Neck Neck: Alex Forrest

Neck
Oral Biology
Alex Forrest
Associate Professor of Forensic Odontology Forensic Science Research & Innovation Centre, Griffith University Consultant Forensic Odontologist, Queensland Health Forensic and Scientific Services, 39 Kessels Rd, Coopers Plains, Queensland, Australia 4108
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Learning Goals
You should aim to achieve a good appreciation of the general plan of the neck, with particular reference to the layout of the major fascial sheets. You should be able to explain what a fascia is, and describe its general purpose. You should aim to gain a deeper appreciation of the posterior triangle of the neck and be able to recognize the muscles in its floor with the exceptions of splenius capitis and semispinalis capitis.
Learning Goals
You should be able to recognize and describe the superficial cutaneous branches of the cervical plexus, and also the phrenic nerve.
Approach
When we discuss the neck, you should recall the session in which we examined the way in which the head and neck have been designed. Ask yourself what are the functions of the neck, and how are they reflected in its layout and shape, and how in turn do these determine the internal structure?
Approach
Only then will their structures make sense, and be integrated into the plan you develop for the neck. Finally, think in clinical terms
Approach
A good way to visualize the neck is to think of it in terms of skeleton, muscles, fasciae and viscera. Categorizing the contents in this way makes the plan easy to comprehend, and helps you to locate structures in a simple way.
Skeleton
The skeleton of the neck is essentially the vertebral column, although the larynx has a cartilaginous skeleton of its own.
Skeleton
Be able to identify the vertebral body, neural arch, pedicles, laminae, transverse foramina, spinous processes, anterior and posterior roots and tubercles of the transverse processes, articular surfaces and the intervertebral foraminae.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 236.
Skeleton
Intervertebral foraminae are only obvious when adjacent vertebrae are articulated.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 237.
Skeleton
Be sure that you can draw the basic plan of a typical cervical vertebra and label these features.
Fasciae
Being able to draw the fasciae of the neck provides a key to the comprehension of its overall structure, so it is an important piece of understanding to acquire.
Diagram A. Forrest 2008.
Fasciae
In the diagram on the right, note the superficial fascia which is coloured pink, and the deep fasciae which are drawn in red.
Fasciae
The superficial fascia lies immediately beneath the skin and is continuous with it. One removes it when one removes the skin in dissection. Note that it contains the platysma muscle.
Fasciae
The deep fascia is designed to permit easy movement between groups of structures, and lets groups of muscles and viscera move independently. It essentially provides a layer between adjacent sliding surfaces.
Fasciae
Layers of deep fascia divide the neck into a number of compartments, and leave the so-called tissue spaces potential spaces which lie along the planes of cleavage between the layers. These spaces are important in the spread of infection in the neck.
Fasciae
The deep fasciae comprise a number of layers. The most superficial of these is called the investing layer of the deep cervical fascia.
Fasciae
Sometimes it is misleadingly called the superficial investing layer of deep cervical fascia, and this can be confusing because the terms superficial and deep are used in the same name to describe a layer of deep fascia in the neck. For this reason, the term investing layer is preferred.
Fasciae
The investing layer lies deep to the superficial fascia, and forms a continuous sheath around the entire neck. It splits to contain the trapezius muscle and the sternocleidomastoid muscle on each side, and in between the two muscles it forms a sheet that acts as a roof over the posterior triangle of the neck.
Fasciae
The presence of the sternocleidomastoid and trapezius in this layer gives them mobility independent of other muscles in the neck.
Fasciae
The carotid sheath lies deep to the investing layer, and wraps the internal jugular vein, common carotid artery and vagus nerve (X) in a bundle. As we ascend in the neck, the carotid sheath contains the internal carotid artery rather than the common carotid after we pass above the junction between the two vessels.
Fasciae
The pre-vertebral fascia separates the larynx and oesophagus from the prevertebral muscles, giving these viscera freedom of movement in this important area.
Fasciae
The potential space that lies between the pharynx and the prevertebral muscles is called the retropharyngeal space, and this is important from the point of view of spread of infection, since it communicates inferiorly with the mediastinum, and provides a pathway for infection to spread into this area.
Fasciae
