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Anatomy, Head and Neck, Levator Scapulae Muscles

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James P. Henry; Sunil Munakomi.

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Last Update: December 22, 2019. Introduction

Structure and Function

Introduction Go to:
Embryology
The levator scapulae muscles are superficial extrinsic muscles of the back that primarily function to
Blood Supply and Lymphatics
elevate the scapulae. Levator comes from the Latin levare, meaning "to raise." Scapulae refer to
the scapulas, or shoulder blades, possibly originating from the Greek "skaptein," meaning "to dig." In Nerves
conjunction with other posterior axial-appendicular muscles, the levator scapulae can inferiorly rotate Physiologic Variants
the glenoid cavity as well as extend and laterally flex the neck. The levator scapulae also serve a role in
Surgical Considerations
connecting the axial skeleton with the superior appendicular skeleton. The levator scapulae can have
involvement in numerous pathologies, including snapping scapula syndrome, levator scapulae Clinical Significance
syndrome, Sprengel deformity, cervical myofascial pain, and fibromyalgia. Other Issues

Questions

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 Structure and Function Go to:
References
The levator scapulae muscle originates from the posterior tubercles of transverse processes of C1
(atlas), C2 (axis), C3, and C4 vertebrae.[1][2] The muscle inserts on the posterior lip of the medial
scapular border, typically between the superior angle and root of the scapular spine.[3][4] The Related information
sternocleidomastoid and trapezius overlay the superior and inferior aspect of the levator scapulae, PMC
respectively, with the levator scapulae comprising part of the floor of the posterior triangle of the neck. PubMed
[5] The primary action of the levator scapulae is to elevate the scapula. The levator scapula works in
conjunction with the trapezius and rhomboid muscles to accomplish this motion. The levator scapulae,
in conjunction with the descending fibers of the trapezius, latissimus dorsi, rhomboids, pectoralis major Similar articles in PubMed
and minor, and gravity, also inferiorly rotates the scapula, depressing the glenoid cavity.[6] Unusual origin of the levator scapulae muscle from
[7] Additionally, the levator scapulae muscle also assists in neck extension, ipsilateral rotation, and mastoid process. [Surg Radiol Anat. 2015]
lateral flexion.[8] A cadaveric study of the motor nerves to the levator
scapulae muscle. [Otolaryngol Head Neck Surg. 1997]
Embryology Go to:
Levator scapulae muscle asymmetry presenting as a
palpable neck mass: CT evaluation.
[AJNR Am J Neuroradiol. 1993]
Levator scapulae muscles derive from the paraxial mesoderm along with the rhomboid major and
minor. Their development is induced by tailbud neuromesodermal progenitors by fibroblast growth Review Anatomy, Back, Trapezius
factor (FGF) and Wnt signaling. The dorsal scapular nerve derives from the anterior (motor) rami of [StatPearls. 2020]

C5. The anterior root forms from the basal plate region of the spinal cord.[9][10] Anatomic variation of Review Anatomy, Back, Extrinsic Muscles
the subclavian artery can be implicated in failed supraclavicular brachial plexus blocks. Clinicians [StatPearls. 2020]
perform supraclavicular brachial plexus blocks for analgesia and anesthesia of the upper limb. Kohli et See reviews...
al. present a case of a variant branch of the subclavian artery visualized on ultrasound, which they
See all...
hypothesize could be the dorsal scapular artery, passing through the brachial plexus nerve bundle.[11]

Blood Supply and Lymphatics Go to: Recent Activity

Turn Off Clear
Dorsal Scapular Artery
Anatomy, Head and Neck, Levator Scapulae Muscles
The dorsal scapular artery is the predominate blood supply of the levator scapulae muscle. The origin is - StatPearls
currently in dispute in the literature. The origin most frequently cited is from the subclavian artery, with
See more...
the second most common being a branch of the thyrocervical trunk.[12] The transverse cervical artery,
a branch of the thyrocervical trunk, divides into the superior and deep branches at the level of the

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 levator scapulae.[6] The deep branch of the transverse cervical artery is also known as the dorsal
scapular artery.[13]

Anatomic Variation

Anatomic variation of the subclavian artery has implications in failed supraclavicular brachial plexus
blocks. Supraclavicular brachial plexus blocks are useful for analgesia and anesthesia of the upper
limb. Kohli et al. present a case of a variant branch of the subclavian artery visualized on ultrasound,
which they hypothesize could be the dorsal scapular artery, passing through the brachial plexus nerve
bundle.[11]

Lymphatics

Generally, the shoulder blade is associated with the axillary and supraclavicular lymph nodes. The
lymph nodes from the right scapula drain into the right lymphatic duct. The left scapula drains directly
into the thoracic duct.[7]

Nerves Go to:

Dorsal Scapular Nerve

The innervation of the levator scapulae is typically from the dorsal scapular nerve, or DSN,
originating from the C4 and C5 nerve roots. This nerve also provides motor innervation to the
rhomboids. The DSN arises from the anterior rami of C5 root, from the upper brachial plexus, and
traditionally is the first nerve branch off of the C5 root. Innervation can also be from cervical nerves
(C3, C4) via the cervical plexus.[7][14]

Physiologic Variants Go to:

There are reports of anatomic variations of the levator scapulae origin and insertion. The clinical
implications and significance are not definite.[2][6][15][16][17]

Surgical Considerations Go to:

Eden-Lange Procedure

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 Few surgical procedures primarily involve the levator scapulae. The Eden-Lange procedure, first
described in 1924, aims to recreate the functionality lost in trapezius muscle palsy, better known by the
eponym "winged scapula." The tendon of the levator scapulae is transferred to the acromion while the
rhomboids are attached to the infraspinatus fossa.[4]

