Surg Radiol Anat (2010) 32:277284 DOI 10.

1007/s00276-010-0631-7

ORIGINAL ARTICLE

Anatomical basis of the suprascapular nerve entrapment, and clinical relevance of the supraspinatus fascia
Fabrice Duparc Dorothee Coquerel Jocelyn Ozeel Maxime Noyon Antoine Gerometta Chantal Michot

Received: 30 November 2009 / Accepted: 28 January 2010 / Published online: 21 February 2010 Springer-Verlag 2010

Abstract Introduction The entrapment of the suprascapular nerve (SSN) is commonly considered at the level of the suprascapular notch and more rarely in the spinoglenoid notch. Recent per-operative ndings showed a compression of the SSN along its course in the supraspinatus fossa. The removal of a fascia for releasing the nerve between the suprascapular notch and spinoglenoid notch led us to purchase an anatomical study. Materials and methods 30 cadaver shoulders have been dissected. The morphological features about the suprascapular notch, the supraspinatus fascia, and the spinoglenoid notch have been observed. Histological studies of the fascia and the spinoglenoid ligament have been performed. Morphometric parameters such as shape of the suprascapular notch, diameters of the SSN before and after the suprascapular notch, distance between the two notches, length of the course of the SSN into the supraspinatus fossa, diameters of the spinoglenoid notch have been measured. Results The shape of the suprascapular notch could be seen as U- or V as previously reported. The fascia
F. Duparc (&) D. Coquerel J. Ozeel M. Noyon A. Gerometta Laboratory of Anatomy, Faculty of Medicine, Rouen University, 22 Boulevard Gambetta, 76183-1 Rouen, France e-mail: [email protected] F. Duparc D. Coquerel Department of Orthopedic and Plastic Surgery, Rouen University Hospital, 1 rue de Germont, 76031 Rouen, France C. Michot Department of Anatomopathology, Rouen University Hospital, 1 rue de Germont, 76031 Rouen, France

was quite constant (completely identied in 29 shoulders) and was the lateral extension of the supraspinatus fascia. The SSN coursed between the bone and the fascia and was surrounded by fat tissue. This fascia was thickened at the level of the spinoglenoid notch and joined the infraspinatus fascia. The spinoglenoid ligament was seen in 28 shoulders. Discussion and conclusion In pathologic and post-trauma conditions, the fascia can be retracted or thickened and the SSN may be entrapped along its course in the supraspinatus fossa, between the suprascapular notch and the spinoglenoid notch and without any compression in any notch. These anatomical data lead us to consider that a tunnel syndrome may concern the SSN. Keywords Suprascapular nerve Nerve entrapment Supraspinatus fascia Tunnel syndrome Anatomy

Introduction The entrapment of the suprascapular nerve (SSN) is commonly considered as related to a compression in the suprascapular notch or in the spinoglenoid notch. The SSN may be entrapped in the suprascapular notch as it runs below the superior transverse scapular ligament. It can be compressed at the level of the lateral edge of the spine of the scapula, when it courses around this bony structure, between the bone and the so-called spinoglenoid ligament (inferior transverse scapular ligament). Ganglion cysts are considered as responsible of the compression and may extend from the scapulohumeral joint, especially in cases of superior labral from anterior to posterior (SLAP) lesions. Recent clinical and peroperative unusual etiologies have been encountered and showed a true entrapment of

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the SSN along its course in the supraspinatus fossa: lipomas, scarred tissues in post trauma conditions, bony structures in hypertrophic or vicious healing of fractures, increased muscular mass of the supraspinatus. In these cases, no real entrapment was seen, neither in the scapular notch nor in the spinoglenoid notch. A release of the SSN in the supraspinatus fossa had been performed by fasciectomy, with removal of a fascial tissue until complete mobility of the nerve could be obtained. The goal of this anatomical study was to carry some answer to these clinical questions by determining the presence of a fascia in the supraspinatus fossa that could explain the SSN entrapment. Morphometric parameters of the portion of the SSN that coursed between the two notches have also been studied. Furthermore, the nature (ligament?) of the structure that could surround the nerve close to the lateral edge of the spine of the scapula has been assessed.

