Avoidance of scapular winging while approaching tumors of the middle scalene region

  • Ross C. PufferEmail author
  • Jonathan Stone
  • Robert J. Spinner
Original Article - Neurosurgical Anatomy
Part of the following topical collections:
  1. Neurosurgical anatomy



Large tumors arising from the middle scalene region can displace the middle scalene muscle and distort regional anatomy, placing nerves at risk. Understanding the surgical anatomy of these nerves is key to approaching pathology of the middle scalene muscle and avoiding damage to the dorsal scapular, long thoracic, and spinal accessory nerves, each of which can cause scapular winging and associated morbidity if injured.


IRB approval was obtained for this study, allowing cases with relevant pathology to be reviewed and presented to highlight the relevant surgical technique. Anatomical depictions were created to correlate intraoperative images with known anatomical relationships.


Key to this approach is consideration of the regional anatomy in a standard supraclavicular approach, the superficial plane, containing the anterior scalene muscle and brachial plexus, and the oblique plane containing the middle scalene muscle, long thoracic, spinal accessory, and dorsal scapular nerves. Identification and mobilization of each of these structures prior to lesion removal can not only provide likely boundaries of the tumor, but also allow for protection of the nerves to avoid injury that may lead to scapular winging with associated morbidity and functional impairment of the upper extremity.


Lesions of the middle scalene region often split two important anatomical planes, the superficial and deep, creating an advantageous surgical corridor through an anterolateral approach. Through early identification of known anatomy, these two planes can be developed, and a safe approach to the lesion of the middle scalene region can be exploited.


Scapular Winging Brachial Plexus Approach Technique 


Compliance with ethical standards

The authors have been compliant with all applicable ethical standards in the publication of this manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

IRB approval was obtained for this study. All patients included signed consent forms for the use of non-identifying medical information in medical research, including this study. For this type of study, formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Akgun K, Aktas I, Terzi Y (2008) Winged scapula caused by a dorsal scapular nerve lesion: a case report. Arch Phys Med Rehabil 89:2017–2020. CrossRefGoogle Scholar
  2. 2.
    Belmonte R, Monleon S, Bofill N, Alvarado ML, Espadaler J, Royo I (2015) Long thoracic nerve injury in breast cancer patients treated with axillary lymph node dissection. Support Care Cancer 23:169–175. CrossRefGoogle Scholar
  3. 3.
    Benoit P, Deplante F (1994) Paralysis of the dorsal nerve of the scapula: an unusual cause of scapular displacement. Presse Med 23:348Google Scholar
  4. 4.
    Bertelli JA, Ghizoni MF (2005) Long thoracic nerve: anatomy and functional assessment. J Bone Joint Surg Am 87:993–998. Google Scholar
  5. 5.
    Bishop KN, Varacallo M (2018) Anatomy, shoulder and upper limb, dorsal scapular nerve. In: StatPearls. Treasure Island (FL)Google Scholar
  6. 6.
    Cesmebasi A, Spinner RJ (2015) An anatomic-based approach to the iatrogenic spinal accessory nerve injury in the posterior cervical triangle: how to avoid and treat it. Clin Anat 28:761–766. CrossRefGoogle Scholar
  7. 7.
    Crowe MM, Elhassan BT (2016) Scapular and shoulder girdle muscular anatomy: its role in periscapular tendon transfers. J Hand Surg Am 41:306–314; quiz 315. doi:
  8. 8.
    Didesch JT, Tang P (2019) Anatomy, etiology, and management of scapular winging. J Hand Surg Am 44:321–330. CrossRefGoogle Scholar
  9. 9.
    Fardin P, Negrin P, Dainese R (1978) The isolated paralysis of the serratus anterior muscle: clinical and electromyographical follow-up of 10 cases. Electromyogr Clin Neurophysiol 18:379–386Google Scholar
  10. 10.
    Leinberry CF, Wehbe MA (2004) Brachial plexus anatomy. Hand Clin 20:1–5CrossRefGoogle Scholar
  11. 11.
    Lung K, Lui F (2018) Anatomy, thorax, long thoracic nerve. In: StatPearls. Treasure Island (FL),Google Scholar
  12. 12.
    Malessy MJ, Thomeer RT, Marani E (1993) The dorsoscapular nerve in traumatic brachial plexus lesions. Clin Neurol Neurosurg 95(Suppl):S17–S23CrossRefGoogle Scholar
  13. 13.
    Mandoorah S, Mead T (2018) Phrenic nerve injury. In: StatPearls. Treasure Island (FL),Google Scholar
  14. 14.
    Nevola Teixeira LF, Lohsiriwat V, Schorr MC, Luini A, Galimberti V, Rietjens M, Garusi C, Gandini S, Sarian LO, Sandrin F, Simoncini MC, Veronesi P (2014) Incidence, predictive factors, and prognosis for winged scapula in breast cancer patients after axillary dissection. Support Care Cancer 22:1611–1617. CrossRefGoogle Scholar
  15. 15.
    Restrepo CE, Tubbs RS, Spinner RJ (2015) Expanding what is known of the anatomy of the spinal accessory nerve. Clin Anat 28:467–471. CrossRefGoogle Scholar
  16. 16.
    Rizzi SK, Haddad CA, Giron PS, Pinheiro TL, Nazario AC, Facina G (2016) Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection. Support Care Cancer 24:2707–2715. CrossRefGoogle Scholar
  17. 17.
    Stone J, Puffer RC, Spinner RJ (2019) Interfascicular resection of benign peripheral nerve sheath tumors. JBJS Essential Surgical Techniques 9Google Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryMayo ClinicRochesterUSA

Personalised recommendations