Root of the Neck and Thoracic Outlet

Question 1

Root of the neck

Answer 1

• junction of the thorax and neck
• superior thoracic aperture (STA)
  
  • AKA thoracic inlet (anatomical)
  • AKA thoracic outlet (clinical)

Question 2

Structures Passing Through STA

Answer 2

• GI/Respiratory
  
  • trachea, espophagus
  • apices of lungs

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• Cardiovascular
  
  • subclavian aa., vv.
  • comon carotid aa.
  • internal jugular vv.

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• Nerves
  
  • vagus nn. (CN X)
  • reccurrent laryngeal nn.
  • phrenic nn.
  • brachial plexus (passes over, not through STA)

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• thoracic duct (lymph)

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Question 3

Apex of the Lungs

Answer 3

• apices of lungs extend above sternal end of the first rib
• affected by centrilobar emphysema (smoker’s emphysema), the breakdown of alveolar lung tissue
• apical lung tumors=pancoast tumors

Question 4

Subclavian Artery (Artery of Root of Neck)

Left and right branch from?

Answer 4

• left branches from aortic arch
• right branches from the brachiocephalic a.
• passes over first rib and becomes axillary artery
• axillary artery passes the teres major muscle and becomes the brachial artery to upper extremity

subclavian–>axillary–>brachial artery

Question 5

Branches of Subclavian Artery

Answer 5

• internal thoracic a.
• vertebral a.; supplies posterior brain
• thyrocervical trunk
  
  • inferior thyroid a.
  • ascending cervical a.
  • suprascapular a.
  • transverse cervical a.
    
    • superfiscial branch to trapezius
    • deep branch=dorsal scapular a.
• costocervical trunk
  
  • located behind the anterior scalene m.
  • deep cervical a.
  • superior intercostal a.

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Question 6

Nerves in the STA

Answer 6

• vagus n. (CN X): visceral motor (GVE) and sensory (GVA) to throax and abdomen
• recurrent laryngeal n.: motor (SVE) to larynx (speech)
• phrenic n.: motor (GSE) to diaphragm m., sensory to pericardial sac
• brachial plexus: motor (GSE) and sensory (GSA) to upper extremity and pectoral girdle
• sympathetic chain: visceral motor (GVE) to head, neck, and heart

Question 7

Vagus nerve (CN X) Function

Answer 7

• motor function of swallowing, speech (SVE)
• taste of epiglottis (SVA)
• monitors BP in aortic arch (GVA)
• controls heart and respiratory rates (PN, GVE)
• controls digestion in foregut, midgut (PN, GVE)

Question 8

Recurrent Laryngeal Nerve (Right and Left)

Answer 8

• branch of CN X in thorax
• motor fxn (SVE) to intrinsic mm. of larynx (speech)
• may be affected by thoracic/neck surgery, lymph node biopsy, or tumors
• Right RLN wraps around r. subclavian artery
• Left RLN wraps around aortic arch

Question 9

Cervical Spinal Nerves

Answer 9

• phrenic n. (C3-C5)
  
  • GSE to diaphragm m.
  • passes over anterior scalene m.
• brachial plexus (C5-T1)
  
  • GSE and GSA to upper limb and pectoral girdle
  • passes between anterior and middle scalene mm.

BP

Question 10

Scalene Muscle Functions

Answer 10

• flex the neck
• elevate first and second ribs
• accessory muscle of respiration

Question 11

Causes of Thoracic Outlet Syndrome

Answer 11

• compression on the neurovasculature of the STA by:
  
  • scalene muscle spasms or tension
  • clavical fracture or congenital defects
  • cervical ribs (long cervical transverse processes)
  • pancoaste (apical) lung tumor
• repetitive strain injury (RSI) from non ergo keyboard use, neck posture, etc.

Question 12

Signs of Thoracic Outlet Syndrome

Answer 12

• numbness, pain (nerve compression)
• discoloration, temp. abnormalities (CV vessels)

Question 13

Brachial Plexus Innervation

Answer 13

• VPR’s from spinal levels C5-T1
  
  • (ventral primary rami)
• GSA and GSE innervation
• upper limb and pectoral girdle

Question 14

Major Terminal Branches of Brachial Plexus

Answer 14

• axillary nerve: to shoulder muscles
• radial nerve: to posterior arm and forearm; extensor muscles
• musculocutaneous nerve: to anterior arm; flexor muscles of shoulder and elbow
• median nerve; to anterior forearm (flexors of wrist and fingers) and 1st digit (thumb)
• ulnar nerve: to anterior forearm (flexors of wrist and fingers) and fifth digit (pinky)

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Question 15

Brachial Plexus Neuropathies

Answer 15

• Affect motor (GSE) and sensory (GSA) fxn between target tissue and lesion
• Can be transient palsies due to compression or inflammation

Question 16

Signs of Brachial Plexus Neuropathies

Answer 16

muscle paralysis or paresis (weakness)

paresthesia

pain

Question 17

Radial Nerve Travels Through…

Answer 17

• the axilla
  
  • crutch palsy from poorly fitted axillary crutches
  • affects extensor muscles of the elbow and wrist
• travels on surface of posterior humerus (in spinal groove)
  
  • saturday night palsy from compressing nerve against humerus, affects wrist extensors (wrist drop)
  • mid-humeral fractures can also damage the nerve in the spinal groove

Question 18

Median Nerve

Answer 18

• travels with the brachial artery in arm
• crosses the cubital fossa (elbow pit)
• travels through the carpal tunnel with digital flexor tendons (carpal tunnel syndrome)
• innervates the lateral (thumb) side of hand

Question 19

Ulnar Nerve

Answer 19

• travels posterior to the medial epicondyle of humerus
  
  • medial side of elbow joint
  • “funny bone”
• innervates the medial (pinky finger) side of hand

Question 20

Hand–> Sensory Skin Dermatomes

Answer 20

• Digit 1 (thumb): C6
• Digit 3 (middle): C7
• Digit 5 (pinky): C8