Thorac Surg Clin 17 (2007) 529–547

Anatomy of the Neck and Cervicothoracic Junction

Jean Deslauriers, MD, FRCS(C)
Centre de Pneumologie de Laval, Department of Thoracic Surgery, 2725, Chemin Sainte-Foy,
Québec, QC G1V 4G5, Canada

Although thoracic surgeons often use cervical Surgical landmarks and triangles of the neck
and cervicothoracic incisions for operations on
Over the anterior neck, the laryngeal prom-
the upper airway, cervical esophagus, superior
inence (Adam’s apple) is formed by the angle of
mediastinum, and lung apices, the neck and
union of the two lateral laminae of the thyroid
thoracic inlet are anatomically complex regions
cartilage at the level of C4–C5 (Fig. 1). It is more
that traditionally have posed a problem for
prominent in men than in women because in
surgical access [1]. Important neurovascular struc-
men this angle of union is more acute. Above
tures traversing the neck often are crowded to-
the laryngeal prominence, the laminae diverge
gether, making exposure difficult and resectional
to create a V-shaped depression, the thyroid
surgery hazardous. Malignancies arising in the
notch. The anterior arch of the cricoid cartilage
thoracic inlet such as anteriorly located Pancoast
(level of C6) lies immediately inferior to the thy-
tumors or mediastinal neoplasms also may mag-
roid cartilage to which it is united by a thick and
nify the problem because they distort the normal
avascular membrane, the cricothyroid mem-
anatomy in addition to invading local structures
brane. It is through this membrane that crico-
such as the spine, major blood vessels, or brachial
thyroidotomies [2] and minitracheotomies used
plexus.
for pulmonary toilet are performed [3,4]. Al-
The anatomic information that every thoracic
though upper tracheal rings sometimes can be
surgeon must know and understand about the
felt at the base of the neck, they usually are
neck and thoracic inlet may not appear as such in
not palpable because they are covered by the
standard anatomy textbooks, because in those
thyroid isthmus, which often must be divided
volumes the anatomy is seen through the eyes of
or retracted superiorly to gain access to the up-
an anatomist rather those of a surgeon. Indeed
per trachea during an open tracheotomy or a tra-
there often are considerable differences in what is
cheal resection. The hyoid bone (level of C3),
seen in an immobile cadaver lying in its back and
which is not a true part of the larynx, lies above
what is observed in the operating room with
the thyroid cartilage, to which it is united by the
patients lying in different positions. Attempts to
thyrohyoid membrane.
perform operative procedures in the neck or over
The thoracic inlet, which is the anatomic
the cervicothoracic junction without both per-
region where the neck communicates with the
spectives can result in incomplete operations or
mediastinum, is the superior aperture (inlet) of the
technical mishaps.
thorax. It is bounded by the spine posteriorly
(level of T1), the cartilage of the first ribs laterally,
and the sternal (jugular) notch anteriorly.
The sternocleidomastoid muscle, which runs
superiorly and laterally from the manubrium
(sternal head) and the medial half of the clavicle
E-mail address: hopitallaval.chir-thor@ssss.gouv. (clavicular head) to the mastoid process of the
qc.ca temporal bone (Fig. 2), divides the side of the
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530 DESLAURIERS

Body of
hyoid bone

Thyrohyoid
membrane

Thyroid
notch
Thyroid
cartilage

Laryngeal
prominence

Cricothyroid
membrane

Anterior
cricoid
arch
First
tracheal ring

Thyroid

Fig. 1. The laryngeal landmarks of the anterior neck. Note the two laminae of the thyroid cartilage that are fused
together in the midline to form the laryngeal prominence.

