The Journal of Laryngology & Otology (2006), 120, 494–496.

Short Communication
# 2006 JLO (1984) Limited
doi:10.1017/S0022215106000879
Printed in the United Kingdom
First published online 31 March 2006

A technique to identify and preserve the spinal accessory

nerve during neck dissection
D A CHAUKAR, MS, DNB, A PAI, MS, DNB, A K D’CRUZ, MS, DNB

Abstract
Introduction: Preservation of the spinal accessory nerve during neck dissection should be the rule rather than the
exception. Despite the presence of many described techniques to locate the nerve, a tedious dissection is often
required; as a consequence, it remains vulnerable to damage.
Method: We describe a novel method, not previously reported, based on identifying a constant vein which
crosses the nerve. This aids in the nerve’s early identification.
Conclusion: Our method enables the surgeon to locate the nerve precisely and to avoid damage to it, thereby
maximizing post-operative function.
Key words: Accessory Nerve; Neck Dissection; Morbidity; Shoulder

Introduction nerve. The spinal accessory nerve is located 2 mm deep

The spinal accessory nerve is an important structure of the
head and neck, providing motor innervation to the trape-
zius and sternocleidomastoid muscles. Preservation of
this nerve in the course of neck dissection is mandatory
to avoid the drooping shoulder syndrome, characterized
by serious limitation of function of the shoulder girdle.
There are a number of methods described to aid location
of the nerve, but it sometimes remains difficult to find,
and the presence of multiple branches of the cervical
plexus are often mistaken for the main nerve trunk. All
the methods described to locate the accessory nerve
depend on visual identification as it passes a constant
landmark.
We describe a method of identification based on locating
a small but constant vein which runs anterior to the nerve
and which serves as a reliable marker. This helps in locating
the nerve early in the course of dissection and reduces the
chances of accidental damage and unnecessary handling of
the nerve.
Technique
Subplatysmal flaps are raised in the standard manner, and
the anterior border of the sternocleidomastoid muscle is
delineated. The sternomastoid muscle is divested of its
fascia and the avascular plane, which binds the sternomas-
toid to the infrahyoid straps, is opened by sharp dissection.
The posterior belly of the digastric muscle is identified and
retracted. The loose areolar tissue on the inner aspect of
the sternomastoid, which separates it from the internal
jugular vein, is opened up and small feeder vessels are care-
fully coagulated. Approximately at the junction of the
upper and middle thirds of the muscle, there is a small
but constant vein which drains the sternomastoid into the
pharyngeal plexus of veins. Occasionally, there is a plexus
of three to four veins, all of which lie anterior to the
to this vein, which may accompany the nerve or cross it
from lateral to medial. The vein is divided between liga-
tures and the fascia below it is opened by sharp dissection
to expose the accessory nerve. The nerve is dissected cra-
nially from this point to the skull base and caudally to
the anterior border of the trapezius, in the standard
manner.
Discussion
Modified radical neck dissection with preservation of the
spinal accessory nerve and the internal jugular vein is
now the accepted treatment for metastatic nodal disease
in squamous cell carcinoma of the head and neck. The
pioneering work by Bocca and Pignataro showed that
the nerve is located in an aponeurotic compartment separ-
ated from the cervical nodes; this provided the anatomic
basis for preservation of the nerve.1 These authors
viewed the removal of the nerve, muscle and vein as
failing to add to the radical nature of the procedure, but
simply making it easier and quicker to perform. This
work has been substantiated by large series, which have
shown that preservation of the accessory nerve is onco-
logically safe.2
Shoulder dysfunction is the most common major long
term complication of neck dissection, and preservation of
the nerve helps to avoid this. Nahum et al. described the
pathophysiology of the ‘shoulder syndrome’ as occurring
due to the strain placed on the levator scapulae and rhom-
boid muscles due to drooping of the shoulder following
nerve damage or division.3
The spinal accessory nerve is formed by the spinal root
of the accessory nerve and the upper five or six cervical
nerve roots. From the skull base, it runs in relation to the
internal jugular vein, being lateral to it in two-thirds of
cases and medial in the remainder. It passes through the

From the Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
Accepted for publication: 13 November 2005.