for histological examination. When a brous or osteobrous space was present and well delineated, length and width were measured. The SSN was released till its penetration into the infraspinatus muscle below the spine of the scapula. The following morphometric parameters of the SSN were measured with a digital caliper (Mitsutuno*) (Fig.1a, b):

Diameter of the SSN just before entering into the scapular incisura: d1. Diameter of the SSN just as it exits out of the scapular incisura: d2. Length of the distance between the suprascapular notch and the spinoglenoid notch: Lt. Length of the SSN portion after section in the suprascapular notch and in the spinoglenoid notch: Ln.

Materials and methods 30 shoulders from 15 embalmed adult human donated bodies have been dissected (5 females and 9 males, mean age 82 years (4999), mean height 163 cm (148180). The bodies were placed in prone position and a large posterior cutaneous ap centered on the spine of the scapula was removed from the basis of the neck to the apex of the scapula. The trapezius and the deltoid muscles were desinserted and reclined, in order to expose the complete spine of the scapula and the supraspinatus an infraspinatus muscles. The spine of the scapula and the lateral extremity of the clavicle were sawed and removed. The scapulohumeral joint was lled with water under manual pressure for assessing a potential cyst. After removal of the subacromial and subdeltoid bursae, the tendon of the supraspinatus muscle was sectioned and dorsally and medially elevated. The posterior aspect of the coracoid process was exposed and the suprascapular vessels and nerve were observed in the suprascapular notch. The following features were observed and measured: The positions of the suprascapular vessels and nerve related to the superior and inferior scapular transverse ligament were noted. Fascia. The presence of a fascia covering the SSN in the supraspinatus fossa was assessed, and a 1 cm2 pieces was harvested for histological examination (Hematoxylin Eosin Safran). Course of the SSN. The course of the SSN around the edge of the spine of the scapula was carefully observed and the presence of the so-called spinoglenoid ligament was noted. If it was present, a piece was resected

After complete releasing of the SSN, it was elevated out of the suprascapular notch and spinoglenoid notch and the shape and morphometric parameters of the two incisura were measured. Shape of the suprascapular notch. U-shape with parallel boundaries, V-shape with oblique convergent boundaries, O shape with round boundaries. Morphometric parameters were measured with a digital caliper: length L and height H (Fig. 1b). Shape of the spinoglenoid notch, length dL and width dT (Fig. 1b) when a clear opening was seen.

Results Relationships between the SSN, the suprascapular vessels, and the superior transverse scapular ligament The nerve ran alone through the suprascapular notch in 23 shoulders (76.7%), with the suprascapular artery in 4 (13.3%), with the suprascapular vein in 2 (6.7%), and with both the suprascapular artery and vein in 1 (3.3%). A single superior transverse ligament was seen in 29 shoulders (96.7%), it was double with two different superposed bundles in one shoulder (3.3%) (Fig. 2). In 8 shoulders (26.7%), the superior transverse ligament appeared calcied and rigid, in 22 (73.3%) shoulders it was found rather oppy but bended between the two sides of the incisura. The measurements are listed in Table 1. Mean diameters of the SSN were: d1 = 3.8 mm (1.86) and d2 = 3.1 mm (3.15). The length between the two notches was Lt = 24.3 mm (1729). The length of the SSN between the two notches was Ln = 30.2 mm (2328).

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Fig. 1 a Course of the SSN into the suprascapular fossa, 1 Suprascapular nerve 2 Superior scapular transverse ligament, 3 Ramus of the SSN to the supraspinatus muscle, 4 Supraspinatus fossa, 5 Sectioned spine of the scapula, Cr cranial, L lateral. b Diameter of the SSN just before entering into the scapular incisura, d1. Diameter of the SSN just as it exits out of the scapular incisura, d2. Length of the

distance between the suprascapular notch and the spinoglenoid notch, Lt. Length of the SSN portion after section in the suprasuprascapular notch and in the spinoglenoid notch, Ln. Shape of the scapular incisura, length L and height H. Shape of the spinoglenoid notch, length dL and width dT, Cr cranial, M medial