neck into anterior and posterior triangles, which
are important descriptive landmarks (Box 1).
The supraclavicular fossa is a depression lo-
cated above the clavicle lateral to the clavicular
site of insertion of the sternocleidomastoid
muscle.
Muscles and skeleton of the neck
In the neck, there are several groups of
muscles, all of which are important to the thoracic
surgeon. These muscles include the prevertebral
muscles, the scalene muscles, the infrahyoid and
suprahyoid muscles, the sternocleidomastoid
muscle, the platysma, and, over the back of the
neck, the trapezius muscle.
There are three sets of deep prevertebral
muscles which are covered by the prevertebral
fascia and whose actions are to flex the neck and
to flex the head on the neck.
The scalene muscles (Box 2) have an oblique
orientation from their origin on the transverse
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION 531

Sternocleidomastoid
muscle

Mandible

Posterior
triangle

Anterior
triangle

Clavicle

Inferior belly of
omohyoid muscle

Supraclavicular
triangle

Fig. 2. Topography of the triangles of the neck. Note that the inferior belly of the omohyoid muscle divides the posterior
triangle into an occipital triangle and a supraclavicular triangle.

processes of the cervical vertebrae to their sites of
insertion on the superior border of the first two
ribs (Figs. 3 and 4). The scalene anterior is
located under the sternocleidomastoid muscle
and inserts on the scalene tubercle of the first
rib. The subclavian vein passes in front of it to
unite with the internal jugular vein; the subcla-
vian artery, and brachial plexus pass behind it.
The scalenus medius also inserts on the superior
border of the first rib lateral to the scalenus ante-
rior, and the scalenus posterior muscle inserts on
the external surface of the second rib. The scalene
triangle is bounded by the scalenus anterior ante-
riorly, the scalenus medius posteriorly, and the
first rib inferiorly. Collectively, the scalene mus-
cles elevate the first two ribs and thus are con-
sidered inspiratory muscles. For the thoracic
surgeon, the importance of the costoclavicular
space and of the scalene triangle is that anatomic
variations can cause compression of the brachial
plexus and subclavian artery (see the article on
the anatomy of the thoracic outlet by Urschel
in this issue). When a Pancoast tumor is resected
from the anterior cervical approach, the middle
532 DESLAURIERS
Box 1. Boundaries of the triangles of the
neck
Anterior triangle
Anterior border of sternocleidomastoid
muscle
Inferior margin of mandible
Anterior midline of the neck
Posterior triangle
Posterior border of sternocleidomastoid
muscle
Middle part of clavicle
Anterior border of trapezius
Box 2. Origin and site of insertion of the
scalene muscles
Scalenus anterior
Origin: Transverse process of C3–C6
Insertion: Scalene tubercle on the
superior border of the first rib
Scalenus medius
Origin: Transverse process of C2–C7
Insertion: Superior border of first rib,
lateral to the scalenus anterior
Scalenus posterior
Origin: Transverse process of C4–C6
Insertion: Superior border of second rib
and anterior scalenus muscles must be divided
above their site of insertion on the first rib to
gain access to the brachial plexus.
The infrahyoid muscles (Box 3) lie inferior to
the hyoid bone and are called ‘‘strap muscles’’
because they have a ribbon-like appearance.
They anchor the hyoid bone to the sternum,
clavicle, and scapula. These muscles include the
sternothyroid, the thyrohyoid, the sternohyoid,
and the omohyoid, which has two bellies (ante-
rior and posterior) united by an intermediate
tendon (Fig. 5) and extends obliquely from the
hyoid bone to the scapula. Between the left-
and right-sided strap muscles, a layer of loose
connective tissue must be accessed and elevated
to gain access to the prevertebral fascia and
superior mediastinum while doing a mediastino-
scopy. As a group, the infrahyoid muscles de-
press the hyoid bone and larynx and thus help
lower the lower jaw during the process of
swallowing.
The suprahyoid muscles (Box 4) are located in
the submandibular region superior to the hyoid
bone and connect the hyoid bone to the skull
(see Fig. 5). These muscles include the genio-
hyoid (deep layer), the mylohyoid (middle layer),
and the stylohyoid muscles (superficial layer).
The digastric muscle also is superficial and, like
the omohyoid, has an anterior and a posterior
belly united by an intervening tendon. The poste-
rior belly arises from the mastoid process (tem-
poral bone), and the anterior belly is attached
on the digastric fossa on the inferior border
of the mandible. Collectively, the suprahyoid
muscles lower the lower mandible (geniohyoid,
mylohyoid, anterior belly of digastric) or elevate
the hyoid bone (posterior belly of digastric,
stylohyoid).
The sternocleidomastoid muscle (Fig. 6) is
a large muscle located in the anterolateral portion
of the neck. As previously described, it extends
obliquely up the neck from the manubrium (ster-
nal head) and medial third of the clavicle (clav-
icular head) to the mastoid process of the
temporal bone. Its main actions are to flex the
head and tilt the head. It is crossed superficially
by the external jugular vein, and it covers the
great vessels of the neck.
The platysma muscle is a wide, thin quadrilat-
eral muscle that covers the front and side of the
neck and the lower face.
The important muscle in the posterior part of
the neck is the trapezius (Fig. 7), which is a wide,
thin, and triangular muscle extending from the
spinous processes of C7 and T1 to T10 to the clav-
icle (posterior lateral third), the acromion, and
the scapula. Its action is to elevate and rotate
the scapula.
The bony skeleton of the neck consists of the
upper sternum, clavicles, first ribs, and cervical
vertebrae. The upper sternum is called the ‘‘ma-
nubrium’’; its superior surface is indented by
a depression, suprasternal or jugular notch. On
each side of this notch is the articular facet for the
articulation of the medial end of the clavicle (see
Fig. 4). Part of the sternodeidomastoid muscles
originates from the anterior surface of the
manubrium.
The clavicle or collarbone extends from the
manubrium (sternoclavicular joint) to the
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION 533

