USLS COLLEGE OF MEDICINE c) Carotid

d) Muscular
ANATOMY 2. Posterior
a) Occipital
b) Supraclavicular or Subclavian
TITLE: Neck Region I. Arteries
DATE: 10/12,14,15/20 1. Common carotid artery
a) Carotid sinus
LECTURER: Fernandez, MD b) Carotid Body
(asynchronous) 2. External carotid artery
3. Internal carotid artery
4. Subclavian arteries
J. Veins
I. Neck Region 1. External jugular vein
A. Bones 2. Anterior jugular vein
1. Cervical vertebrae 3. Internal jugular vein
2. Hyoid bone 4. Subclavian veins
B. Skin K. Lymph Drainage
1. Cutaneous 1. Pericervical​ nodes
C. Superficial Fascia a) Occipital
1. Platysma b) Retroauricular (mastoid)
2. Superficial Veins c) Parotid
3. Superficial Lymph Nodes d) Buccal (facial)
D. Deep Cervical Fascia e) Submandibular
1. Investing layer f) Submental
2. Pretracheal layer 2. Cervical​ nodes
3. Prevertebral layer a) Anterior cervical
4. Carotid sheath b) Superficial cervical
5. Axillary Sheath c) Retropharyngeal
E. Cervical Ligaments d) Laryngeal
1. Stylohyoid e) Tracheal (paratracheal)
2. Stylomandibular 3. Deep cervical​ nodes
3. Sphenomandibular a) Jugulodigastric
4. Pterygomandibular b) Juguloomohyoid
F. Muscles of the Neck L. Nerve Supply
1. Key Muscles 1. Anterior Triangle
a) Sternocleidomastoid a) Facial
b) Scalenus anterior b) Vagus
2. Suprahyoid​ Muscles c) Hypoglossal
a) Digastric anterior and posterior belly 2. Posterior Triangle
b) Stylohyoid a) Phrenic
c) Mylohyoid b) Spinal Accessory
d) Geniohyoid c) Cervical Plexus
3. Infrahyoid​ Muscles d) Cervical Part of the Sympathetic Trunk
a) Deep e) Brachial Plexus
(1) Thyrohyoid M. Additional Clinical Notes
(2) Sternothyroid
b) Superficial
(1) Omohyoid
(2) Sternohyoid
G. Root of the Neck
1. Boundaries
2. Contents
3. Muscles
H. Triangles of the Neck
1. Anterior
a) Submental
b) Submandibular

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ■ C7 (Vertebra prominens)
● Longest spinous process
● Process is not bifid
● Transverse process – Large, but the Transverse
foramen is small and transmits the vertebral
● Vertebral Body: Small vein/s only
● Foramina: One Vertebral and two transverse ● May possess a Cervical Rib/ “extra rib” – a rib
● Spinous Processes: Short and Bifid arising from the anterior tubercle of the
○ Typical Cervical Vertebrae transverse process of the C7
■ Transverse foramen/Foramen transversarium in the
transverse processes – possess a for the passage of
● mobile single bone found in the
the vertebral artery and veins. (Vertebral artery
midline of the neck below the
passes through C1 to C6 only and not through C7)
mandible and abides the larynx
■ Spines are small and bifid
● U-Shaped
■ Body is small and broad from side to side
● consists of:
■ Vertebral foramen is large and triangular
○ body
■ Superior articular processes facets – faces
○ 2 greater and 2 lesser cornua
posteriorly & superiorly
● attached to the:
■ Inferior articular processes facets – faces anteriorly
○ skull by ​stylohyoid
& inferiorly
ligament
○ thyroid cartilage by
thyrohyoid ligament
● forms a base for the tongue

● natural lines of cleavage of the skin are constant and run almost
horizontally around the neck
● Clinical Importance:
○ incision ​along a cleavage​ line will heal as a ​narrow scar
○ Atypical Cervical Vertebrae (C1, C2, C7) ○ incision that ​crosses the lines will heal as a ​wide ​or
■ C1 (Atlas) heaped-up scar
● Body is absent
● Spinous Process is absent
● Anterior & Posterior arches are present
● Lateral mass on each side with articular
surfaces on its:
○ upper surface – articulation with the
occipital condyles (Atlanto-occipital
joints)
○ inferior surface – articulation with the
axis (Atlantoaxial joints)
● “Yes” bone
■ C2 (Axis)
● Odontoid process (Dens) – projects from the
superior surface of the body (representing the
body of the atlas that has fused with the body
of the axis)
● “No” bone

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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● Posterior Rami of Cervical Nerves 2 to 5
○ supplies skin overlying the ​trapezius muscle on the back of
the neck and on the ​back of the scalp as high as the vertex ● External Jugular Vein
○ branch at C2: ​Greater Occipital Nerve ● Anterior Jugular Vein
● Anterior Rami of Cervical Nerves 2 to 4
○ supplies skin of the ​front and sides of the neck
● Lesser Occipital Nerve (C2)
○ supplies skin over the ​lateral part of the occipital region
and the ​medial surface of the auricle
● Great Auricular Nerve (C2 and 3)
○ supplies skin over the ​angle of the mandible​, the parotid
gland​, and on ​both surfaces of the auricle
● Transverse Cutaneous Nerve (C2 and 3)
○ supplies skin on the anterior and lateral surfaces of the
neck​, from the ​body of the mandible to the sternum
● Supraclavicular Nerves (C3 and 4)
○ Medial part ​- supplies the ​skin as far as the median plain Clinical Notes
○ Intermediate part ​- supplies the ​skin of the chest wall Visibility of the External Jugular Vein
○ Lateral part ​- supplies the ​skin over the shoulder and ● women and children: less obvious because their subcutaneous tissue
upper half of the deltoid muscle tends to be thicker than the tissue of men
● obese individuals: may be difficult to identify even when they are asked to
○ supplies the ​posterior aspect of the shoulder down to the
hold their breath, which impedes the venous return to the right side of the
spine of the scapula heart and distends the vein
● superficial veins of the neck - tend to be enlarged and often tortuous in
professional singers because of prolonged periods of raised intrathoracic
● forms a thin layer that encloses the cutaneous nerves, the pressure
platysma muscle, the superficial veins, and the superficial External Jugular Vein as a Venous Manometer
lymph nodes ● serves as a useful venous manometer
○ when the patient is lying at a horizontal angle of 30°: level of the
blood in the external jugular veins reaches about one third of the
● thin but clinically important muscular sheet embedded in the way up the neck
superficial fascia ○ as patient sits up: blood level falls until it is no longer visible behind
the clavicle
Clinical Notes
External Jugular Vein Catheterization
Clinical Identification of the Platysma
● presence of valves or tortuosity may make the passage of the catheter
● can be seen as a thin sheet of muscle just beneath the skin by having
difficult
the patient clench his or her jaws firmly
● right external jugular vein - most direct line with the superior vena cava
● muscle extends from the body of the mandible downward over the
○ most commonly use
clavicle onto the anterior chest wall
● vein is catheterized about halfway between the level of the cricoid
Platysma Tone and Neck Incisions
cartilage and the clavicle
● in lacerations or surgical incisions in the neck: very important that the
● passage of the catheter should be performed during inspiration when the
subcutaneous layer with the platysma be carefully sutured, since the
valves are open
tone of the platysma can pull on the scar tissue, resulting in broad,
unsightly scars
Platysma Innervation, Mouth Distortion, and Neck Incisions
● innervated by the cervical branch of the facial nerve
○ emerges from the lower end of the parotid gland and travels
forward to the platysma ● Superficial cervical lymph node
● sometimes crosses the lower border of the mandible to supply the ○ lie along the ​external jugular vein superficial to the
depressor anguli oris muscle sternocleidomastoid muscle
● skin lacerations over the mandible or upper part of the neck may ○ receive lymph vessels from the ​occipital and ​mastoid
distort the shape of the mouth lymph nodes
○ drain​ into the ​deep cervical​ lymph nodes