494

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 SPINAL ACCESSORY NERVE IDENTIFICATION AND PRESERVATION
FIG. 1
Relation of the vein to the spinal accessory nerve. 1 ¼ Vein crossing the accessory nerve; 2 ¼ spinal accessory nerve; 3 ¼ level IIB
nodes (Bocca’s area); 4 ¼ posterior belly of digastric muscle; 5 ¼ internal jugular vein; 6 ¼ sternocleidomastoid muscle.
FIG. 2
The relevant anatomy. 1 ¼ Posterior belly of digastric muscle;
2 ¼ sternocleidomastoid muscle; 3 ¼ level IIB (Bocca’s area)
nodes; 4 ¼ spinal accessory nerve; 5 ¼ vein crossing nerve;
6 ¼ internal jugular vein; 7 ¼ common carotid artery;
8 ¼ omohyoid muscle.
sternomastoid, which it innervates, and enters the posterior
triangle 1 cm above Erb’s point (greater auricular point),
which is where the greater auricular nerve curves around
the sternomastoid muscle. It then runs a tortuous course
to the trapezius, exiting the posterior triangle under cover
of the muscle, approximately 5 cm above the clavicle. In
this course, there are four locations where the nerve may
be identified. These are on the transverse process of C2,
at the junction of the upper one-third and lower two-thirds
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495
of the sternomastoid muscle, approximately 11 mm above
Erb’s point,4 and at the anterior border of the trapezius
5 cm above the clavicle.
Different methods have been described for identifying
the nerve.4,5 All rely on visual identification of the nerve
but the landmarks may not be constant. The plethora of
sensory branches of the cervical plexus often makes
identification tedious, but our method relies on identifi-
cation of a constant vein which is always predictable in its
relation to the nerve – although there may be variance in
the point where it enters the sternomastoid muscle. We
have used all the described techniques and have found
this method to be the easiest and quickest method of
identifying the nerve. In addition, identifying and ligating
this vein avoids troublesome bleeding in Bocca’s area and
the risk of nerve damage while achieving haemostasis.
The possibility of accidentally damaging the nerve when
electro-cautery dissection is used is also avoided with this
method.
We have not objectively evaluated trapezius function in
patients in whom this method has been used, but logic dic-
tates that a method of identifying the nerve precisely
should avoid unnecessary dissection and prevent damage,
thereby maximizing post-operative function.
Acknowledgements
We acknowledge with thanks the assistance of Dr Ashok
Kumar Das and Dr Ajay S Punpale in the preparation of
this manuscript.
References
1 Bocca E, Pignataro O. A conservation technique in radical
neck dissection. Ann Otol Rhinol Laryngol 1967;76:975 –87
2 Lingeman RE, Helmus C, Stephens R, Ulm J. Neck
dissection: radical or conservative? Ann Otol Rhinol
Laryngol 1977;86:737– 44
 496 D A CHAUKAR, A PAI, A K D’CRUZ

3 Nahum AM, Mullally W, Marmor L. A syndrome result- Department of Surgical Oncology,

ing from radical neck dissection. Arch Otolaryngol 1961; Head and Neck Service,
74:424– 8 Tata Memorial Hospital,
4 Eisele DW, Weymuller EA, Price JC. Spinal accessory nerve Ernest Borges Road, Parel,
preservation during neck dissection. Laryngoscope 1999; Mumbai 400012, India.
101:433 –5
5 Pathak KA, Gupta S, Agarwal R, Sanghvi VD. A novel
approach to spinal accessory nerve. J Surg Oncol 2002;81: E-mail: dchaukar@rediffmail.com
213–14
Dr D A Chaukar takes responsibility for the integrity of the
Address for correspondence: content of the paper.
Dr Devendra A Chaukar, Competing interests: None declared
Assistant Surgeon,

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https://doi.org/10.1017/S0022215106000879