C2

Scalenus
anterior
muscle
C3

Scalenus
C4
medius
muscle

C5
Scalenus
posterior C6
muscle

C7

Scalene
tubercle

First
rib

Second
rib

Fig. 3. The origin and insertion of the scalene muscles. Note that the anterior scalenus and middle scalenus insert on the
first rib, whereas the posterior scalenus inserts on the second rib.
534 DESLAURIERS

C1

C2 Origins of
Scalenus anterior
muscle

Origins of C3
Scalenus medius
muscle
C4
Scalenus
C5 anterior muscle

Scalenus
Insertion of C6 medius muscle
Scalenus
medius muscle Scalenus
C7
posterior
muscle
Insertion of
Scalenus
anterior
muscle

First rib

Clavicle
Second
rib

Fig. 4. Topographic anatomy of the scalene muscles. The scalene muscles descend obliquely from the transverse
processes of the cervical vertebrae to the first two ribs.

acromion of the scapula laterally (acromioclavic-
ular joint). This latter articulation connects the
upper limb to the chest wall. The clavicle is
important for the stability of the shoulder–girdle
complex. The acromioclavicular joint, whose con-
struction is reinforced by the powerful coracocla-
vicular ligament, provides mobility between
clavicle and scapula [5].
In their original description of the anterior
transcervical–thoracic approach for the resection
of Pancoast tumors, Dartevelle and colleagues [6]
recommended that the medial half of the clavicle
be resected to gain better surgical exposure. Be-
cause the clavicle is the site of insertion of the
sternocleidomastoid muscle (superior surface)
and of the pectoralis major muscle (inferior sur-
face), and because it stabilizes the shoulder
girdle, its resection can lead to shoulder instabil-
ity, especially when the clavicular resection is
associated with first rib resection and cervical
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION
Box 3. Infrahyoid muscles (strap
muscles)
Superficial plane
Sternothyroid
Extends from sternum to thyroid
cartilage
Located deep to sternohyoid muscle
Omohyoid
Extends from the hyoid bone to the
scapula
Has two bellies united by a tendon
Deep plane
Thyrohyoid
Continuation of sternothyroid muscle
up to the hyoid bone
Sternohyoid
Anterior to sternothyroid and
thyrohyoid
Extends from clavicle to hyoid bone
vertebra resection. Because clavicular resection
also can lead to serious alterations of shoulder
mobility, cervical posture, and discomfort,
most thoracic surgeons now advocate the trans-
manubrial approach described by Grunenwald
and Spaggiari [7]. This approach spares the clavi-
cle and all its muscular insertions while affording
excellent access to the supraclavicular region.
The first rib is important for maintaining
stability of the shoulder girdle. It is the shortest,
broadest, and most curved of all ribs, and it
extends from the lateral margin of the manubrium
inferior to the clavicular notch to a single-facet
articulation with the body of the first thoracic
vertebra. The first rib has a prominent scalene
tubercle on the inner border of its superior surface
for the insertion of the scalene anterior muscle.
This site of insertion is important because the
scalene triangle located between the scalene ante-
