The spinal accessory nerve and its entry point into the posterior triangle of the neck

Background: The course of the spinal accessory nerve in the neck is long and superficial rendering it at high risk of injury during procedures performed in the posterior triangle. The majority of spinal accessory nerve injuries are iatrogenic in nature. This is associated with significant morbidity including reduction in shoulder movements, drooping of the shoulder, winging of the scapula and neuropathic pain. Knowledge of the nerve anatomy reduces the risk of intra-operative nerve injury. Traditional teaching describes the point of entry into the posterior triangle as the intersection between the upper and middle third of the posterior border of sternocleidomastoid. The aim of this study was to determine whether this is in fact the case and if so, whether this landmark can reliably be used to identify the spinal accessory nerve in order to improve patient outcomes.

Materials and methods: The spinal accessory nerve was identified unilaterally in 26 cadavers. The total length of sternocleidomastoid was measured as well as the length along the posterior border from the inferior aspect of the mastoid process to the point at which the accessory nerve enters the posterior triangle of the neck. These measurements were used to calculate the ratio of the entry point of the nerve into the posterior triangle along the length of the posterior border of sternocleidomastoid from its superior insertion point. The mean ratio was 0.35 with 95% confidence intervals of 0.33 to 0.36.

Results and conclusions: Our findings confirm the traditional description of the entry point of the spinal accessory nerve into the posterior triangle of the neck. We describe a so-called 'safe zone' inferior to the midpoint of the posterior border of sternocleidomastoid within which the spinal accessory nerve is unlikely to be found, thereby reducing the risk of iatrogenic injury.