Korean J Pain.  2020 Jan;33(1):48-53. 10.3344/kjp.2020.33.1.48.

New insights into pathways of the accessory nerve and transverse cervical artery for distal selective accessory nerve blockade

• Heo Y
• Cho N
• Cho H
• Won HS
• Yang M
• Kim YD

• KMID: 2506642
• DOI: http://doi.org/10.3344/kjp.2020.33.1.48

Abstract

Background
The aim of this study was to clarify the topographical relationship between the accessory nerve (AN) and transverse cervical artery (TCA) to provide safe and convenient injection points for AN blockade.
Methods
This study included 21 and 30 shoulders of 14 embalmed Korean adult cadavers and 15 patients, respectively, for dissection and ultrasound (US) examination.
Results
The courses of the TCA and AN in the scapular region were classified into four types based on their positional relationships. Type A indicated the nerve that was medial to the artery and ran parallel without changing its location (38%). In type B (38%), the nerve was lateral to the artery and ran parallel without changing its location. In type C (19%), the nerve or artery traversed each other only once during the whole course. In type D (5%), the nerve or artery traversed each other more than twice forming a twist. At the levels of lines I-IV, the nerve was relatively close to the artery (approximately 10 mm). TCAs were observed in all specimens around the superior angle of the scapula at the level of line II, whereas they were not found below line VI. In US images of the patients, the TCA was commonly observed at the level of line II (93.3%) where all ANs and TCAs were observed in cadaveric dissection.
Conclusions
The results expand the current knowledge of the relation between the AN and TCA, and provide helpful information for selective diagnostic nerve blocks in the scapular region.

Keyword

Accessory Nerve; Diagnosis; Injections; Scapula; Scapular Region; Selective Nerve Blockade; Transverse Cervical Artery; Ultrasound

Figure

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  Fig. 1 Marking method showing the course of the accessory nerve (yellow colored head pins) and transverse cervical artery (red colored head pins). Tz: trapezius muscles.

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  Fig. 2 Lines and points defined for analyzing the positional relationship between the spinal accessory nerve and reference line connecting the superior and inferior angles of the scapula. SA: superior angle of scapula, SS: spine of scapula, IA: inferior angle of scapula.

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  Fig. 3 Frequency and distance of the transverse cervical artery (A) and accessory nerve (B) at the level of each line of the cadavers (green and red colored bars indicate the structures passing toward the medial and lateral sides of the reference line connecting the superior and inferior angles of the scapula, respectively).

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  Fig. 4 Ultrasound (US) images and frequency of the detected transverse cervical artery; In the panels A–D show US images of the same patient at the lines I–IV, respectively. Tz: trapezius muscle, Rm: rhomboid minor muscle, Sc: scapula, SS: supraspinatus muscle.

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  Fig. 5 Recommendable point under ultrasound guided or blind injection technique. SA: superior angle of scapula, SS: spine of scapula, IA: inferior angle of scapula.

Reference

1. Shiozaki K, Abe S, Agematsu H, Mitarashi S, Sakiyama K, Hashimoto M, et al. Anatomical study of accessory nerve innervation relating to functional neck dissection. J Oral Maxillofac Surg. 2007; 65:22–9. DOI: 10.1016/j.joms.2005.11.091. PMID: 17174759.

2. Nystrom NA, Champagne LP, Freeman M, Blix E. Surgical fasciectomy of the trapezius muscle combined with neurolysis of the Spinal accessory nerve; results and long-term follow-up in 30 consecutive cases of refractory chronic whiplash syndrome. J Brachial Plex Peripher Nerve Inj. 2010; 5:7. DOI: 10.1186/1749-7221-5-7. PMID: 20374624. PMCID: 2864276.

3. Chandawarkar RY, Cervino AL, Pennington GA. Management of iatrogenic injury to the spinal accessory nerve. Plast Reconstr Surg. 2003; 111:611–7. DOI: 10.1097/01.PRS.0000041943.47622.EB. PMID: 12560682.

4. Cappiello J, Piazza C, Giudice M, De Maria G, Nicolai P. Shoulder disability after different selective neck dissections (levels II–IV versus levels II–V): a comparative study. Laryngoscope. 2005; 115:259–63. DOI: 10.1097/01.mlg.0000154729.31281.da. PMID: 15689746.