rior muscle anteriorly, the scalene medius muscle
posteriorly, and the first rib inferiorly allows the
passage of the subclavian artery and brachial
plexus. The subclavian vein crosses the first rib
in front of the scalene tubercle and scalene
anterior muscle.
The cervical spine is made of seven vertebrae
(C1–C7), the first one being called the ‘‘atlas,’’ the
second one the ‘‘axis,’’ and the seventh the ‘‘verte-
bra prominens’’ because of its long spinous pro-
cess that can be palpated easily and seen
535
through the skin. Their distinctive feature is their
transverse process, which circumscribes the trans-
verse foramen through which the vertebral ar-
teries and veins pass. The sixth cervical vertebra
has a prominent anterior tubercle of its transverse
process called the ‘‘tubercle de Chassignac,’’
which has a close relationship with the common
carotid artery.
Topographic anatomy of the neck: anterior
and posterior triangles
Topographically, the neck is divided into an
anterior and a posterior triangle by the sterno-
cleidomastoid muscle (see Box 1 and Fig. 2).
Complete knowledge of the anatomy of these tri-
angles is important for the thoracic surgeon oper-
ating in the area, because they contain many
important structures that must be identified and
preserved during surgery. Superior sulcus tumors
located anteriorly and extending in front of the
anterior scalene muscle, for example, may invade
the subclavian and internal jugular veins, whereas
tumors extending between the anterior and med-
ius scalene muscles may invade the phrenic nerve,
the subclavian artery and its branches, and the
brachial plexus [8].
The general shape of the posterior triangle of
the neck is that of a triangle whose base is the
middle third of the clavicle and whose apex is the
meeting of the sternocleidomastoid muscle and
trapezius muscles on the superior nuchal line. Its
exact boundaries are presented in Box 1. The floor
of the posterior triangle is made of four muscles,
including the scalenus medius and scalenus poste-
rior, which are covered by a deep cervical fascia.
The inferior belly of the omohyoid muscle divides
the posterior triangle into an occipital triangle
(superior to the omohyoid) and a supraclavicular
triangle that is crossed superficially by the external
jugular vein.
The anterior triangle of the neck, whose apex is
the sternal notch and whose base is the inferior
border of the mandible, contains the common
carotid artery and its division into external and
internal branches (carotid triangle).
Topographic anatomy of the neck: the root of
the neck
The root of the neck, the thoracocervical
region, is bounded laterally by the first ribs,
anteriorly by the sternal notch and manubrium,
536 DESLAURIERS

Anterior belly of
digastric muscle

Mylohyoid muscle

Stylohyoid muscle

Thyrohyoid
muscle Posterior belly of
digastric muscle

Sternocleidomastoid
muscle (cut)

Sternohyoid muscle

Anterior belly of
Sternothyroid omohyoid muscle
muscle
Posterior belly of
omohyoid muscle

Fig. 5. Topography of the infrahyoid and suprahyoid muscles. Note the two bellies of the omohyoid muscle united by an
intermediate tendon.

