57 - Bones and Joints of the Neck

Question 1

Layers of fascia in the neck
1
2
3
4
5

Answer 1

Superficial fascia.
Deep cervical fascia (four layers)
1) Investing layer
2) Pretracheal layer
3) Prevertebral layer
4) Carotid sheath

Question 2

Location of pretracheal fascia

Answer 2

Around trachea and oesophagus, also contains thyroid

Question 3

Bundles of nerves and vessels in the neck

Answer 3

Common carotid artery (most interior), internal jugular vein (most exterior), vagus nerve (most posterior)

Question 4

What encloses the common carotid artery, internal jugular vein and vagus nerve

Answer 4

Carotid sheath

Question 5

Where are the majority of cervical muscles located?

Answer 5

Between transverse and spinous processes of cervical vertebrae (extension of erector spinae)

Question 6

Layer of fascia that contains muscles around cervical vertebrae

Answer 6

Prevertebral fascia

Question 7

Two muscles attached to tip of the cervical transverse process

Answer 7

Scalenus anterior and scalenus medius (the scalenes)

Question 8

Importance of scalenus anterior and medius

Answer 8

Create a gap for brachial plexus and subclavian arteries to exit neck.

Question 9

Outermost layer of fascia in the neck

Answer 9

Investing layer of fascia

Question 10

What does the investing layer of fascia enclose?

Answer 10

Trapezius (posterior) and sternomastoid (anterior)

Question 11

Number of cervical vertebra

Answer 11

Seven

Question 12

First two cervical vertebra

Answer 12

Atlas and axis

Question 13

Regions of the neck
1
2
3
4
5

Answer 13

1) Back of the neck (vertebral region)
2) Posterior triangle
3) Sternomastoid region
4) Anterior triangle
5) Root of the neck

1-3 are posterior, 4-5 are anterior

Question 14

Where does the line of gravity of the head fall?

Answer 14

Anterior to vertebral column.

Hence need posterior muscles of back to keep head upright.

Question 15

Ligamentous band of fibres in posterior neck

Answer 15

Ligamentum nuchae.

Formed by tendinous insertions of muscles of neck at midline.

Question 16

Typical cervical vertebrae 
1
2
3
4
5
6
7

Answer 16

• Transverse mass – anterior & posterior tubercles
• Transverse foraminae
• Bifid spinous processes (to increase surface area for muscle and ligament contact)
• C7 (atypical) has longest spinous process (vertebra ‘prominens’)
• Articular surfaces oriented at ~45º
• I-V foramen
• ‘Uncinate’ (hook-like) processes on bodies C3-6

Question 17

Angle of pedicles from cervical vertebral bodies

Answer 17

Angle of about 45 degrees.

Means that spinal nerves also need to exit at about 45 degrees

Question 18

Transverse mass of cervical vertebra

Answer 18

Transverse process has a hole in it -> Transverse foramen.

Termination of transverse processes have two tubercles.
Bar linking tubercles is a remnant of rib process.

Question 19

Role of transverse foramen

Answer 19

Makes tube for vertebral arteries

Question 20

Uncinate processes

Answer 20

Hooklike processes from vertebral bodies of C3 to C6.

Question 21

Atypical aspects of C1
1
2
3
4
5
6

Answer 21

• No body
• Made up of anterior & posterior arches
• Facet for dens (dens is an articular surface on the axis, articulates with anterior arch of the atlas)
• Shift of position of facet surfaces anterior, relative to other C-vertebrae
• Saucer-shaped (very concave) upper surfaces for occipital condyles
• Long transverse process

Question 22

What happened to vertebral body of C1?

Answer 22

Attached to C2 during development, to form the spike of the axis

Question 23

Atypical aspects of C2
1
2
3

Answer 23

• Dens (odontoid process) –developmental body C1
• Surfaces on dens for articulation with anterior arch of atlas
• Strong spinous process

Question 24

Cranial shift

Answer 24

Rib can begin on C7

Question 25

Caudal shift

Answer 25

Larger rib on T12, rib developed on L1

Question 26

Attachment of scalenus anterior

Answer 26

Anterior tubercle of C vertebrae

Question 27

Role of scalenes

Answer 27

Elevate 1st rib

Question 28

Prevertebral muscles, location and function

Answer 28

• Prevertebral muscles located anteriorly, deep to prevertebral fascia
• Largest is longus colli - helps maintain curvature of cervical spine
• Provides access to cervical discs & spinal cord

Question 29

Muscles attaching to spinous process of C2

Answer 29

Erector spinae

Question 30

Where does common carotid bifurcate?

