CS of a few axons whose cell bodies reside in the caudal part of nucleus ambiguus Sternomesiod (cull (3-Page 144). These join to form the Lent or scapulae cranial accessory trunk which enters the Trap-axles jugular foramen with the spinal trunk. Within the foramen, the trunks exchange fibers (Figure XI-2). Upon exiting the jugular foramen, the trunks separate. The cranial accessory trunk blends with the vagus nerve (CN X) and supplies the same target musculature as CN X (uvula Figure XI-3 Brunch. Motor Component el Accessory Nerve –± Summer 1996 AAO Jouma1/13 levator veli palatini, pharyngeal Accessory nerve xi constrictor muscle and muscles of the larynx and esophagus). The spinal trunk Lateral corticospinal tract turns backwards, lying ventral to the internal jugular vein in two-thirds and dorsal to it in one-third of the population (1-Page 944). It then passes posteriorly to the stylohyoid and digastric muscles to the sternocleidomastoid (SCM) and Accessory (spinal) trapezius muscles (to which it supplies nucleus in voluntary motor function). The spinal lateral aspect of anlerior accessory trunk, after exiting the jugular grey column foramen, communicates with the second, CI-05 third, and fourth cervical nerves (Figures XI-3, 4, 5). The jugular foramen lies between the lateral portion of the occipital bone and the petrous portion of the temporal bone. CN XI, along with Figure XI-3 Cervical Segment of Bronchial Motor Component (See Level of Section on Fig XI-4j the glossopharyngeal (CN IX) and vagus (CN X) nerves, lies in the jugular foramen between the inferior petrosal sinus anteriorly and the transverse sinus posteriorly (1-Page 142). Somatic dysfunctions (SD) of the sphenoid, occiput, temporals, and upper cervical vertebrae can play an important part in the pathology of CN XI's pathway (4- Page 150). Damage to CN XI results in the patient experiencing downward and lateral rotation of the scapula and some shoulder drop resulting from loss of action of trapezius. Also, the patient Basilar artery experiences weakness Foramen Styioid when turning the head magnum process to the side opposite Vertebral artery Internal the somatic dys- CI jugular vein function (especially C2 C3 Internal against resistance). carotid arter9 Somatic dysfunc- Ca Posterior C5 tions of the sphenoid Trapezius belly of Dorsal root muscle and occiput will be -abill digastric ganglion Levator muscle considered together Ventral root scapulae and named, tradition- L■gamenium Cervical lymph denticulatum nodes ally, sphenobasilar. Dysfunc- Slernomasloid tion names will be listed, followed muscle by a brief description of each. These dysfunctions are named for the direction in which the involved bone(s) Acromion of the moves most freely within the limit of scapula normal motion. In treatment, the ease position, that exhibiting the least possible Clavicle membranous tension, is found. This position (balance point) is held with the 14/AAO Journal Summer 1996 least possible effort. According to Nucleus ambiguus Magoun, "...if the membranous articular 0 strain...is held at the precise neutral Conjoint region of XI with caudal position, conditions will be most fibers of X favorable for adjustment because every part of the delicate complex is under the least possible strain. Then the power Jugular inherent in the tension tone of the dura foramen can operate effectively to secure X Vagus nerve functional freedom." (4-Page 100.) One then waits for spontaneous release and resumption of the Cranial Rhythmic Foramen Impulse (CRI). Retesting follows. magnum XI Accessory Somatic dysfunctions of the nerve Accessory sphenobasilar symphysis are: (spinal) nucleus 1. Flexion - the sphenoid is rotated forward around a transverse axis through the body, anterior to and level with the floor of the sella turcica. The occiput is rotated backward around the transverse axis of the jugular process at the level of Figure XI-5 Cross - Section Through Rostra( (Open) Medulla the sphenobasilar symphysis. The vault approach can be used for this and the dysfunctions that follow. Finger 4. Sidebending rotation - The sphenoid will move (rotation, sidebending, positions are: and occiput rotate in the same direction flexion/extension) in response to the around an anteroposterior axis (one-half occiput, since the dura is firmly attached • Thumbs - interlocked over the vault, of the cranium rotates inferiorly, the at the foramen magnum. The sacrum can