and posteriorly by the first dorsal vertebra (D1).
Its general arrangement is shown diagrammati-
cally in Fig. 8.
Veins and thoracic duct
When Pancoast tumors are resected through
the anterior cervical approach, the venous system
(Fig. 9) at the root of the neck (Box 5) is usually
dissected first.
Most of the external jugular vein is located in
the posterior triangle of the neck, where it runs
downward crossing the sternocleidomastoid mus-
cle obliquely to empty into the subclavian vein.
The anterior jugular vein’s anatomy is variable as
it arises from submental venous plexuses and
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION
Box 4. Suprahyoid muscles (connect the
hyoid bone to the skull)
Deep layer
Geniohyoid: Extends from inferior
maxillary to the hyoid bone
Middle layer
Mylohyoid
Large and thin muscle that supports
the floor of the mouth
Located above the anterior belly of
digastric muscle
Superficial layer
Stylohyoid: Small strip of muscle located
along the upper border of posterior
belly of digastric
Digastric
Has two bellies (anterior, posterior)
joined by an intervening tendon
Anterior belly arises from mandible
Posterior belly arises from mastoid
process
drains into the external jugular vein posterior to
the sternocleidomastoid muscle.
The subclavian vein begins on the lateral
border of the first rib and crosses that rib anterior
to the scalenus anterior muscle (anterior to
scalene tubercle). On the medial border of the
scalenus anterior muscle it joins the internal
jugular vein to form the innominate vein.
The internal jugular vein is the largest vein of
the neck. It begins in the posterior cranial fossa,
where it drains blood from the brain, and runs
inferiorly lateral to the carotid artery (carotid
sheath) in the anterior triangle of the neck. It then
passes deep to the sternocleidomastoid muscle to
unite with the subclavian vein to form the in-
nominate vein posterior to the sternal end of the
clavicle.
On the left side, the thoracic duct, which
ascends from the mediastinum, empties in the
venous system at the union of the left internal
jugular vein and subclavian vein.
When Pancoast tumors are resected through
the cervicothoracic approach, all branches of the
subclavian vein must be visualized clearly, and
proximal and distal control should be obtained
early during the dissection. If the subclavian vein
537
is invaded by the tumor, it can be resected
without a need for reconstruction. On the left
side, ligation of the thoracic duct usually is
required.
Arteries of the root of the neck
The right subclavian artery (Box 6) is a termi-
nal branch of the innominate artery. The left sub-
clavian artery originates directly from the aortic
arch. Both arteries enter the root of the neck be-
hind their respective sternoclavicular joints. Each
artery then arches superiorly and posteriorly be-
hind the scalenus anterior muscle.
Three branches of the subclavian artery orig-
inate in the sternocleidomastoid region. The first
and most important one is the vertebral artery,
which arises in the first portion of the artery
medial to the anterior scalenus muscle. Next to
the vertebral branch and also medial to the
scalene anterior muscle is the thyrocervical trunk,
which gives rise to the inferior thyroid artery and
to the ascending cervical branch that supplies the
muscles of the posterior triangle of the neck. The
internal mammary branch arises from the inferior
aspect of the subclavian artery opposite the
thyrocervical trunk. It runs downward into the
thorax parallel to the sternum.
During surgery for Pancoast tumors, the sub-
clavian artery and its branches must be dissected.
This maneuver is much easier when the operation
is done from above, through the anterior supra-
clavicular approach. If necessary, the subclavian
artery can be resected locally and reconstruction
performed either with an end-to-end anastomosis
or graft interposition. The vertebral artery never
should be sacrificed unless the continuity of the
circle of Willis has been well documented
preoperatively.
Nerves of the root of the neck
From the skull, the vagus nerve passes in-
feriorly through the neck within the carotid
sheath behind the internal carotid artery and
internal jugular vein. At the base of the neck,
the right vagus nerve crosses the origin of the
right subclavian artery behind the sternoclavicu-
lar joint, where it gives off the right recurrent
laryngeal nerve (inferior laryngeal nerve) that
loops around and under the subclavian artery
(Figs. 10 and 11). This nerve ascends in the tra-
cheoesophageal groove (Box 7), where it can be
injured during extensive cervicomediastinal dis-
sections done for tumors located near or at the
538 DESLAURIERS