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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● supports the muscles, vessels, and viscera of the neck
● condensed to form well-defined, fibrous sheets called the
investing layer​, the pretracheal layer​, and the ​prevertebral
layer
● also condensed to form the​ carotid sheath
Clinical Notes
Clinical Significance of the Deep Fascia of the Neck
● deep fascia in certain areas forms distinct sheets called the
investing, pretracheal, and prevertebral layers
○ easily recognizable to the surgeon at operation
Fascial Spaces
● between the more dense layers of deep fascia in the neck is loose ● thick layer that passes like a ​septum across the neck ​behind
connective tissue
pharynx and esophagus
○ forms potential spaces that are clinically important
○ more important spaces are the visceral, retropharyngeal, ● in front of the prevertebral muscles and the vertebral column
submandibular, and masticatory spaces ● forms the fascial floor of the posterior triangle
● deep fascia and the fascial spaces are important because organisms ● extends laterally over the first rib into the axilla to form the
originating in the mouth, teeth, pharynx, and esophagus can spread important ​axillary sheath
among the fascial planes and spaces
○ tough fascia can determine the direction of spread of infection
and the path taken by pus
○ possible for blood, pus, or air in the retropharyngeal space to
spread downward into the superior mediastinum of the thorax
Acute Infections of the Fascial Spaces of the Neck
● Dental infections​ - most commonly involve the lower molar teeth
○ infection spreads medially from the mandible into the
submandibular and masticatory spaces and pushes the tongue
forward and upward
○ further spread downward may involve the visceral space and
lead to edema of the vocal cords and airway obstruction
● Ludwig’s angina ​- acute infection of the submandibular fascial space
○ commonly secondary to dental infection
Chronic Infection of the Fascial Spaces of the Neck
● Tuberculous infection ​of the deep cervical lymph nodes - result in ● local condensation of the prevertebral, the pretracheal
liquefaction and destruction of one or more of the nodes investing layers of the deep fascia
○ pus is at first limited by the investing layer of the deep fascia ● contents:
○ becomes eroded at one point, and the pus passes into the less
○ common and internal carotid arteries
restricted superficial fascia
○ dumbbell or collar-stud abscess is now present
○ internal jugular vein
○ clinician is aware of the superficial abscess but must not forget ○ vagus nerve
the existence of the deeply placed abscess ○ deep cervical lymph nodes

● sheath of the ​prevertebral​ fascia

● carried by the subclavian artery and brachial plexus as they
● thick layer that emerge between the ​scalenus anterior and ​scalenus medius
encircles the neck muscles
● splits to enclose the
trapezius muscle and
sternocleidomastoid 1. Stylohyoid ligament
muscle ○ connects the styloid process to the ​lesser cornu of the hyoi​d
bone
2. Stylomandibular ligament
○ connects the styloid process to the ​angle of the mandible
3. Sphenomandibular ligament
○ connects the spine of the sphenoid bone to the lingula of
the mandible
4. Pterygomandibular ligament
● thin layer that attached ​above to the laryngeal cartilage ○ connects the hamular process of the medial pterygoid plate
● surrounds the ​thyroid​ and the ​parathyroid​ glands to the posterior end of the mylohyoid line of the mandible
● encloses the ​infrahyoid​ muscles ○ gives attachment to the superior constrictor and the
buccinator muscles

