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MORPHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH: CLINICAL RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-VIS OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT

Authors:
  • SBH Government Medical College Dhule Maharashtra India
Int J Anat Res 2017, 5(3.1):4168-72. ISSN 2321-4287 4168
Original Research Article
MORPHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH:
CLINICAL RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-VIS
OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT
Roopali D Nikumbh *1, Dhiraj B Nikumbh 2, Anjali N Wanjari 3.
ABSTRACT
Address for Correspondence: Dr. Roopali D Nikumbh MD., Associate Professor, Department of
Anatomy, JMFs ACPM Medical college, Dhule, Maharashtra, India (424001).
E-Mail: drrdnikumbh@gmail.com
Background: Suprascapular notch is an indentation in the superior border of the scapula which is just medical
to base of the coracoid process. The superior transverse scapular ligament (STSL) ossifies to form suprascapular
foramen and serves as passage for suprascapular nerve. Morphological variations of SSN play a crucial role in
the suprascapular neuropathy due to nerve entrapment.
Objective: To study variations of suprascapular notch in dry scapulae and to find out and compare the incidence
of ossified STSL/ suprascapular foramina with previous studies from different regions.
Materials and Methods: The present study was conducted on 106 dry human scapulae of unknown age and sex in
the Department of Anatomy, ACPM Medical College, Dhule. This was an observational study over a period of nine
months from July 2016 to March 2017.The scapulae were examined to assess morphological variations of SSN
and various types were classified as per Rengachary et al. The results of present work were compared with
previous studies.
Result: Complete ossification of STSL leading to foramina (Type VI) was observed in 09(8.5%) out of 106 scapulae.
The most frequent type seen was Type III in 43(40.6%) scapulae, second most common- Type I-26.4%, and rest
were Type II-17%,Type IV-4.7%, and Type V-2.8% .
Conclusion: Better understanding and thorough knowledge of variations of suprascapular notch vis-à-vis ossified
STSL leading to foramina is important for anatomists and clinicians (surgeons and orthopedics) for making
proper diagnosis of suprascapular neuropathy and planning the most suitable surgical corrections.
KEY WORDS: Suprascapular Notch, Foramina, Superior Transverse Scapular Ligament, Neuropathy, Scapula.
INTRODUCTION
International Journal of Anatomy and Research,
Int J Anat Res 2017, Vol 5(3.1):4168-72. ISSN 2321-4287
DOI: https://dx.doi.org/10.16965/ijar.2017.275
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DOI: 10.16965/ijar.2017.275
*1 Associate Professor, Department of Anatomy, JMFs ACPM Medical college, Dhule, Maharashtra,
India.
2 Professor, Department of Pathology, JMFs ACPM Medical college, Dhule, Maharashtra, India.
3Professor & Head, Department of Anatomy, JMFs ACPM Medical college, Dhule, Maharashtra,
India.
Received: 30 May 2017
Peer Review: 30 May 2017
Revised: 19 Jun 2017
Accepted: 10 Jul 2017
Published (O): 31 Jul 2017
Published (P): 31 Jul 2017
3 processess and 2 surfaces [1]. The action of
scapula is like fulcrum and important for the
motions of humerus. Scapula has three borders;
superior border is thin, sharp and shortest while
Shoulder blade or scapula is a point of attrac-
tion to many anatomists due to its characteris-
tic triangular shape having 3 borders, 3 angles,
Int J Anat Res 2017, 5(3.1):4168-72. ISSN 2321-4287 4169
Roopali D Nikumbh, Dhiraj B Nikumbh, Anjali N Wanjari. MORPHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH: CLINICAL
RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-VIS OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT.
it is interrupted by semicircular indentation just
medial to coracoid process known as supras-
capular notch (SSN) [2]. The superior transverse
scapular ligament (STSL) is a fibrous band
connecting two borders of notch forming supras-
capular foramina (SSF), transmitting suprascapu-
lar nerve to supraspinatus fossa [2].
The suprascapular nerve, a branch from upper
trunk of branchial plexus gives motor branch to
supraspinatus and infraspinatus muscle and
sensory branch to rotator cuff muscles,
ligaments of shoulder and acromioclavicular
joint [2].