Shape of the scapular transverse incisura A U-shape was seen in 19 shoulders (63.3%) and a V-shape in 11 (36.7%) (Fig. 3). In the two types, the incisura could be more or less opened, narrow or wide. In all the cases, the SSN was running in the deep part of the incisura, at the contact of the upper edge of the scapula. The length and height of the suprascapular notch were L = 9.2 mm (415) and H = 5.9 mm (2.511). The length and width of the spinoglenoid notch were dL = 8.7 mm (810) and dT = 6 mm (57), but only measured on three shoulders. Mean morphometric parameters of the inferior scapular notch (dL and dT) have been very difcult to identify and to determine as unique measurement of one longitudinal and one transverse diameters. This will be explained below and related to the ndings about the supraspinatus fascia and the inferior transverse ligament. The SSN appeared compressed in 15 (50%) cases, in the suprascapular notch (Fig. 4). This SSN stenosis was associated with an atrophy of both the supraspinatus and infraspinatus in four shoulders and only the supraspinatus muscle in two. In 9 shoulders out of 15, a SSN stenosis was present but without any muscular atrophy. In 15 shoulders (50%), no nerve stenosis was observed. The ramus to the supraspinatus originated from the SSN before it penetrated into the suprascapular notch in one case (3.3%). It originated in the incisura in two shoulders

Fig. 2 Posterior view of the double superior 1 Suprascapular nerve, 2 suprascapular vein, incisura, 4 inferior portion of the double 5 superior portion of the double superior Cr cranial, L lateral

transverse ligament, 3 lower part of the transverse ligament, transverse ligament,

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280 Table 1 Measurements and results Specimen Age Size (years) (cm) Suprascapular incisura H (mm) L (mm) No. 1 No. 2 No. 3 No. 4 No. 5 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 No. 12 No. 13 No. 14 No. 15 Mean 66 92 88 85 89 96 90 75 83 49 99 86 89 66 86 82.6 175 165 155 168 160 150 153 180 170 176 148 153 165 160 167 163 Left Left Left Left Left Left Left 5 6 5 3 8.5 7 6 8 9 9 4 7 8 7 8.5 6 7 8 8 8 8 10 10 13 11.5 10 10 11 11 9 10 10 7 9 10 14 15 9.2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 Supraspinatus Suprascapular nerve fascia

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Inferior Spinoglenoid transverse notch ligament d1 (mm) d2 (mm) Lt (mm) Ln (mm) dL (mm) dT (mm) 5 1.8 3 3 3.5 3 4 4 3 3 5 6 4 4 6 4 3.5 3 3.5 4 3 3 4 3 6 4 3 3 3 5 3.8 4 1 2 2 3.5 3 3 5 4 3 2 3 4 4 4 4 3 4 3.5 4 3 4 3 2 1.5 2.5 1.5 3 2 4 3.1 23 28 25 21 25 22 29 20 26 26 23 17 21 24 30 27 24 28 24 27 22 18 21 25 25 30 26 27 22 23 24.3 32 35 28 33 37 24 32 27 35 30 36 25 23 33 35 x 33 38 28 28 22 24 35 31 29 32 25 30 26 29 30.2 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 9 9 9 8 9 9 9 9 9 9 9 9 8 9 9 9 9 9 9 9 9 9 10 9 9 9 9 9 9 9 8.7 9 9 9 6 9 9 9 9 9 9 9 9 5 9 9 9 9 9 9 9 9 9 7 9 9 9 9 9 9 9 6

Right 10 Right 3 Right 4 Right 5 Right 8 Right 6 Right 5 Left 5 Right 5 Left Left Left Left Left Left 6 6 3 11 2.5 6 Right 7 Right 6 Right 4 Right 6 Right 5 Right 7 Left 10 Right 9 5.9

