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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 55-57

Safer dissection of spinal accessory nerve from sternocleidomastoid muscle during neck dissection


1 Department of Surgical Oncology, Dr. RMLIMS, Lucknow, Uttar Pradesh, India
2 Department of Paediatrics, Dr. RMLIMS, Lucknow, Uttar Pradesh, India

Date of Submission18-Aug-2018
Date of Acceptance07-Apr-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Akhlak Hussain
Department of Surgical Oncology, Dr. RMLIMS, Lucknow - 226 010, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_17_18

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  Abstract 


Background: The spinal accessory nerve (SAN) may damage during its dissection from the sternocleidomastoid (SCM) muscle during modified neck dissection type II due to their intimate relation. Routinely, it is dissected from the anterior aspect of the SCM. The aim of this study is to describe and simplify the safer dissection of the SAN from the SCM muscle. Objectives: We proposed a different method of dissection describing it to be posterior approach. Materials and Methods: Posterior dissection of SAN was done as routine. Conclusion: Although more studies are required to depict the superiority of one over another, we found this method to be easier and time-saving approach.

Keywords: Modified neck dissection, spinal accessory nerve, sternocleidomastoid


How to cite this article:
Hussain A, Singhal A, Siddiquee N, Thakur B. Safer dissection of spinal accessory nerve from sternocleidomastoid muscle during neck dissection. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:55-7

How to cite this URL:
Hussain A, Singhal A, Siddiquee N, Thakur B. Safer dissection of spinal accessory nerve from sternocleidomastoid muscle during neck dissection. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 9];3:55-7. Available from: http://www.aiaohns.in/text.asp?2019/3/2/55/271598




  Introduction Top


The spinal accessory nerve (SAN) passes through the belly of the sternocleidomastoid (SCM) muscle. Thus, it has a higher chance of injury during its separation from the SCM muscle in case of modified radical neck dissection (MRND) type II. We thus elaborate the relation of SAN with the SCM, and based on our understanding, we tried to describe a novel way of safer dissection of nerve in relation to the SCM.


  Materials and Methods Top


All works have been done in Dr. RML Institute of Medical Sciences, Lucknow, India. The description includes normal dissection during routine surgery after proper consent. No deviation from routine methods has been applied.

Statistical analysis

No statistical analysis was done. It was only an observational study.


  Results and Discussions Top


Anatomical review

The anatomy and course of SAN in the neck and its variation has been extensively described in the literature. Jugular foramen, located between the petrous temporal bone and the occipital bone, is the most important to remember during neck dissection since it transmits the glossopharyngeal nerve, the vagus nerve, the SAN, and the sigmoid sinus (becoming the internal jugular vein). Unless grossly involved, SAN has to be preserved.

Landmarks for SAN:

  1. Internal jugular vein (IJV)[1]


    1. Ventral, 39.8%
    2. Dorsally, 57.4%
    3. Through IJV, 2.8%.


  2. SCM


    1. Through the belly – 54.1%[1]–66%:[2] Branching within SCM
    2. Branching before entering the SCM; thus, trapezius branch travels posterior to SCM remaining superficial to cervical C4 root (22%).[2] Lee et al.[1] described that in 45.9% of the cases, the nerve sent branches to the SCM muscle without penetrating it.


Some authors demonstrate that functional outcomes after the MRND are worse compared to selective neck dissection.[3],[4] The significant postoperative shoulder disability is described to be due to the resection of the cervical branches and lymph node dissection in levels IIb and V that leads to damage to branches to the trapezius muscle.[2] However, the contribution of the cervical roots to the innervation of the trapezius is still controversial. Haas and Solberg, based on electromyographical studies, stated that the trapezius received innervation from the cervical and thoracic branches as well as from SAN.[5] However, many studies found that the trapezius muscle innervation from the cervical plexus is present but unpredictable and that most important motor inputs came from SAN.[6],[7]

Surgical review

Most of the high volume centers are able to preserve SAN during neck dissection. But still, significant shoulder disability is quite common in early postoperative period. The preservation of cranial contribution is common and easier, but the preservation of spinal contribution (cervical branch) is still difficult and uncommon. Understanding of surgical landmarks is deemed important to preserve SAN.

  1. Most describe the preservation of SAN through its identification in the lower neck, near its entry at the anterior border of the trapezius muscle, with a description of subsequent retrograde dissection.[8],[9],[10],[11] The landmarks include (a) the distance between the clavicle and the point where the SAN passes under or pierces the anterior border of the trapezius (locates to within 2–5 cm of the clavicle in the majority) and (b) the relationship of the SAN to the point of emergence of the greater auricular nerve at the posterior border of the SCM (greater auricular point) (the SAN is always located above this point, usually within 2 cm of it)
  2. With the increasing use of selective neck dissection, some described the method of identifying the nerve anterior to the SCM, finding the nerve high in the neck with anterograde dissection.[12],[13],[14] The landmark here is the silvery white tendinous part (upper third of cleido-occipitalis) at the superior aspect of the SCM at its anteromedial surface. Immediately deep to the tendinous portion, one or more vessels are noted. These originate from the occipital artery and supply the SCM segmentally. Immediately deep to this point, the SAN is noted consistently passing into the SCM between the superficial sheet and the deeper sternocleidomastoid fibers Superior landmark is the transverse process of the  Atlas More Details (C1).[15] This is easily palpable, and the IJV consistently sits anterior to it. Both the internal carotid artery and the SAN are intimately associated with the IJV at this point, deep to the posterior belly of digastric but anterior transverse process of C1.
  3. Description of approach to dissect SAN from SCM.


