Clinical Anatomy 19:540–543 (2006)

CASE REPORT

Ansa Cervicalis as a Variant of Spinal Accessory Nerve

Plexus: A Case Report
AMIR AFSHIN KHAKI,1* GHAFFAR SHOKOUHI,2 MOHAMMADALI MOHAJEL SHOJA,3
RAMIN MOSTOFI ZADEH FARAHANI,4 SINA ZARRINTAN,5 ARASH KHAKI,6
HASAN MONTAZAM,7 ASGHAR TANOOMAND,8 AND R. SHANE TUBBS9
1
Department of Anatomy, Tabriz University of Medical Sciences, Tabriz, Iran
2
Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
3
Faculty of Medicine, Department of Neurosurgery and Anatomical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
4
Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
5
Faculty of Medicine, Department of Anatomy, Tabriz University of Medical Sciences, Tabriz, Iran
6
Department of Pathology, Faculty of Veterinary, Tabriz Islamic Azad University, Tabriz, Iran
7
Bonab Azad University, Bonab, East Azarbaijan, Tabriz, Iran
8
Faculty of Nursery, Tabriz University of Medical Sciences, Tabriz, Iran
9
Senior Author, Section of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama

The ansa cervicalis is a neural loop in the neck formed by the union of two main nerve
roots, namely superior and inferior roots, derived from ventral rami of the cervical nerves.
With the expanding use of the ansa cervicalis for reinnervation procedures and the fact
that it is located in the vicinity of major nerves and vessels of the neck, knowledge of the
topography and morphology of this loop is quite necessary in the modern era. Any varia-
tion in the course, contributing roots or branching pattern of the ansa cervicalis, potentially
alters and perhaps complicates the course of the procedures involving this nerve such as
neurorrhaphy, skull base surgery, neck dissection, and anterior cervical spinal approach.
Here, we present an unusual case of an ansa cervicalis encountered upon routine dissection
of an adult male cadaver. In this case, the inferior root of the ansa cervicalis was formed
by the joining of two rootlets, one originating from spinal accessory nerve and the other
from a branch of the cervical plexus to the sternocleidomastoid muscle. The fibers travers-
ing the branch of spinal accessory nerve were derived from the first segments of the cervi-
cal spinal cord. This case demonstrates a variant of the spinal accessory nerve plexus that
contributed to the formation of the ansa cervicalis. Review of the literature was performed
to reveal the possible clinical aspects of this anatomical variation. Clin. Anat. 19:540–543,
2006. VC 2006 Wiley-Liss, Inc.

Key words: ansa cervicalis; accessory nerve; anatomical variation; reinnervation

INTRODUCTION The spinal accessory nerve with all its intra- and
extracranial connections to other nerves, principally
Anatomical variation is defined as the normal range
cranial, cervical, and sympathetic, has been referred
in topography and morphology of the body structures.
to as the spinal accessory nerve plexus. Functionally,
This concept is different from anomalies, abnormal-
the plexus provides a union of motor, sensory, and
ities, and malformation terms frequently used in the
medical literature. These terms should be applied *Correspondence to: Dr. Amir A. Khaki, Department of anatomy,
when a given structure has a negative influence on Tabriz University of Medical Sciences, Golgasht St., Daneshgah
organ function under normal conditions. New advan- St., Tabriz, Iran. E-mail: [email protected]
ces in imaging techniques as well as various surgical Received 2 January 2005; Revised 18 August 2005; Accepted 28
procedures, especially minimal invasive and recon- September 2005
structive surgeries, necessitate a new field of research Published online 2 August 2006 in Wiley InterScience (www.
for descriptive anatomy (Sañudo et al., 2003). interscience.wiley.com). DOI 10.1002/ca.20299

