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OUTLINE
I. Cervical Rib
A. Pressure in the Upper
Trunk
B. Pressure in the Lower
Trunk
II. Brachial Plexus
A. Brachial Plexus Nerve
Block
B. Injury
III. Pleura and Lung Injuries in
the Root of the Neck
A. Stellate Ganglion
IV. Sympathectomy for Arterial
Insufficiency of the Upper Limb
A. Raynaud’s Disease
B. Horner’s Syndrome
V. Nerve Injury
A. Phrenic Nerve Injury
B. Injury to Spinal Part of
Accessory Nerve
VI. Deep Fascia of Neck
A. Clinical Significance
B. Ludwig’s Angina
VII. Citation
VIII. References

I. CERVICAL RIB
Figure 2. ​Cross Section of the Lower Trunk
A. PRESSURE IN THE UPPER TRUNK
A. BRACHIAL PLEXUS NERVE BLOCK
Thoracic Outlet Syndrome
● A brachial plexus nerve block can easily be obtained via the
● Lower trunk and subclavian artery are raised and angulated as
axilla or the posterior triangle
they pass over the rib exerting pressure
→ Locate the pulsations of the axillary artery to find the brachial
● Interference with the circulation of the upper limb → Partial or plexus
complete occlusion of the artery → Injecting a local anesthetic solution on the axillary sheath
→ Ischemic muscle pain in the arm, which is worsened by → Massaging along the sheath, producing a nerve block
exercise
Approaches to the Brachial Plexus Nerve Block
→ Interscalene approach - at the neck, posterior to the border
of the sternocleidomastoid muscle
→ Supraclavicular Approach - reference point is the sternal
notch
→ Infraclavicular Approach​ - inferior surface of the clavicle

Figure 1.​ Thoracic Outlet Syndrome

Subclavian Steal Syndrome
● Because of the location of the blockage, blood is shunted
(“stolen”) away from the brain to the affected arm

B. PRESSURE IN THE LOWER TRUNK

● Causes symptoms of pain or numbness down the medial side of
the forearm, hand, and wasting the small muscles of the hand

Figure 3. ​Approaches to Brachial Plexus Nerve Block

II. BRACHIAL PLEXUS
B. INJURY
● Covered by the axillary sheath (intertwines with and separated
● Incomplete lesions can result from stab or bullet wounds in the
by the axillary artery into the lateral cord, medial cord, and
posterior triangle of the neck, traction, or pressure injuries
posterior cord ) from the prevertebral layer of deep cervical
● Erb-Duchenne and the Klumpke’s lesions during difficult child
fascia
birth
UPPER LESIONS OF BRACHIAL PLEXUS Figure 7. ​Clawed Hand of Newborn
● Erb-Duchenne Palsy
→ Hyperextension of the MCP joints
→ Results in excessive displacement of the head to the
→ Flexion of the IP joints
opposite side, and depression of the shoulder to the same
→ Extensor digitorum is unopposed by the lumbricals and
side → excessive traction or even ​tearing of C5 and C6 roots
interossei and extends the MCP joints
→ Occur in infants during a difficult delivery, by pulling on the
→ Flexor digitorum superficialis and profundus are unopposed
neck of the infant
by the lumbricals and interossei, the middle and terminal
→ Excessive displacement of the head to the opposite side,
phalanges are flexed
and depression of the shoulder to the same side
→ Sensory loss along the medial side of the forearm, hand and
→ In adults following a fall or a blow to the shoulder
medial 2 fingers
→ Major nerves involved
▪ Suprascapular (1)
▪ Musculocutaneous (2) III. PLEURA AND LUNG INJURIES IN THE ROOT OF THE
▪ Axillary (3) NECK
▪ Subclavius (4)
● The cervical dome of the pleura and the apex of the lung extend
→ The following muscles will consequently be paralysed:
up into the root of the neck
▪ Supraspinatus (abductor of the shoulder)
● Penetrating wound of the neck may cause a puncture of the
▪ Infraspinatus (lateral rotator of the shoulder)
lung. (That's why we request for a chest Xray following central
▪ Subclavius (depresses the clavicle)
venous catheterization - Right IJV is the best choice )
▪ Biceps Brachii (supinator of the forearm, flexor of the
● Covered by the supra pleural membrane
elbow, weak flexor of the shoulder)
● Behind the subclavian artery
▪ Brachialis (flexor of the elbow)
● A penetrating wound above the medial end of the clavicle may
▪ Coracobrachialis (flexes the shoulder)
involve the apex of the lung
▪ Deltoid (abductor of the shoulder)
▪ Teres minor (lateral rotator of the shoulder)