Answer 30

C4

Question 31

Where does the vertebral artery enter the transverse foramen?

Answer 31

C6 (at anterior tubercle or carotid tubercle)

Question 32

Where must spinal nerves pass to exit C1 and C2, versus other cervical vertebrae?

Answer 32

Must pass behind facet joints of C1 and C2, because articular surfaces are more anterior.

Other C vertebrae have more posterior articular surfaces, and nerves pass anterior to them.

Question 33

Effect of ageing on C vertebrae and nerves and vessels

Answer 33

Osteophytes can form, impinging on anterior rami of spinal nerves, or vertebral arteries (more in lower C vertebrae, less in C1 and C2)

Question 34

Joints in the C spine

Answer 34

•Inferior joints (C2-C7)

• intervertebral discs
• facet (zygapophyseal) joints

•Superior (suboccipital) joints

• atlanto-occipital (0-C1)
• atlanto-axial (C1-2)

Question 35

Largest discs in the vertebral column (relative to the vertebra)

Answer 35

In the C spine

Question 36

Primary contributors to cervical lordosis

Answer 36

IV discs

Question 37

Processes that hold IV disc of C spine in place

Answer 37

Uncinate processes

Question 38

Features of IV facet joints of the C spine 
1
2
3
4

Answer 38

1) Plane synovial joints, capsule innervated by posterior rami
2) Oriented at 45deg between coronal & horizontal planes (more horizontal in childhood).
3) Permit flexion/extension + rotation
4) Look for symmetry of facet surfaces (shingling) on CT

Question 39

Whiplash injury of spine
1
2
3

Answer 39

1) Acceleration of head in an antero/posterior direction
2) Injury of facet capsule & articular surfaces, + supporting ligaments
3) Particularly susceptible to compression injury in hyper-extension

Question 40

Atlanto-occipital joints

Answer 40

Two lateral synovial joints between occipital condyles and upper surfaces on atlas.
Allows nodding, limits rotation

Question 41

Atlanto-axial joints 
1
2
3
4
5

Answer 41

• Three synovial joints specialised for rotation (no IV disc)
• Median pivot joint between dens of C2 & anterior arch of atlas
• ‘Bursa’ between transverse ligament and dens
• Two lateral facet joints
• Allow approx 50% of rotation of cervical spine

Question 42

Role of transverse ligament in atlanto-axial joint

Answer 42

Allows dens to tilt backwards into vertebral canal

Question 43

Ligaments of the neck
1
2
3
4

Answer 43

• Ligamentum nuchae (supraspinous ligament)
• Ligament between atlas & occiput
- Posterior atlanto-occipital membrane
- Anterior atlanto-occipital membrane
• Ligaments between axis & occiput
- membrana tectoria (extension of posterior longitudinal ligament)
• All ligaments resist movements in sagittal plane (F/E)

Question 44

Specialised ligaments of the neck
1
2

Answer 44

Transverse ligament

Alar ligaments

Question 45

Transverse ligament role

Answer 45

Stabilises dens, prevents posterior translation of dens into vertebral canal

Question 46

Role of alar ligaments

Answer 46

Limits rotation of occipital bone around the axis.

Link dens and occiput.

Question 47

Effect of ageing on C spine
1
2
3

Answer 47

Degeneration of IV discs.
Causes vertebral wedging, reduces C spine lordosis.
Osteophytes can develop from uncinate processes and facet surfaces

Question 48

Hangman’s fracture

Answer 48

Extension fracture of the C spine.
Both pedicles are fractured.
Dens are rarely fractured.

Question 49

Jefferson’s fracture

Answer 49

From falling onto top of skull.

Bilateral fracture of anterior arch and pedicle.