V
C 2006 Wiley-Liss, Inc.
 Ansa Cervicalis 541

autonomic nerves for the mouth, palate, pharynx, and Hereby, we presented a variant of the spinal acces-
larynx to gain maximal efficacy in phonation, swallow- sory nerve plexus associated with an unusual ansa cer-
ing, and respiration. The spinal accessory nerve plexus vicalis nerve detected upon routine dissection of an
is of high individual flexibility; variable connections adult, 40-year-old male cadaver. Related neural struc-
intracranially and extracranially between nerve root- tures such as the cervical plexus, interior cranial
lets and nerves themselves make the neural composi- nerves, and sympathetic plexus were dissected out to
tion of the plexus very different at a given point clarify their potential neural interconnections. This
amongst individuals (Brown, 2002). The spinal acces- variation was noted on both sides of the neck.
sory nerve is prone to injury during neck dissection.
Damage to this nerve leads to significant shoulder CASE REPORT
drop, loss of shoulder elevation, and pain. Prevention
Following the dissection of the fascia of the carotid
of inadvertent injury to the accessory nerve is critical
triangle, the hypoglossal nerve was found passing
during dissections of the neck (Lu, 2000). Hence,
rather transversely over the external and internal
knowledge of the topography and morphology of the
carotid arteries. The descending branch of the hypo-
cervical nerve structures and their variations is neces-
glossal nerve, descendens hypoglossi, was detected
sary to improve the outcome of head and neck sur-
and traced downward to locate the ansa cervicalis on
geries, especially those involving the skull base, cervi-
the anterior wall of the carotid sheath. After locating
cal spine, and upper neck structures.
the ansa cervicalis, the inferior root was traced up-
The ansa cervicalis is a neural complex in the
ward, while carefully dissecting the nerve from the
neck formed by the union of ventral rami of the first
internal jugular vein.
cervical nerves through two main roots, namely,
The inferior root originated as a strand from the
superior and inferior roots. The two roots anasto-
spinal accessory nerve, 5 cm below the jugular fora-
mose in the anterior wall of carotid sheath and form
men, approximately at the level of the facial artery
a loop known as the ansa cervicalis or ansa hypo-
(Fig. 1). It was initially behind the internal jugular
glossi (Chaurasia, 1980).
vein and over the levator scapulae. Then, it turned
Usually, the superior root (descendens hypoglossi)
around the lateral aspect of internal jugular vein and
is derived from the hypoglossal nerve and descends
while receiving a communicating branch at its lateral
in the anterior wall of the carotid sheath. After giving
midpoint, directed downward, forward, and medially
off a branch to the superior belly of the omohyoid,
on the anterior wall of the carotid sheath. Ultimately,
it joins the inferior root to form the ansa cervicalis
it was joined by the superior root derived from the
(Chaurasia, 1980; Williams and Warwick, 1990; Chhe-
hypoglossal nerve in front of the common carotid ar-
tri and Berke, 1997). The ansa cervicalis travels ante-
tery. The aforementioned communicating branch was
rior to the internal jugular vein in the majority of the
derived from the muscular branch of the cervical
population (Tubbs et al., 2005). The superior root
plexus just before its distribution beneath and inside
contains fibers only from the first cervical nerve that
the sternocleidomastoid muscle. Another communi-
is transmitted through the sheath of the hypoglossal
cating nerve passed between the inferior and superior
nerve after joining it near the skull base (Chaurasia,
roots, and traversed obliquely over the anterior wall of
1980).
the carotid sheath, and connected both roots at their
The inferior root is commonly derived from the
midways (Fig. 1).
first cervical nerves. In general, C3, C1, C2, and C4
ventral rami contribute to the fibers of the inferior root
DISCUSSION
in a descending order of frequency. Branches from the
ansa cervicalis supply most of the infrahyoid (strap) In this unusual case, the inferior root of the ansa
muscles, namely, steronohyoid, sternothyroid, and in- cervicalis was formed by the joining of two rootlets,
ferior belly of omohyoid. Another branch descends one originating from the spinal accessory nerve and
into the thorax to join the cardiac and phrenic nerves. the other from the branch of the cervical plexus to
The ansa cervicalis nerve is mostly an efferent the sternocleidomastoid muscle. This variation may
nerve and provides a source of multi segmental inner- be of significant clinical importance.
vation for the muscles of the anterior neck. However, The course and location of the ansa cervicalis
an afferent neural composite has been suspected for it along the great vessels of the neck widely varies
as well, because the infrahyoid muscles contribute among individuals. The superior root of the ansa
to the laryngeal steadiness and excursion, a processes cervicalis is more constant in origin, morphology, and
that requires sensory feedback that is necessary for relations to nearby structures than the inferior root.
phonation and deglutition (Chhetri and Berke, 1997). Approximately 25% of specimens demonstrate mor-
542 Khaki et al.

phologically asymmetric patterns owing to different

combinations of neural structures in their formation.
Caliot et al. (1988) revealed seven morphologic forms
of the ansa cervicalis with respect to its inferior roots.
The inferior root of the ansa cervicalis is derived
from the primary ventral rami of C2 and C3 in 74%
of cases. Absence of the inferior root has been re-
ported with a frequency of 3% (Chhetri and Berke,
1997). Reports of unusual origins of the superior root
of the ansa cervicalis are very rare in the literature.
Replacement of the ansa cervicalis with a vagocervi-
cal complex formed by the vagus nerve and a C1-C2
component of the cervical plexus has been reported
by Rath and Anand (1994) in one out of 200 cases
examined. This should be differentiated from a
pseudo ansa cervicalis, which replaces and anatomi-
cally resembles the ansa cervicalis but never gives off

Fig. 1. Photograph and scheme of the cadaveric specimen

showing the ansa cervicalis (superior and inferior roots) and its rela-
tion with nearby nerves and vascular structures. AC, ansa cervicalis;
SR, superior root; IR, inferior root; SAN, spinal accessory nerve;
HN, hypoglossal nerve; BrCP, branch of cervical plexus; ECA,
external carotid artery; FA, facial artery. Note the inferior root of
the ansa cervicalis originates from the spinal accessory nerve. [Color
figure can be viewed in the online issue, which is available at
Figure 1. www.interscience.wiley.com.]

Fig. 2. Laryngeal reinnervation procedures. AC, ansa cervicalis; window in the thyroid cartilage. B: Nerve anastomosis. ARA, ansa cer-
SR, superior root of ansa cervicalis; RLN, recurrent laryngeal nerve. A: vicalis-recurrent laryngeal anastomosis. Note RLN has been cut and
Neuromuscular pedicle transport procedure. IM, infrahyoid muscles; anastomosed to the SR. [Color figure can be viewed in the online issue,
NMP, neuromuscular pedicle. Note AC has been detached at its en- which is available at www.interscience.wiley.com.]
trance to the IM and transported to the paralyzed vocal cord through a
 Ansa Cervicalis 543

muscular branches to the infrahyoid muscles. A 2000; Tubbs et al., 2005). With high anatomical flexi-
pseudo ansa cervicalis should be highly suspected if bility of the nerve structures in the neck, a thorough
the superior or inferior roots are derived from the knowledge of the variations affecting this region
superior cervical sympathetic ganglion and vagus may significantly improve the outcome of head and
nerve, respectively (Indrasingh and Vettivel, 2000). neck operations and is quite necessary for surgeons.
The spinal accessory nerve arises from the first
five cervical spinal segments and receives communi-
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