The Incidence of Ossified Superior Transverse Scapular Ligament during Nerve Transfer through Posterior Shoulder Approach

Document Type : RESEARCH PAPER


1 Department of Plastic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Iran university of Medical Sciences, & Fellow of plastic and reconstructive surgery, Department of plastic surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Department of Hand Surgery, Tehran University of Medical Science, Tehran, Iran

4 Department of Orthopedics, Imam Hospital Complex, Joint Reconstruction Research Center, Tehran, Iran


Background: The purpose of this study was to assess the incidence and importance of bony bridge that covers the
supra scapular notch during posterior approach to transfer accessory nerve to suprascapular nerve.
Methods: Between 2010 and 2015, the frequency and importance of suprascapular bony bridge instead of transverse
ligament was assessed among patients with brachial plexus injury candidate to shoulder function restoration by
accessory to suprascapular nerve transfer through posterior approach.
Results: Forty three patients, 41 male and 2 female, (mean age: 32.5 years, range 14 to 36) were included in this
study. Five male patients (11.6%) had a complete bony rim on the superior scapular notch. Suprascapular nerve
release needed osteotomy of the bony bridge and related equipment.
Conclusion: Although all previous cadaveric studies among different ethnic groups had reported the prevalence
between 0.3 to 30% of suprascapular canal, this in vivo study showed the incidence of 11.6%. Preoperative alertness
about this variation could make the exploration and release of the suprascapular nerve easier and reduce the risk of
nerve injury or failing to anatomize it.