but not touching it. other superiorly). The sphenoid and be treated using an indirect • Index fingers - over the lateral occiput also rotate in opposite directions (exaggeration) approach. This can also surface of the greater wings. around parallel vertical axes, through be termed fascia] release (5). For • Middle fingers - just in front of the the middle of the body of the sphenoid example, if the sacrum is restricted in ears. and through the middle of foramen nutation (craniosacral extension/sacral • Ring fingers - behind the ears. magnum. The dysfunction is named for base anterior and inferior) and moving • Little fingers - occiput squama the inferior cranial half (right or left). more freely in counter nutation (medial to the occipitomastoid (craniosacral flexion/sacral base superior suture). 5. Vertical strain. The sphenoid and and posterior), the patient would be asked occiput rotate in the same direction to hold a deep inhalation and exhale 2. Extension - the opposite of flexion, around their transverse axes. The when absolutely necessary. The DO the return to the neutral position after dysfunction is named for the position follows the sacrum into counter nutation, flexion occurs. In this dysfunction, (superior or inferior) of the basisphenoid. during inhalation, and monitors it during flexion is restricted. Both anterior the held inhalation. The sacrum is then quadrants of the sphenoid and both 6. Lateral strain. The sphenoid and followed/gently encouraged during posterior quadrants of the occiput are in occiput rotate in the same direction exhalation: A counter nutation restriction internal rotation. around their parallel vertical axes. The would be treated by asking the patient to dysfunction is named for the position inhale, hold a deep exhalation, and then 3. Torsion - the sphenoid and occiput (right or left) of the basisphenoid. inhale when absolutely necessary. The rotate in opposite directions around an DO follows the sacrum into nutation anteroposterior axis. The dysfunction is After correcting the above during exhalation, monitors it during the named for the superior greater wing of sphenobasilar somatic dysfunctions, the held exhalation, and follows/gently the sphenoid. osteopathic physician (DO) shoulddirect encourages it during inhalation. his/her attention to the sacrum. Since the Retesting follows. sacrum has a firm dural attachment at Dysfunctions of the temporal bone the level of the second sacral segment, it continued on page 29 Summer 1996 AAO Journal/15 The Effects of Somatic jugular foramina (4-Page 96), it is treatment of C1-2 (rotation makes up Dysfunction on the important that venous congestion be about 90 percent of its mobility) which prevented or treated. The venous sinus requires the typical cervicals to be in Spinal Accessory Nerve technique is directed toward enhancing flexion (this removes any rotational (CN XI) with Subsequent venous flow through the jugular foramina. component from C2-7, which would be Distal Dysfunctions This technique is frequently used before present if rotation was tested without by Sherman Gorbis, DO, FAAO approaching specific articular restrictions flexion and isolates rotation to C1-2). when the initial palpatory screening exam Using the principles explained by continued from page 15 revealed a hard, rigid skull with loss of Goodridge (8) and Greenman (7-Page resiliency (7-Page 120). To begin, the 131), ERS dysfunctions can be treated Dysfunction of the temporal bone can weight of the head is supported on the (FRS dysfunctions should not be also alter the function of CN XI. The middle fingerpads having contact on the neglected). These dysfunctions are temporal bones rotate around the axes external occipital protuberance. The DO restricted in flexion, rotation, and which run from the external auditory awaits for a softening sensation and freer sidebending to the same side. When the canals, through the petrous portions of motion. Sequential treatment is directed flexion, sidebending, and rotation the temporals to the sphenobasilar toward the foramen magnum, affecting barriers are engaged, an isometric regions (6-Page 172). External rotation, the cerebellar sinus. When softening contraction is performed by the patient the separation of the temporal squama, occurs, treatment is directed back to the against resistance. Upon patient occurs during sphenobasilar flexion.
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