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 2. Scalenus Anterior
○ key muscle in understanding
the root of the neck and is
1. Sternocleidomastoid deeply placed
○ oblique band crossing the side of the neck ○ ascends ​vertically from the
○ divides the neck into: vertical column to the 1st rib
■ anterior triangle
■ posterior triangle
○ anterior​ border covers the:
■ carotid arteries
■ internal jugular vein 1. Digastric Anterior belly
■ deep cervical lymph nodes ● Origin: ​Digastric fossa of the mandible
■ overlaps the thyroid gland ● Insertion: ​Tendon of the digastric muscle on hyoid bone
○ deep surface of the ​posterior​ border is related to: ● Action: ​Depresses mandible, elevates hyoid
■ cervical plexus of the nerve ● Nerve: ​Mylohyoid nerve
■ phrenic nerve 2. Digastric Posterior belly
■ upper part of the brachial plexus ● Origin: ​Mastoid process of temporal bone
○ covered superficially by: ● Insertion: ​Tendon of the digastric muscle on hyoid bone
■ skin ● Action: ​Depresses mandible, elevates hyoid
■ platysma ● Nerve: ​Facial Nerve
■ fascia 3. Stylohyoid
■ external jugular vein ● Origin: ​Styloid process
Clinical Notes ● Insertion: ​Greater cornu of hyoid bone
Sternocleidomastoid Muscle and Protection from Trauma ● Action: ​Elevates the hyoid
● sternocleidomastoid - strong, thick muscle crossing the side of the neck ● Nerve: ​Facial nerve
○ protects the underlying soft structures from blunt trauma 4. Mylohyoid
● suicide attempts by cutting one’s throat often fail because the ● Origin: ​Mylohyoid line of mandible
individual first extends the neck before making several horizontal cuts
● Insertion: ​Body of hyoid bone and median raphe
with a knife
● extension of the cervical part of the vertebral column and extension of ● Action: ​Depresses mandible, elevates hyoid
the head at the atlanto occipital joint cause the carotid sheath with its ● Nerve: ​Mylohyoid nerve
contained large blood vessels to slide posteriorly beneath the 5. Geniohyoid
sternocleidomastoid muscle ● Origin: ​Inferior mental spine of mandible
● to achieve the desired result with the head and neck fully extended, ● Insertion: ​Hyoid bone
some individuals have to make several attempts and only succeed ● Action: ​Depresses mandible, elevates hyoid
when the larynx and the greater part of the sternocleidomastoid ● Nerve: ​First cervical
muscles have been severed
● common sites for the wounds are immediately above and below the
hyoid bone Deep Group:
​Congenital Torticollis 1. Thyrohyoid
● result of excessive stretching of the sternocleidomastoid muscle during ● Origin: ​Thyroid cartilage of the larynx
a difficult labor ● Insertion: ​Hyoid bone
● hemorrhage occurs into the muscle and may be detected as a small,
rounded “tumor” during the early weeks after birth
● Action: ​Depresses hyoid and elevate the larynx
● later, this becomes invaded by fibrous tissue, which contracts and ● Nerve: ​First cervical
shortens the muscle 2. Sternothyroid
● mastoid process is thus pulled down toward the sternoclavicular joint ● Origin: ​Manubrium of Sternum
of the same side, the cervical spine is flexed, and the face looks upward ● Insertion: ​Thyroid cartilage
to the opposite side ● Action: ​Depresses larynx
● if left untreated, asymmetrical growth changes occur in the face, and ● Nerve: ​Ansa cervicalis
the cervical vertebrae may become wedge shaped
Superficial Group:
Spasmodic Torticollis
● results from repeated chronic contractions of the sternocleidomastoid 1. Omohyoid Superior and Inferior bellies
and trapezius muscles ● Origin: ​Upper border of the scapula
○ usually psychogenic in origin ● Insertion: ​Hyoid bone
● section of the spinal part of the accessory nerve may be necessary in ● Action: ​Depresses hyoid
severe cases ● Nerve: ​Ansa cervicalis
2. Sternohyoid
● Origin: ​Manubrium of sternum
● Insertion: ​Hyoid bone
● Action: ​Depresses hyoid
● Nerve: ​Ansa cervicalis

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ● boundaries:
○ sternocleidomastoid muscle
○ midline of the neck
○ lower margin of the body of the mandible
1. Muscular Triangle
○ boundaries:
■ Anterior midline
■ Anterior edge of the
Sternocleidomastoid
■ Superior belly of the
Omohyoid
○ contents​:
■ Infrahyoid muscles
■ Thyroid and
Parathyroid glands
2. Carotid Triangle
○ boundaries:
■ Superior belly of the Omohyoid
■ Anterior edge of Sternocleidomastoid
■ Posterior belly of the Digastric
○ contents:
■ Common Carotid artery
■ Carotid sinus - baroreceptor
■ Carotid body - chemoreceptor
3. Submental Triangle
○ boundaries:
■ Anterior midline
■ Hyoid bone
■ Anterior belly of the Digastric
○ contents:
■ Submental lymph nodes
■ Anterior jugular vein
● area of the neck immediately ​above the thoracic inlet 4. Submandibular (digastric) Triangle
● junctional area between the neck and the thorax ○ boundaries:
○ inferior​ boundary is the ​superior thoracic aperture ■ Lower margin of the body of
● boundaries: the Mandible
○ Inferiorly​: Manubrial notch ■ Anterior belly of Digastric
○ Laterally​: 1st rib ■ Posterior belly of Digastric
○ Posteriorly​: Body of the vertebra (T1) ○ contents:
● contents: ■ Submandibular gland
○ Clavicle
○ Subclavian vessels
○ Innominate vessels
○ Carotid Sheath and contents
○ Thoracic duct and right lymphatic duct
○ Trachea and Esophagus
● msuscles:
○ Scalenus anterior ​– A key muscle, deeply placed and
descends almost vertically from the vertebral column to
the 1st rib
○ Scalenus medius ​– Lies behind the anterior scalene and
extends from the transverse process of C1-C6 downward
and laterally to insert to the upper surface of the 1st rib
behind the groove for subclavian artery

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 Carotid Body and Sinus
● both located ​at the bifurcation (ECA and ICA) and function as
● boundaries: important receptors within the body
○ sternocleidomastoid muscle ● Carotid body
○ trapezius muscle ○ chemoreceptor that is
○ clavicle sensitive to chemical
1. Occipital Triangle changes including
○ boundaries: oxygen, carbon
■ Sternocleidomastoid dioxide, and hydrogen
■ Trapezius ion concentration
■ Inferior belly of the omohyoid within the blood and
○ contents: helps control
■ Occipital artery respiration
■ Spinal accessory nerve ( CN XI) ○ innervated by
■ Brachial plexus (trunks) glossopharyngeal
2. Omoclavicular (subclavian) Triangle nerve
○ boundaries: ● Carotid Sinus
■ Sternocleidomastoid ○ baroreceptor helping
■ Inferior belly of Omohyoid detect and correct
■ Clavicle changes in blood
○ contents: pressure
■ Subclavian artery (third part)
Clinical Notes
Carotid Sinus Hypersensitivity
● pressure on one or both carotid sinuses can cause:
○ excessive slowing of the heart rate
● runs upwards through the neck ○ fall in blood pressure
under cover of the anterior ○ cerebral ischemia with fainting
border of the SCM, from the Taking the Carotid Pulse
sternoclavicular joint to the ● bifurcation of the common carotid artery into the internal and
upper border of the thyroid external carotid arteries can be easily palpated just beneath the
cartilage anterior border of the sternocleidomastoid muscle at the level of
● bifurcates within the sheath the superior border of the thyroid cartilage
○ convenient site to take the carotid pulse
into the external and internal
carotid arteries at the level of
the upper border of the thyroid cartilage
○ Right common carotid artery - originates from the ● one of the terminal branches of the common carotid artery
bifurcation of the ​brachiocephalic artery
● supplies structures in the ​neck​, ​face​, and ​scalp
○ Left common​ carotid artery - arises from the ​aortic arch
○ also supplies the ​tongue​ and the ​maxilla
● relations: ● begins​ at the level of the upper border of the ​thyroid cartilage
○ Anterolaterally:
○ emerges from undercover of the ​sternocleidomastoid
■ skin ​and​ fascia
muscle
■ sternocleidomastoid ■ where its pulsations can be felt
■ sternohyoid
● terminates in the substance of the ​parotid gland behind the
■ sternothyroid
neck of the mandible by ​dividing​ into:
■ superior belly of the omohyoid) ○ superficial temporal artery
○ Posteriorly​:
○ maxillary artery
■ transverse processes of the lower four cervical
● relations:
vertebrae
○ Anterolaterally:
■ prevertebral muscles
■ overlapped at its beginning by the ​anterior border of
■ sympathetic trunk the ​sternocleidomastoid
■ in the lower part of the neck: vertebral vessels
■ above this level: artery is comparatively superficial,
○ Medially​:
being covered by ​skin​ and ​fascia
■ larynx and pharynx ■ crossed by ​hypoglossal nerve), ​posterior belly of the
■ below these: trachea and esophagus
digastric​ muscle, and ​stylohyoid​ muscles
■ lobe of the thyroid gland
■ within the parotid gland: crossed by the ​facial​ nerve
○ Laterally​: ■ internal jugular vein first lies lateral to the artery and
■ internal jugular vein
then posterior to it
■ posterolaterally​: vagus nerve