The most common risk factor for the suprascapu-
lar nerve entrapment is a completely ossified
STSL [3]. The main manifestations of neuropa-
thy are dull, diffuse pain in posterior and lateral
aspect of shoulder, weak abduction and
rotation of upper extremity at joint and atrophy
of supra and infraspinatus muscle [4]. Such
injuries are more common in sport personals due
to repeated stress on shoulder. Hence SCN is an
important landmark of suprascapular nerve
during arthroscopic ligament repairs.
Rengachary SS et al [5,6] classified SCN into six
different types on morphological features and
stated that size of SCN played a important role
in predisposition of suprascapular nerve entrap-
ment.
In the present study, we studied all six morpho-
logical variants of suprascapular notch (Type I
to VI) as per Rengachary SS et al. [5,6]. We
correlated our findings with previous Indian
studies and various ethnic population from
available literature.
variation of SCN and its types as classified by
Rengachary SS et al.5,6 The results of present
study vis-à-vis superior transverse scapular
ligament were tabulated and compared with
various Indian and other ethnic studies avail-
able from the literature.
We classified the morphology of SCN into six
types as per Rengachary SS et al 5,6 based on
shape as well as ossification of STSL, as follows:
Type I- Complete absence of notch, wide
depression from the superior angle to base of
coracoid process.
Type II- Wide blunted V-shaped notch occupy-
ing a third of superior border of scapula.
Type III- Symmetrical U-shaped notch with
parallel margins.
Type IV- Small ,narrow V-shaped notch.
Type V- U-shaped notch with partial ossifica-
tion of medial part of STSL.
Type VI – Completely ossified ligament forming
a foramen of variable size.
MATERIALS AND METHODS
In the present study, 106 dry human scapulae of
unknown age/sex were collected from the
Department of Anatomy, ACPM Medical College,
Dhule. This was an observational study of mor-
phological variants of suprascapular notch over
a period of nine months from July 2016 to March
2017.
The scapulae available in the department with
intact or unbroken superior border were included
whereas the scapulae with broken superior
border were excluded from the study. The
scapulae were examined for the morphological
In the present study on 106 dried human scapu-
lae, we found all the six types of suprascapular
notch as per classification [5,6]. We found
09(8.5%) scapulae with completely ossified STSL
forming SSF (Type VI).After observation and
analysis of morphological variants of supras-
capular notch, we noted: Type I-26.4%,Type II-
17%, Type III-40.6%,Type IV-4.7%,Type V-2.8%
and Type VI-8.5% (Table 1) The gross
photographs of various notch types were shown
in Figure no.1as type I to type VI highlighting
superior border of scapulae with notch variant.
RESULTS
Table 1: Morphological variants of suprascapular notch
as per Rengachary SS et al5,6 in our study.
Type I II III IV V VI Total
Number of scapulae
28
18
43
5
3
9
106
Percentage (%)
26.4
17
40.6
4.7
2.8
8.5
100
In our study, we observed type III (40.6%) as
the most common type of suprascapular notch
as per Rengachary SS et al. [5,6] We noted
various forms of type III in Figure no.2. Second
most common type was type I (26.4%) after type
III. We found 3(2.8%) scapulae of type V
(partially ossified STSL forming incomplete
foramina) highlighted in figure no.3a,b.
Characteristically we noted 09(8.5%) scapulae
Int J Anat Res 2017, 5(3.1):4168-72. ISSN 2321-4287 4170
Roopali D Nikumbh, Dhiraj B Nikumbh, Anjali N Wanjari. MORPHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH: CLINICAL
RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-VIS OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT.
with type VI (completely ossified STSL forming
suprascapular foramina) and the photographs
were highlighted in figure no.4 as 4a,4b,4c
(ventral/anterior aspect) and 4d,4e,4f (dorsal/
posterior aspect).
Fig. 1: Showing various notch types (type I to type VI) as
per Rengachary’s classification.
Fig. 2: Most common type of notch in our study (type III)
with various forms.
Fig. 3: Showing type V notch with partial ossification of
STSL:3a –ventral aspect and 3b-dorsal aspect.