Posterior belly of
digastric muscle

Anterior belly of
Posterior digastric muscle
scalene
muscle

Middle Anterior belly of

scalene omohyoid muscle
muscle

Sternocleidomastoid
muscle

Posterior
belly of
omohyoid
muscle
Anterior
scalene
muscle

Fig. 6. Lateral view of the neck muscles showing the sternocleidomastoid muscle.

thoracic inlet. On the left side, the recurrent laryn-
geal nerve originates close to the ligamentum arte-
riosum where it courses around the aortic arch
from front to back before ascending to the neck,
also in the tracheoesophageal groove. On each
side, the recurrent nerves accompany the laryn-
geal branch of the inferior thyroid artery deep
to the inferior constrictor muscle of the pharynx
behind the cricothyroid articulation. Before enter-
ing the larynx, each recurrent nerve sends off 8 to
14 short branches into the lateral wall of the
esophagus; these branches sometimes can be
seen when operating on the upper esophageal
sphincter. The recurrent nerves supply all of the
intrinsic muscles of the larynx except the cricothy-
roid muscle.
In general, the right recurrent nerve has a more
asymmetrical and diagonal course than the left
recurrent nerve, and this course is one of the
reasons most surgeons choose the left thoracic
inlet as the venue for transposing colon or
stomach [9,10].
The superior laryngeal nerves arise from the
vagus nerves in the neck behind the upper portion
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION 539

Sternocleido-
mastoid
muscle

Trapezius Rhomboideus
muscle minor muscle

Rhomboideus
major muscle

Latissimus
dorsi
muscle

Fig. 7. Topography of the trapezius muscle.

540 DESLAURIERS

Scalenus
anterior
C5 muscle
C6
Phrenic
C7 nerve

C8

T1

Superior trunk of
brachial plexus

Middle trunk of Clavicle

brachial plexus

Lower trunk of
brachial plexus

Cords of First
brachial rib
plexus

Subclavian
artery
Subclavian
vein

Fig. 8. General anatomy of the cervicothoracic region (the root of the neck).

of the triangle made by the carotid artery bi-
furcation and almost immediately divide into two
terminal branches. The internal laryngeal nerve
pierces the thyrohyoid membrane with the supe-
rior laryngeal artery; the external branch accom-
panies the superior thyroid artery posterior to the
sternothyroid muscle.
The phrenic nerve arises from C3-to-C5 (the
main root arises from C4) and descends obliquely
in the neck on the anterior surface of the scalenus
anterior muscle. At the base of the neck, it is
located over the medial surface of this muscle,
3 to 4 cm lateral to the sternoclavicular joint.
The phrenic nerve descends posterior to the sub-
clavian vein and anterior to the internal mammary
artery to enter the thorax.
Surgically, the phrenic nerve can be accessed
by a transverse incision made over the posterior
border of the sternocleidomastoid muscle 2 finger-
breadths above the clavicle. With the sternoclei-
domastoid muscle and internal jugular vein
retracted medially, the phrenic nerve can be seen
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION 541

Scalenus
medius muscle

Scalenus
anterior muscle

Facial External
vein jugular vein

Sternocleidomastoid Internal
muscle jugular vein

Anterior
jugular vein
Omohyoid
muscle
(inferior belly)

Subclavian
vein
Innominate
vein

Fig. 9. Veins at the root of the neck.

over the anterior surface of the scalene anterior
muscle. It can be injured during a prescalene
nodal biopsy for the purpose of staging lung
cancer [11,12], because the floor of the prescalene
space is formed by the scalenus anterior muscle
with the phrenic nerve lying in its sheath. During
resection of a Pancoast tumor through the cervi-
cothoracic approach, every attempt should be
made to preserve the phrenic nerve; for this reason
the scalene anterior muscle must be divided as
close to its site of insertion on the first rib as
possible.
The cervical sympathetic trunks (see Fig. 10)
are made of three sympathetic ganglia (Box 8)
joined by intermediate longitudinal strands of
nerve fibers. There structures are located on the
prevertebral fascia, which separates them from
the transverse processes of the cervical vertebrae.
The superior ganglion is large and fusiform and
is located at the level of the second and third cer-
vical vertebrae. The middle cervical ganglion is
small and inconsistent and is located at the level
of the sixth cervical vertebra. The inferior cervical
ganglion or stellate ganglion lies anterior to the
transverse process of C7 near the superior border
of the neck of the first rib. The stellate ganglion
also is known as the ‘‘cervicothoracic ganglion’’
because it is generally fused with the first thoracic
ganglion. Although it is called the ‘‘stellate
ganglion,’’ its form can be quite variable (eg, semi-
lunar or circular), and indeed it is seldom star-
shaped.
542 DESLAURIERS