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ○ Medially: ■ Below the digastric lie:
■ wall of the ​pharynx ● skin ​and​ fascia
■ internal carotid artery ● anterior border of the sternocleidomastoid
■ stylopharyngeus​ muscle ● hypoglossal nerve
■ glossopharyngeal​ nerve ■ Above the digastric lie the:
■ pharyngeal branch of the ​vagus pass between the ● stylohyoid muscle
external and internal carotid arteries ● stylopharyngeus muscle
● Branches: ● glossopharyngeal nerve
1. Superior thyroid artery ● pharyngeal branch of the vagus
● accompanied by the ​external laryngeal nerve ​which ● parotid gland
supplies the ​cricothyroid​ muscle ● external carotid artery
2. Ascending pharyngeal artery - ​ascends along and supplies ○ Posteriorly:
the ​pharyngeal wall ■ sympathetic trunk
3. Lingual artery - ​loops upward and forward, supplies the ■ longus capitis muscle
tongue ■ transverse processes of the upper three cervical
4. Facial artery - ​loops upward close to the outer surface of vertebrae
the pharynx and the tonsil, branches supply the ​tonsil​, the ○ Medially:
submandibular salivary gland, and the ​muscles and the ■ pharyngeal wall
skin of the face ■ superior laryngeal nerve
5. Occipital artery - ​supplies the ​back of the scalp ○ Laterally:
6. Posterior auricular artery - ​supplies the ​auricle and the ■ internal jugular vein
scalp ■ vagus nerve
7. Superficial temporal artery - ​ascends over the zygomatic ● Branches​:
arch where it may be palpated just in front of the auricle 1. Ophthalmic Artery - ​arises from the internal carotid
● accompanied by the ​auriculotemporal nerve and artery as it emerges from the cavernous sinus
supplies the ​scalp 2. Posterior Communicating Artery - ​runs backward to join
8. Maxillary artery - ​runs forward medial to the neck of the the posterior cerebral artery
mandible and enters the pterygopalatine fossa of the skull 3. Anterior Cerebral Artery - ​terminal branch of the internal
carotid artery
4. Middle Cerebral Artery - ​largest terminal branch of the
internal carotid artery

Clinical Notes
Arteriosclerosis of the Internal Carotid Artery
● extensive arteriosclerosis of the internal carotid artery in the neck
can cause visual impairment or blindness in the eye on the side of
the lesion
○ because of insufficient blood flow through the ​retinal artery
● motor paralysis and sensory loss may also occur on the opposite
side of the body
○ because of insufficient blood flow through the ​middle cerebral
artery

● Right Subclavian Artery

○ arises from the brachiocephalic artery, behind the right
sternoclavicular joint
○ arches upward and laterally over the pleura and between
the scalenus anterior and medius muscles
○ at the outer border of the ​1st rib​: becomes the ​axillary
artery
● begins at the ​bifurcation of the CCA at the level of the upper ● Left Subclavian Artery
border of the ​thyroid cartilage ○ arises from the arch of the aorta in the thorax
○ supplies the ​brain​, ​eyes​, ​forehead​, and part of the ​nose ○ ascends to the root of the neck and then arches laterally in
● terminates​ by dividing into: a manner similar to that of the right subclavian artery
○ anterior cerebral artery ○ scalenus anterior muscle passes anterior to the artery on
○ middle cerebral artery each side and divides it into three parts
● Relations​:
○ Anterolaterally​:

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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First Part of the Subclavian Artery ■ superior intercostal artery - supplies 1st and 2nd
● medial border of the intercostal spaces
scalenus anterior muscle ■ deep cervical artery - supplies the deep muscles of
● branches: the neck
1. Vertebral Artery Third Part of the Subclavian Artery
■ 1st branch of ● lateral​ border of the scalenus anterior muscle
the 1st part ● across the posterior triangle of the neck to the lateral border of
found ​between the​ 1st rib,​ where it becomes the ​axillary artery
anterior ● in the root of the neck, it is closely related to the nerves of the
scalene and brachial plexus
longus colli ● branches:
■ Passes through ○ usually has no branches
the transverse ○ occasionally: superficial cervical arteries, the suprascapular
foramen from arteries, or both
C6 going up to the atlas Clinical Notes
■ bends medially to enter the suboccipital triangle Palpation and Compression of the Subclavian Artery in Patients with
■ then goes inside the foramen magnum and Upper Limb Hemorrhage
terminates as the basilar artery at the lower border of ● in severe traumatic accidents to the upper limb involving laceration
the pons of the brachial or axillary arteries, it is important to remember that
■ branches: the hemorrhage can be stopped by exerting strong pressure
● in the ​neck​: Spinal and muscular arteries downward and backward on the third part of the subclavian artery
○ use of a blunt object to exert the pressure is of great help, and
● in the ​skull​: Meningeal, anterior and posterior
the artery is compressed against the upper surface of the 1st
spinal, Posterior inferior cerebellar artery, rib
medullary arteries
2. Thyrocervical trunk
■ branches:
● Inferior thyroid artery – supplies the thyroid and
parathyroid glands
● Ascending cervical artery – gives branches to the
lateral muscles of the upper neck and spinal
branches into the intervertebral foramina
● Transverse cervical artery (Cervicodorsal trunk) –
supplies trapezius
● Suprascapular artery – supplies supraspinatus
and infraspinatus muscles