(6.9%), immediately after the SSN exited out of the incisura in 19 (65.5), and after the SSN crossed through the incisura in seven shoulders (24.1%) (Fig. 1). Presence of a fascia A fascia that was covering the SSN along its course in the supraspinatus fossa was seen in 29 shoulders (96.7%) (Fig. 5a). In one case (3.3%), it was not well delineated from the fat tissue. The supraspinatus fascia was inserted on the superior edge of the scapula in 26 shoulders (86.7%), it was extended to the inferior surface of the clavicle in four shoulders (13.3%).The histological examination conrmed that this tissue had a fascial layered

structure (Fig. 5b). This fascia was in continuity with the fascia of the supraspinatus muscle. It was covering the lateral third of the supraspinatus fossa (free of muscular insertion) in ten cases (38.4%), the lateral half of the fossa in nine (34.6%), and the two lateral thirds in seven shoulders (27%). The medial part of the supraspinatus fossa was covered by the muscular bers insertion. Some fat tissue was present below the whole surface of the fascia in 18 shoulders (55.5%) and only around the suprascapular vessels and nerve in 12 (44.5%). The supraspinatus fascia was inserted laterally along the lateral edge of the spine of the scapula, making a brous arch bended from the lateral edge of the spine to the posterior surface of the neck of the scapula. This pathway was seen in 28 shoulders (93.3%),

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Spinoglenoid notch and the so-called spinoglenoid ligament In all the shoulders, some fat tissue surrounding the SSN was seen at the contact of the lateral edge of the spine of the scapula. The SSN went through a brous space delineated by the thickening of the supraspinatus fascia (28 shoulders, 93.3%) and by an inferior transverse ligament in 24 shoulders (80%) but absent in 6 (20%) (Fig. 6a). The inferior transverse ligament was seen as an oriented brous tissue (Fig. 6b) on histological examination and could be considered as a ligamentous structure. The supraspinatus fascia joined the infraspinatus fascia in 6 shoulders (20%), it was strongly attached to the periosteum of the scapula in 1 (3.3%) but non-attached in 23 (76.7%). A brous canal rather than a real button-hole was seen in the spinoglenoid notch in 28 shoulders (93.3%), but absent in 2 (6.7%). This is why the measurements of dL and dT diameters were not reliable. When the supraspinatus muscle was upward reclined with the fascia, the isolated inferior scapular transverse ligament did not appear in a closed contact to the SSN. No macroscopic compression of the SSN in the inferior scapular notch has been observed. No correlation was observed with sex, age or side in any measurement.

Fig. 3 The different observed shapes of the superior scapular incisura. A calcied ligament could create a closed aspect that could be considered as an O-shape

Discussion Relationship between the SSN and the suprascapular vessels The suprascapular vessels were seen running on the supercial aspect of the scapular transverse ligament in 76%. This may be relevant in procedures for SSN release, even in open approaches or endoscopic techniques. This position was seen constant by Ticker et al. [13], but could be variant in classical textbooks. The SSN is the scapular incisura: the SSN is relatively xed in the suprascapular notch. The rigidity of the transverse scapular ligament did not appear related to the entrapment of the SSN. Our results are closed to those published by Ticker et al. [13] who found a hard ligament in 23% of the shoulders and rather soft in 77%. However, the ligament, calcied or not remained inextensible and the osteobrous canal could not be enlarged. The calcied aspect is not a sign of entrapment, as previously assessed by Moriggl et al. [7]. Shape of the scapular notch with a real thickening of the fascia, bended between the scapular spine and the posterior surface of the scapular neck and absent in 2 (6.7%). The separation between U-shape and V-shape can be useful for searching for a SSN nerve predisposition. Our results

Fig. 4 1 Suprascapular nerve (compressed), 2 deeper part of the suprascapular notch, 3 inferior part of a double superior transverse ligament (the superior part has been removed) 4 suprascapular vein, Cr cranial, L lateral

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282 Fig. 5 a 1 Suprascapular nerve, 2 supraspinatus fascia, 3 suprascapular vein, 4 superior transverse ligament, Cr cranial, L lateral, b (109) 1 Oriented fascial tissue, 2 fat tissue, c (409) 1 Oriented fascial tissue, 2 fat tissue