Fig. 4: Type VI notch with completely ossified STSL forming
suprascapular foramina on ventral aspect (a,b,c) and
dorsal aspect(d,e,f)
DISCUSSION
In the present study, the incidence of completely
ossified scapular ligament leading to type VI
was 8.5%.This is the characteristic finding in our
study in view of clinical importance leading to
neuropathy. The incidence of type VI by various
Indian researchers in chronological order was
shown in Table 2 ranges from lesser incidence
as 1 to 3% with an average of 10 to 12%.
Table 2: Incidence of type VI by various Indian authors
as per chronological order.
Serial
number
Author/Year of study n (Sample size-
no of scapulae)
Percentage (%)
of type VI
1 Iqbal K et al [7] 2010 250 0
2 Malik G E et al [8] 2012 100 3
3 Jadhav S et al [9] 2012 350 10.57
4 Reddy M [10] 2013 104 1.93
5 Karam K [11] 2013 100 2
6 Vandana Ret al [12] 2013 134 12.6
7 Kannan U et al [13] 2014 400 10
8 Neeta Chhabra et al [14] 2016 126 2.4
9 Shalom Elsy Philip el al [15] 2017 100 3
10 Present study 2017 106 8.5
The incidence of suprascapular foramen in our
study is comparable and in concordance with
various ethnic population based studies. After
going through available literature of study on
completely ossified STSL, we found concordance
of our incidence with Polguj M et al [16]
(Poland) and Grey DJ et al [17] (America and
Europeans) as shown in Table no.3
Int J Anat Res 2017, 5(3.1):4168-72. ISSN 2321-4287 4171
Table 3: Incidence of supras cap ular foramina by
different ethnic population studies.
Serial no Author Race /sample size(n) Percentage(%) of
type VI
1 Polguj M et al [16] Poland (86) 7.00%
2 Grey DJ et al [17] Americans
&Europeans(1151)
6.34
3 Natsis K et al [18] Greek(423) 6
4 Vallois HV [19] French (200) 6.5
5 Olliver G et al [20] French (133) 5-6.5
6 Present study India (106) 8.5
In our morphological study on 106 scapulae, we
found most common type of SCN is type III
(40.6%) and this observation is in accordance
with previous cited studies by Jadhav S et al [9]
(39.79%)and Agrawal D et al [21](45.0%).Sec-
ond most common finding regarding our study
is type I (26.4%) of suprascapular notch
variation and this finding is similar with
previous studies by Iqbal K et al [7] (22.5%),
Kannan U et al [13] (20.0%) and Nagraj S et al
[22](23%) .
There is lack of standard classification regard-
ing morphological study on SCN of scapula. Dif-
ferent authors followed different classification
as by Rengachary SS et al [5,6], Iqbal K et al [7]
and Natsis K et al [17] depending upon
morphology, shape (J,U,V) and morphometry
respectively. Due to several classifications, it is
difficult to compare the morphological findings
and draw conclusion. In the present study, we
followed Rengachary SS el al [5,6] classification
of six types on morphology, and correlated and
compared the results from different studies
across the globe who followed the Rengachary
classification as shown in Table 4.
Table 4: Incidence of different types of suprascapular
notch in different ethnic groups.
Rengachary SS et al [5,6] Americans(211) 8 31 48 3 6 4
Shalom Elsy Philipe el al [15] Indian (100) 9 36 38 8 6 3
10.2
VI(%)
Sinket SR et al [23] 22 21 29 5 18 4
Authors Type
I(%) II(%) III(%) IV(%) V(%)
Albino P et al [24] 12.4 14.8 22.8 31.1
Reddy M et al [10] 21.15 8.65 59.61 2.88
Kinnan U et al [13] 20 10 52 4
Sumathi Shanmugam et al [25] 11.63 23.26 43.03 3.48
Present study 26.4 17 40.6 4.7 8.5
Ethnicity (n)
Indian (106)
Indian (176)
Indian (400)
Indian (104)
Italian (500)
Kenyan (138)
2.8
10
4.81 12.79
4
3.6
5.76 1.93
Indian population and by Rengachary SS et al
[6,7] in Americans and Sinket SR et al [23]
(Kenyan).Albino P et al [24] (Italian)and Reddy
M et al [10](India) and the latest references in
2016 and 2017 like Sumathi Shanmugam et al
[25] and Shalom Elsy Philip el al [15] showed
lesser incidence of type VI and remaining types
of SCN were comparable with present study.