○ Internal thoracic or internal mammary artery

■ descends into the thorax behind the 1st costal
cartilage and in front of the pleura ● formed behind the angle of the jaw by the ​union of the
■ descends vertically one fingerbreadth lateral to the posterior auricular vein with the posterior division of the
sternum retromandibular​ vein
■ in the ​6th intercostal space​, it divides into: ● descends across the sternocleidomastoid muscle and beneath
● superior epigastric artery the platysma muscle
● musculophrenic artery ● drains​ into the ​subclavian​ vein ​behind the middle of the clavicle
Second Part of the Subclavian Artery ● tributaries:
● behind​ the scalenus anterior muscle 1. Posterior external jugular vein​ - from the back of the scalp
● branches: 2. Transverse cervical vein - from the skin and the fascia over
1. Costocervical trunk - runs backward over the dome of the the posterior triangle
pleura and divides into: 3. Suprascapular vein - ​ from the back of the scapula
4. Anterior jugular vein

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ■ above lie the: internal carotid artery and the ​9th,
● descends in the front of 10th, 11th, and 12th cranial nerves
the ​neck close to the ■ below lie the: ​common carotid artery and ​vagus
nerve
midline
● above the sternum​, ● tributaries​:
1. Inferior petrosal sinus
joined to the ​opposite
vein by the jugular arch 2. Facial vein
● joins the external 3. Pharyngeal veins
4. Lingual vein
jugular vein ​deep to the
sternocleidomastoid 5. Superior thyroid vein
muscle 6. Middle thyroid vein
Clinical Notes
Penetrating Wounds of the Internal Jugular Vein
● hemorrhage of low-pressure venous blood into the loose connective
● large vein that ​receives tissue beneath the investing layer of deep cervical fascia may
blood from the ​brain​, present as a large, slowly expanding hematoma
face​, and ​neck ● air embolism - serious complication of a lacerated wall of the
● starts as a ​continuation internal jugular vein
of the ​sigmoid sinus ○ wall of this large vein contains little smooth muscle, its injury is
not followed by contraction and retraction (as occurs with
● leaves the skull through arterial injuries)
the jugular foramen ○ adventitia of the vein wall is attached to the deep fascia of the
● descends through the carotid sheath, which hinders the collapse of the vein
neck in the carotid ● blind clamping of the vein is prohibited because the vagus and
sheath hypoglossal nerves are in the vicinity
○ lateral to the vagus Internal Jugular Vein Catheterization
nerve and the ● remarkably constant in position
internal and common carotid arteries ● descends through the neck from a point halfway between the tip of
the mastoid process and the angle of the jaw to the sternocla vicular
● ends​ by joining the ​subclavian vein joint
○ behind the medial end of the clavicle to ​form the ○ above: overlapped by the anterior border of the
brachiocephalic​ ​vein sternocleidomastoid muscle
● throughout its course, closely related to the deep cervical ○ below: covered laterally by this muscle
lymph nodes ● just above the sternoclavicular joint, the vein lies beneath a skin
● has a dilatation at its upper end “superior bulb” and another depression between the sternal and clavicular heads of the
near its termination “inferior bulb” sternocleidomastoid muscle
○ directly above the inferior bulb is a bicuspid valve ○ posterior approach - tip of the needle and the catheter are
introduced into the vein about two fingerbreadths above the
● Relations: clavicle at the posterior border of the sternocleidomastoid
○ Anterolaterally: muscle
■ skin​ and ​fascia ○ anterior approach - with the patient’s head turned to the
■ sternocleidomastoid opposite side, the triangle formed by the sternal and clavicular
■ parotid salivary gland heads of the sternocleidomastoid muscle and the medial end
■ lower part: covered by the ​sternothyroid​, of the clavicle are identified
sternohyoid​, and ​omohyoid muscles, which intervene ■ shallow skin depression usually overlies the triangle
■ needle and catheter are inserted into the vein
between the vein and the ​sternocleidomastoid
■ higher up: crossed by the ​stylohyoid​, ​posterior belly
of the ​digastric​, and s​pinal part of the accessory
nerve
■ chain of ​deep cervical lymph nodes
○ Posteriorly:
■ transverse processes of the cervical vertebrae
■ levator scapulae
■ scalenus ​medius​ and scalenus ​anterior
■ cervical plexus
■ phrenic nerve
■ thyrocervical trunk
■ vertebral vein
■ first part of the subclavian artery
■ passes in front of the​ thoracic duct
○ Medially:

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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● continuation of the ​axillary ​vein at the outer border of the ​1st ● Pericervical collar - extends
rib from below the chin to the
● joins​ the ​internal jugular​ ​vein​ to ​form​ the ​brachiocephalic​ ​vein back of the head
● receives​ the ​external jugular vein ● Regional cervical group -
● often ​receives the ​thoracic ​duct on the left side and the right located in the neck proper
lymphatic duct on the right ● Deep terminal group -
● Relations: embedded in the carotid
○ Anteriorly: sheath in the neck
■ clavicle
○ Posteriorly:
■ scalenus anterior muscle
■ phrenic nerve
○ Inferiorly:
■ upper surface of the​ 1st rib
Clinical Notes
Subclavian Vein Thrombosis ● arranged roughly in a ring around approximately the junction of
● spontaneous thrombosis of the subclavian and/or axillary veins - the head and neck
occasionally occurs after excessive and unaccustomed use of the ● superficial tissues of the head - drain into appropriately placed
arm at the shoulder joint groups in the collar or directly into the superficial cervical
● factors in its development:
○ close relationship of these veins to the 1st rib and the clavicle
nodes
○ possibility of repeated minor trauma from these structures ○ drain into the nodal group located most closely
● Secondary thrombosis of subclavian and/or axillary veins - common ○ lymph vessels and nodes do not occur in the cranial cavity
complication of an indwelling venous catheter or orbit
○ rarely, may follow a radical mastectomy with a block dissection ● arranged as follows:
of the lymph nodes of the axilla ○ Occipital nodes: ​over the occipital bone on the back of the
○ persistent pain, heaviness, or edema of the upper limb, skull
especially after exercise, is a complication of this condition ■ receive lymph from ​back of the scalp
Anatomy of Subclavian Vein Catheterization
● Infraclavicular Approach - ​subclavian vein lies close to the
○ Mastoid (retroauricular) nodes​: behind the ear over the
undersurface of the medial third of the clavicle mastoid process
○ vein is slightly more medially placed on the left side than on ■ receive lymph from ​scalp above the ear​, ​auricle​, and
the right side external auditory meatus
Anatomy of Complications ○ Parotid nodes​: on or within the parotid salivary gland
● Pneumothorax: needle may pierce the cervical dome of the pleura, ■ receive lymph from ​scalp above the parotid gland​,
permitting air to enter the pleural cavity eyelids​, ​parotid gland​, ​auricle​, and ​external auditory
○ more common in children, in whom the pleural reflection is
meatus
higher than in adults
● Hemothorax: catheter may pierce the posterior wall of the
○ Buccal (facial) nodes​: one or two nodes lie in the cheek
subclavian vein and the pleura over the buccinator muscle
● Subclavian artery puncture: needle pierces the wall of the artery ■ drain lymph that ultimately passes into the
during its insertion submandibular nodes
● Internal thoracic artery injury: Hemorrhage may occur into the ○ Submandibular nodes​: superficial to the submandibular
superior mediastinum salivary gland just below the lower margin of the jaw
● Diaphragmatic paralysis: needle damages the phrenic nerve ■ receive lymph from the ​front of the scalp, ​nose​,
The Procedure in Children
cheek​, ​upper lip and the ​lower lip (except the central
● Supraclavicular Approach - preferred by many for the following
anatomic reasons
part); ​frontal​, ​maxillary​, and ​ethmoid sinuses; the
○ site of penetration of the vein wall is larger, since it lies at the upper and ​lower ​teeth (except the lower incisors);
junction of the internal jugular vein and the subclavian vein, anterior two thirds of the tongu​e (except the tip);
which makes the procedure easier floor of the mouth and vestibule​; and ​gums
Anatomic Complications ○ Submental nodes​: in the submental triangle just below the
● Paralysis of the diaphragm: injury to the phrenic nerve as it chin
descends posterior to the internal jugular vein on the surface of the ■ drain lymph from the ​tip of the tongue​, floor of the
scalenus anterior muscle anterior part of the mouth​, ​incisor teeth, ​center part
● Pneumothorax or hemothorax: damage to the pleura and/or
internal thoracic artery by the needle passing posteriorly and
of the lower lip​, and ​skin over the chin
downward
● Brachial plexus injury: needle passing posteriorly into the roots or ● located in a roughly vertical series in the neck proper
trunks of the plexus
● collect lymph drainage from the pericervical collar and the
superficial and deep tissues of the neck