Box 5. Veins at the root of the neck Box 6. Arteries at the root of the neck

External jugular vein Right subclavian artery

Drains mandibular and auricular regions Originates from the innominate artery
Located in posterior triangle of the neck Enters the root of the neck behind the
Empties into subclavian vein sternoclavicular joint
Anterior jugular vein Left subclavian artery
Drains submental regions Originates from the aortic arch
Variable anatomy Ascends and enters the root of the neck
Empties into internal jugular vein behind the left sternoclavicular joint
Subclavian vein Branches of the subclavian arteries
Continuation of axillary vein Vertebral: Arises medial to the scalenus
Crosses the first rib anterior to the anterior muscle
scalene anterior muscle Thyrocervical trunk: Gives rise to inferior
thyroid and ascending cervical
Internal jugular vein
branches
Drains blood from the brain
Internal mammary:
Runs inferiorly lateral to the common
Arises from inferior aspect of
carotid artery
subclavian artery
Crosses deep to the sternocleidomastoid
Descends inferomedially into the
muscle to unite with the subclavian
thorax
vein

Fascia and fascial spaces of the neck splits to surround the thyroid gland, trachea,
and esophagus completely. It invests the strap
The fascial planes (Box 9) and spaces (Box 10)
muscles, and laterally it fuses with the superfi-
of the neck are important to the thoracic surgeon
cial fascia opposite the carotid sheath. In cases
because they connect the mediastinum with the
of spontaneous pneumomediastinum, interstitial
neck, and air (pneumomediastinum) or infection
air usually reaches the neck by dissecting along
(mediastinitis) can travel that route. The fascia
this fascia [13].
of the neck comprise three layers, the superficial
The posterior cervical fascia consists of two
or investing fascia, the middle or pretracheal fas-
layers. The first or alar fascia lies posterior to the
cia, and the posterior or prevertebral fascia.
visceral compartment of the neck and continues
The superficial (investing) fascia is deep to
laterally to form the carotid sheath. The second or
the subcutaneous fascia and encircles the neck
prevertebral fascia extends from the base of the
completely, investing the platysma, sternoclei-
skull to the third thoracic vertebra and covers the
domastoid, and trapezius muscles. Superiorly it
prevertebral muscles.
is attached to the superior nuchal line and
There are two cervicothoracic spaces (Fig. 12)
spinous processes of the cervical vertebrae,
of importance to the thoracic surgeon, the previsc-
and inferiorly it is attached to the manubrium,
eral or pretracheal space and the retrovisceral or
clavicle, and scapula. Superior to the sternal
retropharyngeal space (see Box 10).
notch, this fascia splits into two layers that are
The pretracheal space, which lies beneath the
attached to the anterior and posterior manubrium.
strap muscles, is opened during mediastinoscopy,
The space between these two layers, the supra-
thyroid surgery, and surgery of the cervical
sternal space or space of Burns, contains the
trachea. It extends from the thyroid cartilage
sternal heads of the sternocleidomastoid muscles
above to the upper border of the aortic arch
and the arch of the internal jugular vein.
where it terminates by adhesions extending from
The middle or pretracheal fascia extends
the fibrous pericardium to the posterior surface of
from the thyroid and cricoid cartilages down
the manubrium. These fibrous adhesions form
into the thorax. It is an extensive fascia that
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION 543

Superior
cervical
ganglion

Vagus nerve
(CN X)

Sympathetic
trunk

Middle
cervical
ganglion

Common
carotid
artery

Scalenus
anterior
muscle
Cupula
Phrenic
nerve

Inferior cervical
(Stellate)
ganglion

Vertebral
artery

Subclavian
artery

Ansa subclavia

Right recurrent
laryngeal nerve

Fig. 10. Arteries and nerves at the root of the neck.