Figure 8. ​Pleura

Figure 4. ​Erb-Duchenne Displacement
Figure 5. ​Erb-Duchenne Palsy of Newborn
→ Limb hang limply by the side, medially rotated by the
unopposed sternocostal part of the pectoralis major
→ The forearm will be pronated because of loss of the action of
the biceps
→ “Porter or waiter hinting for a tip”
→ There will be a ​loss of sensation down the lateral side of the
arm
A.STELLATE GANGLION
● Inferior cervical ganglion is fused with the first thoracic ganglion
= stellate ganglion
● Lies in the interval between the transverse process of the 7th
CV and the neck of the first rib, behind the vertebral artery
(between C7&T1)
● Sympathetic nerve supply to the face, head, and neck on the
side

LOWER BRACHIAL PLEXUS LESION

● Klumpke Palsy
→ Excessive abduction of the arm as a result of someone
clutching for an object when falling from a height clutching at
an object to save himself or herself
→ (T1) is torn
→ Major nerves involved: ​ulnar (1) and median (2) nerves that
supply all the small muscles of the hand
→ The​ hand is clawed Figure 9. ​Stellate Ganglion

OVERSYMPATHETIC STIMULATION
● Stellate Ganglion Block
1. Performed the first palpating the large anterior tubercle
(carotid tubercle) of the transverse process of the CV6,
→ a ginger breadth lateral to the cricoid cartilage
2. Carotid sheath and the SCM are pushed laterally and the
needle of the aesthetic syringe is inserted through the
skin over the tubercle.
3. The local anaesthetic is then injected beneath the
prevertebral layer of deep cervical fascia. This procedure
Figure 6. ​Klumpke Palsy Clawed Hand
 effectively blocks the ganglion and its rami A. PHRENIC NERVE INJURY
communicantes.
● C3 - C5 → sole nerve supply → diaphragm
● Injured by penetrating wounds in the neck
● Paralyzed hemidiaphragm​: ​half relaxes and is pushed up into
the thorax​ by the positive abdominal pressure
● Consequently, the lower lobe of the lung on that side may
collapse
● Complication of lymph node dissection or thyroid surgery