Main Subjects

1. Kostas-Agnantis I, Korompilias A, Vekris M, Lykissas
M, Gkiatas I, Mitsionis G, et al. Shoulder abduction
and external rotation restoration with nerve
transfer. Injury. 2013; 44(3):299-304.
2. Rinker B. Nerve transfers in the upper extremity:
a practical user’s guide. Ann Plast Surg. 2015;
74(Suppl 4):S222-8.
3. Bertelli JA, Ghizoni MF. Reconstruction of C5 and C6
brachial plexus avulsion injury by multiple nerve
transfers: spinal accessory to suprascapular, ulnar
fascicles to biceps branch, and triceps long or lateral
head branch to axillary nerve. J Hand Surg Am. 2004;
4. Midha R. Nerve transfers for severe brachial plexus
injuries: a review. Neurosurg Focus. 2004; 16(5):E5.
5. Emamhadi M, Chabok SY, Samini F, Alijani B,
Behzadnia H, Firozabadi FA, et al. Anatomical
variations of brachial plexus in adult cadavers; a
descriptive study. Arch Bone Jt Surg. 2016; 4(3):
6. Bhandari PS, Deb P. Dorsal approach in transfer of the
distal spinal accessory nerve into the suprascapular
nerve: histomorphometric analysis and clinical
results in 14 cases of upper brachial plexus injuries.
J Hand Surg Am. 2011; 36(7):1182-90.
7. Bhandari P, Deb P. Posterior approach for both spinal
accessory nerve to suprascapular nerve and triceps
branch to axillary nerve for upper plexus injuries. J
Hand Surg Am. 2013; 38(1):168-72.
8. Elzinga KE, Curran MW, Morhart MJ, Chan KM, Olson
JL. Open anterior release of the superior transverse
scapular ligament for decompression of the
suprascapular nerve during brachial plexus surgery.
J Hand Surg Am. 2016; 41(7):e211-5.
9. Toneva D, Nikolova S. Morphology of suprascapular
notch in medieval skeletons from Bulgaria. Folia
Morphol. 2014; 73(2):210-5.
10. Rengachary SS, Burr D, Lucas S, Hassanein KM,
Mohn MP, Matzke H. Suprascapular entrapment
neuropathy: a clinical, anatomical, and comparative
study: part 2: anatomical study. Neurosurgery.
1979; 5(4):447-51.
11. Polguj M, Sibiński M, Grzegorzewski A,
Waszczykowski M, Majos A, Topol M. Morphological
and radiological study of ossified superior
transverse scapular ligament as potential risk factor
of suprascapular nerve entrapment. Biomed Res Int.
2014; 2014(1):613601.
12. Tubbs RS, Nechtman C, D’Antoni AV, Shoja MM,
Mortazavi MM, Loukas M, et al. Ossification of
the suprascapular ligament: a risk factor for
suprascapular nerve compression? Int J Shoulder
Surg. 2013; 7(1):19-22.
13. Jangde S, Arya RS, Paikra S, Basan K. Bony
suprascapular foramen, a potential site for
suprascapular nerve entrapment: a morphological
study on dried human scapulae. Int J Anat Res. 2015;
14. Hrdlička A. The adult scapula. Additional
observations and measurements. Am J Phys
Anthropol. 1942; 29(3):363-415.
15. Silva J, Abidu-Figueiredo M, Fernandes RM,
Aureliano-Rafael F, Sgrott E, Silva S, et al. High
incidence of complete ossification of the superior
transverse scapular ligament in Brazilians and
its clinical implications. Int J Morphol. 2007;
16. Bhandari PS, Sadhotra LP, Bhargava P, Singh M,
Mukherjee MK, Bhatoe HS. Dorsal approach in
spinal accessory to suprascapular nerve transfer in
brachial plexus injuries: technique details. Indian J
Neurotrauma. 2010; 7(1):71-4.
17. Bayramoğlu A, Demiryürek D, Tüccar E, Erbil M,
Aldur MM, Tetik O, et al. Variations in anatomy at the
suprascapular notch possibly causing suprascapular
nerve entrapment: an anatomical study. Knee Surg
Sports Traumatol Arthrosc. 2003; 11(6):393-8.
18. Rengachary SS, Neff JP, Singer PA, Brackett CE.
Suprascapular entrapment neuropathy: a clinical,
anatomical, and comparative study: part 1: clinical
study. Neurosurgery. 1979; 5(4):441-6.
19. Polguj M, Jędrzejewski K, Majos A, Topol M.
Coexistence of the suprascapular notch and the
suprascapular foramen-a rare anatomical variation
and a new hypothesis on its formation based on
anatomical and radiological studies. Anat Sci Int.
2013; 88(3):156-62.
20. Badagabettu S, Kumar N, Patil J, Sirasanagandla
SR, Shetty SD, Shanthakumar SR, et al. Existence
of suprascapular notch and foramen in the same
scapula. J Morphol. 2005; 23(2):121-2.
21. Nayak SB, Kumar N, Patil J, Rao SS, Shetty SD,
Shanthakumar S, et al. Existence of suprascapular
notch and foramen in the same scapula. OA Case
Rep. 2014; 3(4):1-3.
22. Polguj M, Jędrzejewski K, Majos A, Topol M.
Variations in bifid superior transverse scapular
ligament as a possible factor of suprascapular
entrapment: an anatomical study. Int Orthop. 2012;
23. Polguj M, Jędrzejewski K, Majos A, Topol M. The
trifid superior transverse scapular ligament: a case
report and review of the literature. Folia morphol.
2012; 71(2):118-20.
24. Sinkeet S, Awori K, Odula PO, Ogeng’o JA, Mwachaka
PM. The suprascapular notch: its morphology
and distance from the glenoid cavity in a Kenyan
population. Folia Morphol. 2010; 69(4):241-5.
25. Thounaojam K, Karam R, Singh NS. Ossification of
transverse scapular ligament. J Evolut Med Dent Sci.
2013; 2(12):1790-91.
26. Natsis K, Trifon T, Ioannis G, Konstantinos V,
Efthymia P, Prokopios T. A bony bridge within the
suprascapular notch. Anatomic study and clinical
relevance. Aristotle Univ Med J. 2008; 35(1):204-11.
27. Natsis K, Totlis T, Tsikaras P, Appell H, Skandalakis
P, Koebke J. Proposal for classification of the
suprascapular notch: a study on 423 dried scapulas.
Clin Anat. 2007; 20(2):135-9.