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The supraclavicular nerves are three cutaneous nerves that emerge as a common trunk from the cervical plexus before branching to innervate the skin over the upper chest and shoulders.
The supraclavicular nerves arise from the ventral rami of C3 and C4 spinal nerves, although they receive considerably more fibers from C4.
The supraclavicular nerves emerge as a common trunk underneath the sternocleidomastoid muscle at the punctum nervosum (Erb’s point). The supraclavicular nerve descends in the posterior triangle of the neck passing underneath the platysma muscle. As it approaches the clavicle the common trunk of the supraclavicular nerves divides into three groups of descending branches: the medial supraclavicular nerve, intermediate supraclavicular nerve and lateral supraclavicular nerve.
Branches and Supply
The supraclavicular nerves provide cutaneous innervation in a "cape-like" distribution, spanning the area from the deltoid muscles laterally to the anatomic midline medially and bounded anteriorly by the second rib and posteriorly terminating at the superior border of the scapula. The major divisions supply the following structures:
- the medial (or anterior) supraclavicular nerve crosses obliquely and superficially over the external jugular vein to lie above the medial head of the clavicle to supply the skin as far as the median plane
- branches contribute to the innervation of the sternoclavicular joint
- the intermediate (or middle) supraclavicular nerve crosses the middle of the clavicle anteriorly and supplies the skin of the chest wall over the pectoralis major and deltoid muscles
- communicates with cutaneous branches of the upper intercostal nerves
- the lateral (or posterior) supraclavicular nerve crosses the lateral end of the clavicle and runs obliquely along the surface of the trapezius muscle and acromion supplying the skin of the upper and posterior aspect of the shoulder
As the medial supraclavicular nerve descends in the chest it passes superficially over the external jugular vein. Along with the other cutaneous branches of the cervical plexus the lesser occipital nerve passes posterior to the sternocleidomastoid muscle at the punctum nervosum (Erb’s point) roughly midway between the origin and insertion of the muscle.
The branching pattern of the supraclavicular nerves is highly variable with up to half of the population possessing only medial and lateral branches (i.e. no intermediate branch). A variant of the nerve's anatomical course in which it directly traverses through the clavicle via cortical foramina has been rarely described 4.
Typically sought for purposes of regional anesthesia; it is most commonly targeted as a component of a superficial cervical plexus block rather than selective blockade although the latter has been described.
Along the tapering posterior edge of the mid-sternocleidomastoid, roughly at the level of the cricoid cartilage, the hypoechoic circular nerves composing the superficial cervical plexus are often visualized superficial to the prevertebral fascia and deep to the investing layer of the deep cervical fascia surrounded by a homogenous, hyperechoic thickening of the fascial confluence. The C4 transverse process should be sought as a sonographic landmark; a smaller intertuberculur sulcus than C5, tapering of the scalene muscles and absence of the brachial plexus roots may assist localization. The levator scapulae and longus colli muscles bound the plexus at this level.
The greater auricular nerve is often the most conspicuous cutaneous branch due to its size and superficial course, frequently forming a circuitous loop around the posterior border of the SCM, lying adjacent to the external jugular vein. Scanning caudad toward the clavicle will reveal the course of the supraclavicular nerve as it separates and courses inferiorly, traveling laterally to the anterior scalene muscle and often just superficial to the brachial plexus and prevertebral fascia. Subsequent branches may sometimes be visualized although are quite diminutive, commonly less than 2 mm.
- the supraclavicular nerves may be easily damaged during surgical approach to the clavicular shaft
- sensory blockade may occur during an intrascalene brachial plexus block by way of cephalad local anesthetic spread with blockade of the C4 nerve root
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