5. Restrepo CE, Tubbs RS, Spinner RJ. Expanding what is known of the anatomy of the spinal accessory nerve. Clin Anat. 2015; 28:467–71. DOI: 10.1002/ca.22492. PMID: 25546396.

6. Bremner-Smith AT, Unwin AJ, Williams WW. Sensory pathways in the spinal accessory nerve. J Bone Joint Surg Br. 1999; 81:226–8. DOI: 10.1302/0301-620X.81B2.0810226. PMID: 10204925.

7. Bodner G, Harpf C, Gardetto A, Kovacs P, Gruber H, Peer S, et al. Ultrasonography of the accessory nerve: normal and pathologic findings in cadavers and patients with iatrogenic accessory nerve palsy. J Ultrasound Med. 2002; 21:1159–63. DOI: 10.7863/jum.2002.21.10.1159. PMID: 12369671.

8. Kessler J, Gray AT. Course of the spinal accessory nerve relative to the brachial plexus. Reg Anesth Pain Med. 2007; 32:174–6. DOI: 10.1097/00115550-200703000-00022. PMID: 17350538.

9. Townsley P, Ravenscroft A, Bedforth N. Ultrasound-guided spinal accessory nerve blockade in the diagnosis and management of trapezius muscle-related myofascial pain. Anaesthesia. 2011; 66:386–9. DOI: 10.1111/j.1365-2044.2011.06691.x. PMID: 21418047.

10. Canella C, Demondion X, Delebarre A, Moraux A, Cotten H, Cotten A. Anatomical study of phrenic nerve using ultrasound. Eur Radiol. 2010; 20:659–65. DOI: 10.1007/s00330-009-1579-z. PMID: 19727747.

11. Li AE, Greditzer HG 4th, Melisaratos DP, Wolfe SW, Feinberg JH, Sneag DB. MRI findings of spinal accessory neuropathy. Clin Radiol. 2016; 71:316–20. DOI: 10.1016/j.crad.2015.11.015. PMID: 26787069.

12. Cappiello J, Piazza C, Nicolai P. The spinal accessory nerve in head and neck surgery. Curr Opin Otolaryngol Head Neck Surg. 2007; 15:107–11. DOI: 10.1097/MOO.0b013e3280523ac5. PMID: 17413412.

13. Choi CH, Choi JH, Sung CH. Positive effects of local anesthetic nerve blocks for a patient with newly developed left side spasmodic torticollis after surgical intervention of right side spasmodic torticollis - a case report. Korean J Pain. 2007; 20:246–50. DOI: 10.3344/kjp.2007.20.2.246.

14. Ramamurthy S, Akkineni SR, Winnie AP. A simple technic for block of the spinal accessory nerve. Anesth Analg. 1978; 57:591–3. DOI: 10.1213/00000539-197809000-00017. PMID: 568432.

15. Scott PV. Asystole from tetanic stimulation of the accessory nerve. Anaesthesia. 1996; 51:1148–50. DOI: 10.1111/j.1365-2044.1996.tb15053.x. PMID: 9038452.

16. Waldman SD. Atlas of interventional pain management. 3rd ed. Philadelphia: Saunders;2009. p. 103.

17. Symes A, Ellis H. Variations in the surface anatomy of the spinal accessory nerve in the posterior triangle. Surg Radiol Anat. 2005; 27:404–8. DOI: 10.1007/s00276-005-0004-9. PMID: 16132192.

18. Hagert CG, Christenson JT. Hyperpressure in the trapezius muscle associated with fibrosis. Acta Orthop Scand. 1990; 61:263–5. DOI: 10.3109/17453679008993514. PMID: 2371824.

19. Jobe CM, Kropp WE, Wood VE. Spinal accessory nerve in a trapezius-splitting surgical approach. J Shoulder Elbow Surg. 1996; 5:206–8. DOI: 10.1016/S1058-2746(05)80007-2. PMID: 8816340.

20. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H. Clinical and anatomical study of superficial cervical artery flaps: retrospective study of reconstructions with 41 flaps and the feasibility of harvesting them as perforator flaps. Plast Reconstr Surg. 2006; 118:95–101. DOI: 10.1097/01.prs.0000220880.28359.86. PMID: 16816678.