544 DESLAURIERS

Superior
laryngeal
nerve

Left vagus
nerve (CN X)

Right vagus
nerve (CN X)
Trachea

Right recurrent
laryngeal nerve

Left recurrent
laryngeal nerve

Esophagus

Fig. 11. Anatomy of the left and right recurrent laryngeal nerves.
 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION
Box 7. Anatomy of the recurrent
laryngeal nerves (inferior laryngeal
nerves)
Right recurrent laryngeal nerve
Loops around the right subclavian artery
Ascends in tracheoesophageal groove
Has a more asymmetric and diagonal
course than the left recurrent nerve
Left recurrent laryngeal nerve
Loops around the aortic arch near the
ligamentum arteriosum
Ascends in the tracheoesophageal
groove
a relative barrier to the downward gravitational
spread of infection.
The retrovisceral or retropharyngeal space
consists of loose connective tissue located in front
of the prevertebral fascia. It extends from the skull
through the neck and posterior mediastinum
down to the diaphragm. Laterally, it seals off at
the transverse processes of the cervicothoracic
vertebrae. This space is of considerable impor-
tance, because retropharyngeal abscesses second-
ary to oropharyngeal infections can spread to the
mediastinum producing a diffuse necrotizing
mediastinitis [14,15].
Box 8. Sympathetic ganglia of the neck
Superior cervical ganglion
Large and fusiform
Located at the level of C2, C3
Middle cervical ganglion
Small and inconsistent
Located at the level of C6
Inferior cervical ganglion (stellate
ganglion)
Generally fused with the first thoracic
ganglion
Located at the level of C7
Seldom star-shaped
545
Box 9. Fascias of the neck
Superficial (investing) fascia
Encircles the neck completely
Attached superiorly to superior nuchal
line and spinous processes of C1–C7
Attached inferiorly to manubrium,
clavicle, and scapula
Middle (pretracheal) fascia
Extends from thyroid and cricoid
cartilages down into the thorax
Splits to surround the thyroid, trachea,
and esophagus completely
Posterior (prevertebral) fascia
Extends from the base of the skull to the
third thoracic vertebra
Covers prevertebral muscles
Box 10. Cervicothoracic fascial spaces
Pretracheal (previsceral) space
Located between trachea and strap
muscles and between trachea and
posterior manubrium
Extends from thyroid cartilage to upper
border of aortic arch (T4)
Retropharyngeal (retrovisceral) space
Located in front of the prevertebral fascia
Extends from the skull to the diaphragm
Summary
All thoracic surgeons must have an extensive
knowledge of the anatomy of the neck, because
cervical approaches are used on an almost daily
basis to access the cervical trachea, upper esoph-
agus, and superior mediastinum. In addition to
basic and scholarly knowledge of anatomy, they
also must understand the anatomic relationships
among the neck, the mediastinum, and both
pleural spaces. Indeed, such knowledge forms
the basis for the diagnosis and management of
many aspects of pulmonary, mediastinal, and
esophageal pathologies.
546 DESLAURIERS

Previsceral
space

Retrovisceral
space

Fig. 12. The anatomy of the previsceral and retrovisceral spaces.

 ANATOMY OF THE NECK AND CERVICOTHORACIC JUNCTION
Further readings
Moore KL. Clinically oriented anatomy. 2nd edition.
Baltimore (MD): Williams and Wilkins; 1985.
Gardner E, Gray DJ, O’Rahilly R. Anatomy: a regional
study of human structure. 3rd Edition. Philadelphia:
WB Saunders Co; 1969.
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