B. INJURY TO SPINAL PART OF ACCESSORY NERVE

Figure 10. ​Stellate Ganglion Block
IV. SYMPATHECTOMY FOR ARTERIAL INSUFFICIENCY OF
THE UPPER LIMB
● Sympathetic innervation of the upper limb is as follows:
→ Preganglionic fibres leave the spinal cord in the second to
the eighth thoracic nerves
→ On reaching the sympathetic trunk via the white rami, they
ascend within the trunk and are relayed in the second
thoracic, stellate, and middle cervical ganglia.
→ Post-ganglionic c fibres then going the roots of the brachial
plexus as gray rami
→ Sympathectomy is therefore done for treatment of arterial
insufficiency → ​RAYNAUD’S DISEASE, PALMAR
HYPERHYDROSIS, AXILLARY HYPERHYDROSIS
A. RAYNAUD’S DISEASE
● Cold exposure (winter) vasospasm of hand arteries (esp. digits)
● May cause “gangrene” to digits
● Sympathectomy → ​vasodilation of skin vessels
B. HORNER’S SYNDROME
● Increase in parasympathetic innervation
● Results from interruption of the peripheral part of sympathetic
fibers to the eyelids and pupil face
→ Constriction of the pupil (​Miosis​)
→ Drooping of eyelid; levator palpebrae paralysis (​Ptosis​)
○ W/ or w/o enophthalmos
○ Decreased sweating; vasoconstriction
dehydration (​Anhydrosis​)
○ Hyperemia
○ Unable to close eye
● The spinal part of the accessory nerve crosses the posterior
triangle in a relatively superficial position.
● It can be injured at operation or from penetrating wounds.
● The trapezius is paralyzed, the muscle will show wasting →
shoulder will drop.
● Experience difficulty in elevating the arm above the head,
having abducted it to a right angle by using the deltoid muscle.
CLINICAL EXAMINATION
● Involves asking the patient to rotate the head to one side
against resistance, causing the SCM of the opposite side to
come into action.
● Then the patient is asked to shrug the shoulders, causing the
trapezius muscles to come into action.
VI. DEEP FASCIA OF NECK
● It is possible for blood, pus, or air in the retropharyngeal space
to spread downwards into the superior mediastinum of the
thorax.
A. CLINICAL SIGNIFICANCE
● Between the more dense layers of deep fascia in the neck is
loose connective tissue that forms potential spaces
→ Visceral
→ Retropharyngeal
→ Submandibular
→ Masticatory
● Organisms originating in the mouth, teeth, pharynx, and
esophagus can spread among the fascial planes and spaces,
and the tough fascia can determine the direction of spread of
infection and the path taken by pus.
B. LUDWIG’S ANGINA
● Dental infections most commonly involve the lower molar teeth
(masticatory area); the infection spreads medially from the
mandible into the submandibular and masticatory spaces and
pushes the tongue forward and upwards.
● Further spread downward may involve the visceral space and
lead to edema of the vocal cords and airway obstruction
(protrusion of tongue → blocking airway posteriorly)
● May insert tracheostomy tube (to assist for breathing)

Figure 11. ​Horner’s Syndrome

● Follow spinal cord lesions at the T1 segment (tumor or
syringomyelia)
PENETRATING OR OPERATIVE INJURIES
● Pressure ot the stellate ganglion or the cervical sympathetic
chain
→ Enlarged cervical lymph nodes
Figure 12. ​Ludwig’s Angina
→ Upper mediastinal tumor
→ Carotid aneurysm VII. CITATION
→ Malignant mass in the neck
● Pictures
Thoracic Outlet Syndrome [digital image]. Retrieved from
https://www.slideshare.net/NeurologyKota/thoracic-outlet-syndrome-70720936
V. NERVE INJURY
Cross Section of Lower Trunk [digital image]. Retrieved from
https://web.duke.edu/anatomy/Lab22/Lab22_table.html
Approaches to Brachial Plexus Nerve Block [digital image]. Retrived from
https://www.frca.co.uk/article.aspx?articleid=100446

Erb-Duchenne Displacement [digital image]. Retrieved from

https://www.kenhub.com/en/library/anatomy/upper-and-lower-brachial-plexus-inju
ry

Erb-Duchenne Palsy of Newborn [digital image]. Retrieved from

http://drugline.org/medic/term/duchenne-erb-palsy/

Klumpke Palsy Clawed Hand [digital image]. Retrieved from

http://52.62.202.235/upper-limb/nerves/brachial-plexus/injury

Clawed Hand of Newborn [digital image]. Retrieved from

https://www.sciencedirect.com/science/article/pii/S0363502313005613

Stellate Ganglion Block [digital image]. Retrieved from

https://www.semanticscholar.org/paper/Stellate-ganglion-block-for-treating-hot-fla
shes%3A-a-Guttuso/047fccf7ccd3a2e0b8bce58c3c80f6aa42f52989/figure/0

VIII. REFERENCES
● Doctor. J.I. Sanchez (2019). General lecture for Clinical Anatomy of the
Posterior Neck.