Infection in this space can cause problems with swallowing and with respiration. It communicates with the posterior triangle posteriorly to the carotid sheath.
Fasciae
The thyroid gland and larynx are surrounded anteriorly by the prelaryngeal fascia. The paralaryngeal/ parapharyngeal space lies between this, the investing layer and the carotid sheath.
Fasciae
Retropharyngeal Space
This space provides a pathway for infection to spread into the retropharyngeal space. Infection in this area can also compromise respiration to an extent.
Triangles
For convenience, when we describe the neck, we refer to a series of imaginary lines drawn on its surface which correspond to important anatomical structures which lie beneath. Since these lines form a series of triangular shapes on the neck surface, we refer to them as the triangles of the neck.
Triangles
Note the posterior triangle, shaded pink in the diagram.
Triangles
The space between the investing layer, the carotid sheath and the prevertebral fascia is known as the posterior triangle of the neck, and it is here that many important structures can be found during dissection.
Triangles
If the investing layer, which forms the roof of the triangle, is removed, one looks down on the carotid sheath (deep to sternocleidomastoid) and many important muscles, as well as the superficial branches of the cervical plexus.
Clemente CD, Anatomy, A Regional Atlas of the Human Body, Munich, Urban & Shwarzenberg, 1975, Diagram 429.
Triangles
You should identify the three scalene muscles, scalenus anterior, medius and posterior, levator scapulae, and splenius capitis. You should also identify the accessory nerve (XI) and the phrenic nerve.
Modified from: Clemente CD, Anatomy, A Regional Atlas of the Human Body, Munich, Urban & Shwarzenberg, 1975, Diagram 427.
Triangles
The scalenus anterior attaches to the anterior tubercles of the 3rd to 6th cervical vertebrae, while scalenus medius and posterior attach to the posterior tubercles of the lower 5 and 4th to 6th cervical vertebrae respectively.
Triangles
This means that the cervical and brachial nerves emerge between the scalenus anterior muscle and the scalenus medius muscle.
Nerves
You will learn that the accessory nerve, or cranial nerve (XI), is the nerve that allows us to shrug our shoulders. It is motor to the sternocleidomastoid muscle and to trapezius.
Nerves
You will need to know the branches of the cervical plexus later in your course, so now is a good time to become familiar with them. The trunks of the brachial plexus will not be covered and need not be known .
Nerves
The branches of the cervical plexus emerge from the posterior border of the sternocleidomastoid muscle, and therefore they emerge at the anterior border of the posterior triangle.
Nerves
The lesser occipital nerve hooks around the accessory nerve and runs along the posterior border of the sternocleidomastoid muscle to supply sensation to the back of the neck and lower part of the back of the head.
Nerves
The great auricular nerve is a larger branch which runs across the belly of the sternocleidomastoid on its way towards the parotid gland and the ear. It supplies sensation to the skin in the region of the parotid gland and to much of the auricle of the ear.
Nerves
The transverse cervical nerve crosses the sternocleidomastoid muscle as it passes towards the front of the neck, and then divides into superior and inferior branches which supply common sensation to the front of the neck from the chin down to the upper part of the chest.
Nerves
The reason it is important to dentists is that it can sometimes provide an accessory nerve supply to the lower anterior teeth, and this can prevent conventional block anaesthesia from being successful in this area.
Nerves
The supraclavicular nerves divide into three groups and supply common sensation to the skin overlying the chest and shoulder.
Nerves
Since all of these nerves are sensory, and supply areas of skin, they must pass through the investing layer of cervical fascia to get there.
Nerves
The final branch is the phrenic nerve. This contains fibres from C3, C4 and C5 and is the motor nerve to the diaphragm. It is a deep branch of the cervical plexus, and crosses the belly of the scalenus anterior muscle and the lower anterior end of the posterior triangle, where it is accessible to traumatic injury.
Summary
Examine this diagram now and note its salient features. Can you use your knowledge to label this plan?
Diagram Alex Forrest 2008
Summary
Become familiar with this and use it as a guide to the neck. You can print it out from learning@griffith.
Diagram Alex Forrest 2008.
The End

Neck Neck: Alex Forrest

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Neck

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 236.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 237.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Diagram A. Forrest 2008.

Note the posterior triangle, shaded pink in the diagram.

Diagram A. Forrest 2008.

Diagram Alex Forrest 2008

Diagram Alex Forrest 2008.

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