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could be compared to those reported by Moriggl et al. [7]. The nerve was always crossing the bony edge of the deep part of the notch, but no correlation was found with the parallel or not edges of the notch. In V-shape suprascapular notch, the deeper part of the notch was not aggressive to the SSN because brous tissue was lying. Some superior transverse ligaments appeared calcied, but we did not see any completely ossied hole. Fascia It could be considered as constant. In one case, it was not seen, but the SSN was covered by the fat tissue. Hovelacque [4] had described that the SSN courses between the deep side of the supraspinatus muscle and the bony surface of the supraspinatus fossa, but did not take the fascia into account. This specic subfascial course of the SSN along the supraspinatus fossa is not considered in some classical textbooks and previous publications about clinical anatomy of the SSN [3, 5, 810, 14]. The spinoglenoid notch and ligament Our ndings are close to those of Cummins and Demaio [1, 2]. The spinoglenoid ligament is a reality, and quite constant. It is reinforced by the observed thickening of the supraspinatus fascia, and this pattern contributes to a narrow pathway for the SSN. The nerve is rather protected from the muscular contractions by these associated

brous structures, but this narrow canal may be the site of an entrapment of a compression, as classically described with ganglion cysts originating from the scapulohumeral joint. Recent improvements in the arthroscopic techniques are of interest for the decompression of the SSN [11], both at the level of the suprascapular and spinoglenoid notches. The authors explained that the decompression could be considered as efcient if the SSN could be moved in the notches. This technique offers the advantages of the miniinvasive surgery, but with risk of bleeding and nerve injury, and necessitates a high ability in shoulder arthroscopic surgery and the possibility to switch to an open approach. The exposure of the SSN along its course in the supraspinatus fossa is more difcult, because it needs to recline the supraspinatus muscle. Moreover, and this is a limit of our study, the sensory branches of the SSN course along the basis of the coracoid process just after passing through the suprascapular notch [6]. We did not study these branches, but they could also be entrapped between the bone surface and the deep side of the supraspinatus fascia. Our ndings lead us to consider that the course of the SSN into the supraspinatus fossa may be considered as a tunnel: the SSN may be compressed at three levels: 1in the superior scapular incisura, as classically described; 2 along the course in the fossa between the bone surface and the deep side of the fascia, surrounded by fat tissue; 3in the spinoglenoid notch.

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Fig. 7 Overview of the course of the SSN through the superior scapular incisura, the subfascial portion in the supraspinatus fossa, and the spinoglenoid notch. Cr cranial, L lateral

Conclusion The SSN entrapment may occur at three levels: as commonly described, it can be compressed in the superior and inferior incisura, but the SSN may also be chronically injured along its course in the supraspinatus fossa. The subfascial position of the SSN between the two incisura may be considered as an osteobrous tunnel course, and the entrapment of the nerve along its course may be thought as a tunnel syndrome.
Acknowledgments assistance. Thanks to Mr Bruno Belloncle for his technical

Fig. 6 a Inferior view of the spinoglenoid notch, 1 Lateral edge of the scapular spine, 2 Inferior transverse ligament, 3 posterior edge of the glenoid, 4 spinoglenoid notch, 5 infraspinatus fossa. The course of the SSN is showed by the disrupted line, b Histological pattern of the spinoglenoid ligament, 1 Fibrous collagen orientated tissue

This possibility of tunnel syndrome of the SSN is summarized in the Fig. 7. The clinical relevance is strong. The release of the SSN must make it completely free along its complete course; a limited procedure to a single level of entrapment could achieve a limited release. The entrapment in the superior transverse incisura is the most frequent location, but not unique. In post-traumatic conditions, after hematoma, the supraspinatus fascia may be retracted and the fat tissue may undergo to brosis. In the spinoglenoid notch, extrinsic compression may occur (synovial cysts), but narrowing of the osteobrous space can also be encountered. The complete osteobrous tunnel should be considered when the suprascapular is suffering. Moreover, as stated by Sunderland [12], the xed aspect of the SSN close to the bone surface of the scapula may provoke stretching lesions of the mobile portion located between the origin on the upper trunk of the brachial plexus and the suprascapular notch.

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