Modified Eden-Lange Procedure

The Modified Eden-Lange procedure is a variant also performed to reproduce native scapular
positioning. Instead of transferring the rhomboid to the center of the scapula, the surgeon transfers the
rhomboid minor to the supraspinatus fossa, and the rhomboid major is attached to the infraspinatus
fossa. The levator scapulae muscle then gets attached to the spine of the scapula.[4][18]

Thoracotomy

The levator scapulae have been reportedly implicated in thoracotomy for excision of the lung. A
common deep aponeurosis covering the levator scapulae and serratus anterior must be recognized and
released to avoid functional consequences of dynamic shoulder instability.[19]

Clinical Significance Go to:

Scapulothoracic Articulation

The scapulothoracic articulation is an intricate, sliding, junction that composes part of the shoulder in
conjunction with the glenohumeral, acromioclavicular and coracoclavicular joints. The scapula has a
complex anatomical relationship, comprised of 17 muscular attachments, that function to dynamically
stabilize the scapula and control the position of the glenoid to permit a wide range of motion for the
upper extremity through the glenohumeral joint. The scapula does not have any ligamentous
connections to the thorax. Due to the complexity of the scapulothoracic articulation, scapulothoracic
disorders can present and go underdiagnosed or underestimated because of the various, and often
subtle, morphological alterations in normal architecture.[6]

Levator Scapulae Syndrome

The most common clinical manifestation of levator scapulae pathology is levator scapulae syndrome or
tenderness over the upper medial angle of the scapula. Though well documented, this condition is often
unrecognized. Movements that stretch the muscle tend to exaggerate symptoms. There is a hypothesis

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 that constant trigger points, crepitation, and increased heat emission result from a combination
of anatomic variability and the confluence of a bursa between the insertion of the levator
scapulae, origin serratus anterior and the scapula. Effective treatment modalities include physical
therapy and/or local corticosteroid injections.[16][20]

Snapping Scapula Syndrome

Significant shoulder dysfunction can present as painful crepitus or scapulothoracic bursitis, termed
snapping scapula syndrome or "washboard syndrome." This condition commonly manifests secondary
to a chronic injury, overuse, or muscle imbalance that impacts the scapulothoracic articulation.
Osseous lesions at the superomedial angle of the scapula secondary to repetitive injury or avulsion of
the levator scapulae have also been implicated in the clinical manifestation.[6][21] This condition may
be more common in military personnel due to chronic stress and recurrent injury secondary to load-
bearing activities of the upper extremity. Treatment is typically conservative, with an 80% success rate.
[22] For those that fail conservative treatment, arthroscopic bursectomy with or without partial
scapulectomy is the most effective treatment modality.[23][24]

Myofascial Pain

Cervical myofascial pain is a musculoskeletal disorder consisting of pain attributed to muscles and
their surrounding fascia. The levator scapulae are one of the most commonly involved muscles in the
cervical spine. The etiology of myofascial pain is not completely understood but commonly results
from postural mechanics, muscle overuse, trauma, or secondarily to another pathologic condition, such
as fibromyalgia or arthropathies of zygapophyseal joints. Cervical myofascial pain can be local,
regional, or characterized by trigger points. Trigger points are hypersensitive areas in muscle tissue that
elicit pain with mechanical stimulation and can refer pain to surrounding tissue. The levator scapulae is
a common location for trigger points and frequently has a tender point associated with the diagnosis of
fibromyalgia.[25][26][27][28][29]

Other Clinical Considerations

There are also documented cases of active trigger points of the levator scapula with a high prevalence,
including those secondary to an acute whiplash injury.[30] Pain at the insertion site correlates with
dysfunction of the upper and median cervical spine.[31] Varying degrees of levator scapulae atrophy
are observable in patients with Sprengel deformity.[32]

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 Other Issues Go to:

Association with Posterior Triangle of the Neck

The posterior triangle of the neck, located on the lateral cervical region, is an important anatomic
location for surgeons and anesthesiologists. The contents of this anatomic region include the entire
brachial plexus, cervical sympathetic ganglions, deep cervical lymph nodes, and the major vascular
structures of the neck/upper extremity. Other nerves, such as the spinal accessory, phrenic, vagus, and
cutaneous cervical nerves course through the region. The posterior triangle of the neck forms from
the sternocleidomastoid anteriorly, trapezius posteriorly, and clavicle as the base. The levator scapulae
form part of the floor along with the splenius, scalenus, and anterior scalene muscles. The location of
the levator scapulae in the posterior triangle of the neck is pivotal when performing a cervical
paravertebral block of the brachial or cervical plexuses utilizing a posterior approach. In the posterior
approach to the brachial or cervical plexuses, a muscle-sparing needle trajectory is optimal to decrease
pain and soft tissue injury associated with the procedure. The needle insertion can be between the
levator scapula and trapezius muscles.[5][33]

Medial Angle

The angle at the medial border, or spinovertebral angle, represents the insertion site of the levator
scapulae. Research has noted that the right spinovertebral angle is greater than the left, and alteration of
the angle may result in levator scapulae pathology from directional change of the insertion site,
possibly manifesting as neck stiffness.[3]

Questions Go to:

To access free multiple choice questions on this topic, click here.

Figure

Muscles Of the Neck, Mandible, Mastoid Process, Clavicle,

Trapezius, Sternocleidomastoideus, Sternohyoideus,
Omohyoideus Belly, Scalenus Anterior and medius, Levator
Scapulae, Splenius, Mylohyoideus, Hyoid bone, Thyrohyoideus,
Digastricus, Stylohyoideus. (more...)

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 References Go to:

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muscle: an amendment to the Bertrand procedure for the treatment of spasmodic torticollis. J.
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 View publication stats

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