Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study

Injury to the accessory nerve results in an obvious shoulder droop, loss of shoulder elevation, and pain. Prevention of inadvertent injury to the accessory nerve is critical in neck dissection. No previous study, however, anatomically demonstrates the mechanism of the spinal accessory nerve traction injury. Anatomic determination of the location and course of the spinal accessory nerve may be helpful for a better understanding of the mechanism of the nerve injury. The accessory nerve courses obliquely across the posterior triangle on the surface of the levator scapula muscle and reaches the trapezius. The length of the spinal accessory nerve in the posterior triangle is 34.7+/- 6.3 mm. The nerve passes through the posterior border of the sternocleidomastoid muscle 50.7+/- 12.9 mm below the tip of the mastoid process and reaches the anterior border of the trapezius 49.8 +/- 5.9 mm above the clavicle. It makes a posterior angle of 73.1 degrees +/- 19.4 degrees, on average, relative to the posterior border of the sternocleidomastoid. When the shoulder is pulled down and the head is turned to the opposite direction, the spinal accessory nerve is stretched in the posterior triangle. In the posterior triangle, the nerve is vulnerable, since it is superficial and covered only by skin and subcutaneous fascia. Therefore, extreme caution should be taken with any surgical procedures in the posterior triangle. Traction injury of the spinal accessory nerve in the posterior triangle cannot be ignored.