The exact etiology of morphological variation of
SCN is not clear but Odita JC et al [26] hypoth-
esized that the ossification of the coracoid
process epiphysis influence the shape of the
notch and give rise to different morphologies in
various populations. The varied size and shape
of SCN may predispose to suprascapular nerve
entrapment and neuropathy [14].
From the above table , our results were in ac-
cordance with study by Kinnan U et al [13] from
The thorough knowledge of morphological
variations of suprascapular notch and ossified
STSL is important for anatomists, operating
surgeons ,orthopedicians and neurophysicians
and radiologists for better understanding of
suprascapular nerve entrapment neuropathy. In
the present study, we analyzed six morphologi-
cal variant of suprascapular notch and supras-
capular foramina due to ossified STSL.
In recent advances, the present topic includes
screening of sport personalities for suprascapu-
lar neuropathy, diagnosis of the suprascapular
nerve entrapment syndrome with the help of CT,
MRI and USG, laparoscopic repair of SCN by
orthopedicians and histopathological analysis of
SCN by pathologists.
CONCLUSION
Conflicts of Interests: None
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How to cite this article:
Roopali D Nikumbh, Dhiraj B Nikumbh, Anjali N Wanjari. MOR-
PHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH:
CLINICAL RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-
VIS OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT. Int
J Anat Res 2017;5(3.1):4168-4172. DOI: 10.16965/ijar.2017.275
Roopali D Nikumbh, Dhiraj B Nikumbh, Anjali N Wanjari. MORPHOLOGICAL VARIATIONS OF THE SUPRASCAPULAR NOTCH: CLINICAL
RELEVANCE IN SUPRASCAPULAR NEUROPATHY VIS-A-VIS OSSIFIED SUPERIOR TRANSVERSE SCAPULAR LIGAMENT.
... and Apurba Patra et al (25). i.e. 31% and 39.09% but Rengachary et al. (10)., Usha Kannan et al (12,13)., Udayasree L et al (14,22)., G.H.E.S. Hassanein et al (23)., Manmeet kour et al (24,31)., S. Vedha et al (32)., Reddy et al (28). described the highest rate of Type III suprascapular notch and Iqbal k. et al (8)., Krishna Gopal et al (18). ...
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The study was undertaken to see the variation of the suprascapular notch. The notch is present on the superior border of the scapula near the root of coracoid process. It is roofed by the superior transverse ligament and is converted into foramen for the passage of suprascapular nerve. The study was carried out on 121 scapulae in the department of Anatomy RMC Loni, Ahmednagar. The parameters included in the study were presence of notch, shape of notch, transvers length of notch, edge of notch, ossification of transverse ligament and other finding were also noted. The parameters were measured by Vernier calliper and appropriate statistical tests were applied. The supra-scapular notch was present in 82.64% of scapulae. U Deep shaped notch was most common shape followed by J shallow shaped notch. Round edge at the depth of the notch was more common. The knowledge of suprascapular notch variations is of great importance for surgeons performing suprascapular nerve decompression especially by means of endoscopic techniques. Our anatomical study helps the clinicians before planning a surgery.
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Background and aims : Supra-scapular notch is roofed by superior transverse scapular ligament and converted into a foramen which provides passage for suprascapular nerve. When it is completely ossified that time it manifest as supra-scapular foramen in dry scapulae. Variations of superior transverse scapular ligament include calcification, partial or complete ossification and multiple bands. Presence of this foramen in dry scapulae is considered to be rare. Aim of the study was to verify the prevalence of supra-scapular foramen in Indian dry scapulae. Materials and methods : A total of three fifty dry scapulae were analyzed (Right- 176, Left-174) to see the presence of supra-scapular foramen. Results : In the present study, suprascapular foramen was present in 25 right and in 12 left sided scapulae i.e., 10.57% incidence which is alarming. Conclusion : Present study demonstrates that suprascapular foramen which is the result of complete ossification of superior transverse scapular ligament, is common in Indian population. The anatomical knowledge of this foramen is of extreme importance for clinicians; it can be a risk factor during surgical explorations involving a suprascapular nerve decompression.
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