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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● cervical regional nodes are as follows:
○ Anterior cervical nodes​: along the course of the anterior
jugular veins in the front of the neck
■ receive lymph from ​skin and ​superficial tissues of the
front of the neck
○ Superficial cervical nodes​: along the course of the external
jugular vein on the side of the neck
■ drain lymph from the skin over the ​angle of the jaw​,
skin over the lower part of the parotid gland​, and ​lobe
of the ear
○ Retropharyngeal nodes​: behind the pharynx and in front
of the vertebral column
■ receive lymph from ​nasopharynx​, ​auditory tube​, and
vertebral column
○ Laryngeal nodes​: in front of the larynx
■ receive lymph from the ​larynx
○ Tracheal (paratracheal) nodes​: lie alongside the trachea
■ receive lymph from neighboring structures, including
the ​thyroid gland
Clinical Notes
Clinical Significance of the Cervical Lymph Nodes
● examination of a patient may reveal an enlarged lymph node
● physician’s responsibility to determine the cause and be
knowledgeable about the area of the body that drains its lymph into
a particular node
○ eg. an enlarged submandibular node can be caused by a
pathologic condition in the scalp, the face, the maxillary sinus,
or the tongue
○ infected tooth of the upper or lower jaw may be responsible
● physician has to search systematically the various areas known to
drain into a node to discover the cause
● form a vertical chain along the course of the internal jugular
vein, within the carotid sheath, from the base of the skull to the
root of the neck
● receive lymph from all the groups of regional nodes and as such
are the terminal group of nodes in the neck
T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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○ jugulodigastric node​: below and behind the angle of the
jaw
■ mainly concerned with drainage of the ​tonsil and the
tongue
○ jugulo-omohyoid node​: close to the omohyoid muscle
■ mainly associated with drainage of the ​tongue
● efferent lymph vessels from the deep cervical nodes join to
form the jugular trunks
○ left jugular trunk​ - usually empties into the ​thoracic​ duct
○ right jugular trunk - drains into the right ​lymphatic duct or
independently into the region of formation of the right
brachiocephalic vein
Clinical Notes
Carcinoma Metastases in the Deep Cervical Lymph Node
● in the head and neck, all the lymph ultimately drains into the deep
cervical group of nodes
● Secondary carcinomatous deposits in these nodes are common
○ primary growth may be easy to find
○ at certain anatomic sites, the primary growth may be small and
overlooked
■ eg. in the larynx, the pharynx, the cervical part of the
esophagus, and the external auditory meatus
○ bronchi, breast, and stomach are sometimes the site of the
primary tumor
■ secondary growth has spread far beyond the local lymph
nodes
● when cervical metastases occur: surgeon usually decides to perform
a block dissection of the cervical nodes
○ involves the removal en bloc of the internal jugular vein, the
fascia, the lymph nodes, and the submandibular salivary gland
○ aim of the operation is removal of all the lymph tissues on the
affected side of the neck
○ carotid arteries and the vagus nerve are carefully preserved
○ often necessary to sacrifice the hypoglossal and vagus nerves,
which may be involved in the cancerous deposits
● patients with bilateral spread: bilateral block dissection may be
necessary
○ interval of 3 to 4 weeks is necessary before removing the
second internal jugular vein
12
 ■ supplies cricothyroid cartilage
○ Recurrent laryngeal nerve – supplies larynx muscles
(except cricothyroid), mucous membrane below vocal
1. F​acial (VII​) ​- motor and sensory cords and upper part of trachea
● innervates ​facial expression​, ​salivation​, ​lacrimation ■ Right recurrent​ – hooks to subclavian artery
● emerges on anterior surface of hindbrain between pons ■ Left recurrent​ – hooks to arch of aorta
and medulla oblongata ○ Cardiac Branches – arise in the neck, descend into the
● pass laterally in posterior cranial fossa thorax, end in cardiac plexus
● enter internal acoustic meatus in petrous part of temporal 3. H​ypoglossal (XII​)​ - motor
bone ● innervates ​tongue muscles (controls shape and
● enters facial canal (lateral through inner ear) movement)
● forms geniculate ganglion ○ Ansa cervicalis – ​sternothyroid​, ​omohyoid​,
● nerve descends behind pyramid and emerges from sternohyoid
temporal bone via stylomastoid foramen ● emerges from anterior surface of medulla oblongata
● passes forward though parotid gland ● crosses posterior cranial fossa
● terminates to its distributions for facial expression ● leaves skull via hypoglossal canal
● branches​: ● passes downward and forward in the neck
○ Greater petrosal nerve - from geniculate ganglion; ● crosses ICA and ECA
contains parasympathetic fibers Secretomotor to ● terminates in the tongue
lacrimal gland, with taste fibers ● branches:
○ Nerve to stapedius​ – stapedius muscle in middle ear ○ Meningeal branch
○ Chorda tympani – leaves middle ear through ○ Descending branch (C1 fibers passes downwards
petrotympanic fissure joining descending cervical nerve (C2 and 3) – forms
■ with parasympathetic secretomotor fibers to ansa cervicalis
submandibular and sublingual salivary glands ○ Nerve to thyrohyoid muscle (C1)
With taste fibers ○ Muscular branches to all tongue muscles (except
○ Posterior auricular – from stylomastoid foramen; palatoglossus)
posterior belly of digastric and stylohyoid nerves ○ Nerve to geniohyoid muscle (C1)
○ Facial expression branches​:
■ Temporal – auricular muscles, occipitofrontalis, 1. Phrenic Nerve​ - motor and sensory
corrugator supercilii ● innervates ​diaphragm
■ Zygomatic​ – orbicularis oris
● arises in the neck from the 3rd, 4th, and 5th cervical
■ Buccal -​ buccinators, upper lip muscles, nostril nerves of the ​cervical plexus (C3-C5)
■ Mandibular -​ lower lip muscles ● runs vertically downward across the front of the scalenus
■ Cervical - lower border of gland, platysma,
anterior muscle
depressor anguli oris ● enters the thorax by passing in front of the subclavian
2. V​agus (X​) ​- motor and sesnsory artery
● innervates ​heart​, ​great vessels in the thorax​, ​larynx​,
● further courses in the thorax terminating at the diaphragm
trachea​, ​bronchi​, ​lungs
● emerges from anterior surface of medulla oblongata Clinical Notes
● passes laterally through posterior cranial fossa Phrenic Nerve Injury and Paralysis of the Diaphragm
● considerable clinical importance because it is the sole nerve supply to the
● leaves skull through jugular foramen
muscle of the diaphragm
○ gives off to: ● each phrenic nerve supplies the corresponding half of the diaphragm
■ superior (meningeal and auricular branches) ● can be injured by penetrating wounds in the neck
■ inferior (Pharyngeal) sensory ganglia ○ paralyzed half of the diaphragm relaxes and is pushed up into the
● descends through the neck within the carotid sheath thorax by the positive abdominal pressure
● passes through the mediastinum of the thorax ○ consequently, lower lobe of the lung on that side may collapse
● passes behind root of lungs ● one third of persons have an accessory phrenic nerve
● enters abdomen via esophageal opening in diaphragm ○ root from the fifth cervical nerve may be incorporate in the nerve to
the subclavius and may join the main phrenic nerve trunk in the
● branches:
thorax
○ Meningeal and auricular branches
○ Pharyngeal branch – supplies pharynx muscles and 2. Spinal Accessory Nerve ​- motor
soft muscles ● innervates ​soft palate​, ​pharynx​, ​larynx​,
○ Superior laryngeal nerve sternocleidomastoid​, ​trapezius​ muscles
○ Internal laryngeal nerve​ – larger branch ● Cranial root
■ sensory to mucous membrane of piriform fossa ○ emerges from anterior surface of the medulla
and larynx up to vocal cords oblongata
○ External laryngeal nerve​ – motor

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ○ runs laterally in the posterior cranial fossa and joins ■ Muscular branch to the diaphragm:​ ​Phrenic nerve
the spinal root ● arises in the neck from the ​3rd, 4th, and 5th
● Spinal root cervical nerves​ of the cervical plexus
○ emerges from nerve cells in the anterior gray horn of ● runs vertically downward across the front of the
the upper 5 segments of the cervical part of the spinal scalenus anterior muscle
cord ● enters the thorax by passing in front of the
○ ascends alongside the spinal cord and enters the skull subclavian artery
through the foramen magnum – turns lateral to join ● only motor nerve supply to the ​diaphragm
cranial root ● also sends sensory branches to the pericardium,
● both leave the skull through the jugular foramen and the mediastinal parietal pleura, and the pleura
eventually separate: and peritoneum covering the upper and lower
○ Cranial root – joins vagus nerve; distributed to soft surfaces of the central part of the diaphragm
palate, pharynx, and larynx muscles 4. Cervical Part of the Sympathetic Trunk
○ Spinal root – runs downward and laterally and enters ○ from the base of the skull to the first rib
SCM and over to the trapezius ○ posterior to the carotid vessels
Clinical Notes ○ between the carotid sheath and prevertebral fascia
Injury to the Spinal Part of the Accessory Nerve ○ has three ganglia: ​superior​, ​middle and ​inferior cervical
● spinal part of the accessory nerve crosses the posterior triangle in a relatively ganglia
superficial position ■ all gives innervation to the ​heart
● can be injured at operation or from penetrating wounds ■ each ganglion receive nerve coming from the spinal
○ trapezius muscle is paralyzed cord called rami
■ muscle will show wasting ■ purely ​motor​ innervation
■ shoulder will drop
○ Superior Cervical Ganglion
○ patient will experience difficulty in elevating the arm above the head,
having abducted it to a right angle by using the deltoid muscle
■ below the skull
● Clinical examination: ■ supplies the head and the largest of the ganglia
○ asking the patient to rotate the head to one side against resistance ■ lying on the longus colli muscle, the carotid artery is
■ causing the sternocleidomastoid of the opposite side to come into located anterior to the ganglion
action ■ branches​:
○ then is asked to shrug the shoulders ● Arterial branches – to common and external
■ causing the trapezius muscles to come into action carotid arteries, causes contraction
3. Cervical plexus ● Internal carotid nerve
○ Post ganglionic fibers
○ formed by the anterior rami of ​first four cervical nerves
○ form loops that lie in front of the origins of the levator ○ Divides into branches forming internal
scapulae and the scalenus medius muscles carotid plexus
● Gray rami communicantes – from
○ covered in front by the prevertebral layer of deep cervical
fascia and is related to the internal jugular vein within the C1-C4
carotid sheath ● Cranial nerve branches – joins CN IX,
○ supplies the skin and the muscles of the head, the neck, X and XII
and the shoulders ● Pharyngeal branches – joins CN IX and X forming
○ branches​: the pharyngeal plexus which supplies the
■ Cutaneous branches pharyngeal constrictors
■ Muscular branches to the neck muscles ● Superior cardiac branch – ends in the cardiac
plexus
● Prevertebral muscles
● sternocleidomastoid (proprioceptive, C2 and 3) ○ Middle Cervical Ganglion
● levator scapulae (C3 and 4) ■ level of the cricoid cartilage
■ lies anterior the thyroid gland
● trapezius (proprioceptive, C3 and 4)
● branch from C1 joins the hypoglossal nerve ■ branches:
○ some later leave the hypoglossal as the ● Ramus communicantes​ – anterior rami of C5-C6
○ innervates the common carotid artery
descending branch, which unites with the
descending cervical nerve (C2 and 3), to ● Thyroid branch – by virtue of its proximity to the
form the ansa cervicalis (Fig. 11.60) thyroid gland
● Middle cardiac branch – ends in the cardiac
■ first, second, and third cervical nerve
fibers within the ansa cervicalis - plexus
supply the omohyoid, sternohyoid, and ○ Inferior Cervical Ganglion
■ “costothoracic or stellate ganglion”
sternothyroid muscles
○ other within the hypoglossal nerve leave it ■ between the transverse process of C7 and neck of the
as the nerve to the thyrohyoid and 1st rib
geniohyoid ■ branches:

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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 ● Gray rami communicantes – anterior rami of
C7-C8
● Arterial branch – to subclavian and vertebral
arteries
● Inferior cardiac branch – ends in the cardiac
plexus
■ innervates the ​subclavian artery and vein​, ​trachea​,
esophagus​ and sends​ branches to the heart
5. Brachial Plexus
● formed in the ​posterior triangle of the neck by the union
of the ​anterior rami of the 5th, 6th, 7th, and 8th cervical
and the ​first thoracic spinal nerves
● divided into roots, trunks, divisions, and cords
○ roots of C5 and 6 unite to form the upper trunk
○ root of C7 continues as the middle trunk
○ roots of C8 and T1 unite to form the lower trunk
● each trunk then divides into anterior and posterior
divisions
○ anterior divisions of the upper and middle trunks
unite to form the lateral cord
■ anterior division of the lower trunk continues as
the medial cord
○ posterior divisions of all three trunks join to form the
posterior cord
● roots of the brachial plexus enter the base of the neck
between the scalenus anterior and the scalenus medius
muscles
● trunks and divisions cross the posterior triangle of the
neck
● cords become arranged around the axillary artery in the
axilla
○ brachial plexus and the axillary artery and vein are
enclosed in the axillary sheath
1. Dislocations without Fracture
● occur only in the Cervical region
● d/t inclination of the articular processes of the cervical
vertebrae permits dislocation to take place without
fracture of the processes
● commonly occur between C4 - C5 or C5 - C6, where
mobility is greatest!
● Spinal nerve on the same side is usually nipped in the
intervertebral foramen, producing severe pain
● Large size of the vertebral canal allows the spinal cord to
escape damage in most cases
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2. Bilateral cervical dislocations
● almost always associated with severe injury to the spinal
cord
● death occurs immediately if the upper cervical vertebrae
are involved because the respiratory muscles, including
the diaphragm (phrenic nerves C3 to C5), are paralyzed
3. Fractures of the Odontoid Process of the Axis
● from falls or blows on the head
● excessive mobility of the odontoid fragment or rupture of
the transverse ligament can result in injury to the spinal
cord
4. Fracture of the Pedicles of the Axis (Hangman’s Fracture)
● severe extension injury of the neck
● vertebral canal is enlarged by the forward displacement of
the vertebral body of the axis, the spinal cord is rarely
compressed
5. Vertical Compression Fractures
● occur in the cervical & lumbar regions, where it is possible
to fully straighten the vertebral column
○ Jefferson’s fracture
■ with the neck straight, an excessive vertical force
applied from above will cause the ring of the
atlas to be disrupted and the lateral masses to
be displaced laterally
○ Disruption of the intervertebral disc and breakup of
the vertebral body
■ with neck slightly flexed, the lower cervical
vertebrae remain in a straight line and the
compression load is transmitted to the lower
vertebrae
Clinical Notes
Injury to the Brachial Plexus
● roots and trunks of the brachial plexus occupy the anterior inferior angle of
the posterior triangle of the neck
● Incomplete lesions can result from stab or bullet wounds, traction, or
pressure injuries
● clinical findings in Erb-Duchenne and Klumpke’s lesions are fully described
on page 429.. sorry tamad
Brachial Plexus Nerve Block
● remembered that the axillary sheath, formed from the prevertebral layer of
deep cervical fascia, encloses the brachial plexus and the axillary artery
● brachial plexus nerve block can easily be obtained by closing the distal part
of the sheath in the axilla with finger pressure, inserting a syringe needle
into the proximal part of the sheath, and then injecting a local anesthetic
○ anesthetic solution is massaged along the sheath, producing a nerve
block
○ syringe needle may be inserted into the axillary sheath in the lower
part of the posterior triangle of the neck or in the axilla
Compression of the Brachial Plexus and the Subclavian Artery
● at the root of the neck, the brachial plexus and the subclavian artery enter
the posterior triangle through a narrow muscular– bony triangle
● boundaries of the narrow triangle are formed in front by the scalenus
anterior, behind by the scalenus medius, and below by the 1st rib
● in the presence of a cervical rib, the 1st thoracic nerve and the subclavian
artery are raised and angulated as they pass over the rib
● partial or complete occlusion of the artery causes ischemic muscle pain in
the arm, which is worsened by exercise
● rarely, pressure on the first thoracic nerve causes symptoms of pain in the
forearm and hand and wasting of the small muscles of the hand
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T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 9​TH​ E​D​, T​EACH​ M​E​ A​NATOMY​ (​FIGURES​)