We tried to describe the possible approaches to SAN during its dissection from SCM during modified neck dissection.

  1. Anterior approach: This is quite a common way to dissect SAN. Dissection and identification of the SAN in the posterior triangle is the main requisite for this approach. It involves following the SAN, identified in the posterior triangle, on artery forceps or Lahey forceps. All the bulk of SCM is divided anterior to the nerve, following the whole of its course, without dividing the attachments of SCM. The only advantage we could found is the easy of division of the SCM which remains fixed as the SCM attachments are not divided. This approach involves the division of the major bulk or almost the whole of the SCM which remains anterior to the SAN. This involves more handling of the nerve and thus more chances of neuropraxia. Moreover, the course of SAN in the SCM is not straight, and the attachment of cervical branches is not consistent, so this approach may have more chances of injury to the cervical contributions. It surely involves more time, and more dissection is required to dissect the major bulk of the SCM
  2. Posterior approach: It involves the division of both clavicular and mastoid attachments of SCM and elevating it from the floor. Then, identification and dissection has to be started. In our experience, we found only a small slip of SCM posterior to the nerve, which has to be divided, thus easy to separate the nerve, and the reflections of the branches are more prominent and easier to identify [Figure 1]. Lesser handling may lead to less neuropraxia and more chances to preserve the branches. Moreover, posterior triangle dissection is not required for this type of approach.
Figure 1: The dissected sternocleidomastoid along with spinal accessory nerve from the posterior aspect

Click here to view


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee SH, Lee JK, Jin SM, Kim JH, Park IS, Chu HR, et al. Anatomical variations of the spinal accessory nerve and its relevance to level IIb lymph nodes. Otolaryngol Head Neck Surg 2009;141:639-44.  Back to cited text no. 1
    
2.
Lanisnik B, Zargi M, Rodi Z. Identification of three anatomical patterns of the spinal accessory nerve in the neck by neurophysiological mapping. Radiol Oncol 2014;48:387-92.  Back to cited text no. 2
    
3.
Cheng PT, Hao SP, Lin YH, Yeh AR. Objective comparison of shoulder dysfunction after three neck dissection techniques. Ann Otol Rhinol Laryngol 2000;109:761-6.  Back to cited text no. 3
    
4.
Chepeha DB, Taylor RJ, Chepeha JC, Teknos TN, Bradford CR, Sharma PK, et al. Functional assessment using constant's shoulder scale after modified radical and selective neck dissection. Head Neck 2002;24:432-6.  Back to cited text no. 4
    
5.
Haas E, Sollberg G. Research on the function of the shouder girdle after section of the accessory nerve. Z Laryngol Rhinol Otol 1962;41:669-77.  Back to cited text no. 5
    
6.
Soo KC, Strong EW, Spiro RH, Shah JP, Nori S, Green RF. Innervation of the trapezius muscle by the intra-operative measurement of motor action potentials. Head Neck 1993;15:216-21.  Back to cited text no. 6
    
7.
Kierner AC, Burian M, Bentzien S, Gstoettner W. Intraoperative electromyography for identification of the trapezius muscle innervation: Clinical proof of a new anatomical concept. Laryngoscope 2002;112:1853-6.  Back to cited text no. 7
    
8.
Brandenburg JH, Lee CY. The eleventh nerve in radical neck surgery. Laryngoscope 1981;91:1851-9.  Back to cited text no. 8
    
9.
Pathak KA, Gupta S, Agarwal R, Sanghvi VD. A novel approach to spinal accessory nerve. J Surg Oncol 2002;81:213-4.  Back to cited text no. 9
    
10.
Hone SW, Ridha H, Rowley H, Timon CI. Surgical landmarks of the spinal accessory nerve in modified radical neck dissection. Clin Otolaryngol Allied Sci 2001;26:16-8.  Back to cited text no. 10
    
11.
Becker GD, Parell GJ. Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 1979;89:827-31.  Back to cited text no. 11
    
12.
Soo KC, Hamlyn PJ, Pegington J, Westbury G. Anatomy of the accessory nerve and its cervical contributions in the neck. Head Neck Surg 1986;9:111-5.  Back to cited text no. 12
    
13.
Hill JH, Olson NR. The surgical anatomy of the spinal accessory nerve and the internal branch of the superior laryngeal nerve. Laryngoscope 1979;89:1935-42.  Back to cited text no. 13
    
14.
Eisele DW, Weymuller EA Jr., Price JC. Spinal accessory nerve preservation during neck dissection. Laryngoscope 1991;101:433-5.  Back to cited text no. 14
    
15.
Sheen TS, Chung TT, Snyderman CH. Transverse process of the atlas (C1) – An important surgical landmark of the upper neck. Head Neck 1997;19:37-40.  Back to cited text no. 15
    


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