Cervical Sono-Anatomy

Cervical sono-anatomy

Sang Hoon Lee, MD., Ph.D Madiclinic, Jeonju, Korea Korea University

Surface landmarks

• Posterior cervical triangle – formed by the sternocleidomastoid and trapezi us muscles and the clavicle. – Levator scapular, scalene muscles, omohyoid muscle – Space for nerve root, brachial plexus – Antrior and posterior tubercles, transverse pro cess, facet joints Bony landmark: transverse process

C6 Typical cervical vertebra

• Lateral column – Facet joint – Articular pillar • Waist – Transverse process

• Anterior & posterior t ubercle Anterior oblique, lateral view Transverse process (ant & post tubercle)

• C1, C2: single blunt tip of tr ansverse process • C3,4: small rudimentary an terior tubercle • C5: small, similar size of a nterior & posterior tubercle • C6: tallest, anterior protrusi on of anterior tubercle • C7: single big blunted, rudi mentary or no anterior tube rcle Articular pillar

• C1: no • C2: small, no facet joi nt on roof • C3-C5: typical large, prominent • C6: smaller, deeply lo cated • C7: smallest, deepest AO/AA joint/Facet joint

• C0-C1(AO): synovial joint, anterior location • C1-2(AA): synovial joi nt, anterior location • C2/3 to C7-T1: synov ial joint, posterior loc ation, oblique orientat ion Relation between TP & articular pillar

• C1: no pillar • C2: close, taller trans erverse process • C3-C6: wide, transve rse, TP anterior to th e pillar • C7: TP on the pillar

On Lateral view or scan Nerve supply of joints

Dual innervation

Dorsal rami, medial & lateral branc h Cervical plexus, sinuvertebral nerve Innervation

Structure Nerve supply Posterior neck muscles Cervical dorsal rami Zygapophysial joints Cervical dorsal rami Lateral atlanto-axial joint C2 ventral ramus Atlanto-occipital joint C1 ventral ramus Median atlanto-axial joint and its ligaments Sinuvertebral nerves of C1, C2, and C3

Dura mater Sinuvertebral nerves of C1, C2, and C3 Prevertebral and lateral muscles Cervical ventral rami Cervical intervertebral discs Posteriorly Posterior vertebral plexus by cervical sinuvertebral nerve Anteriorly Anterior vertebral plexus by cervical sympathetic tru nks Laterally Laterally by vertebral nerve Vertebral nerve Cervical gray rami communicantes

Semispinalis capitis • Origin: transverse process of C7-T5 and articular process of C4-6 • Insertion: nuchal line of occipit al bone Semispinalis capitis • Origin: transverse process of C7-T5 and articular process of C4-6 • Insertion: nuchal line of occipit al bone

Semispinalis capitis Inferior oblique capitis

20 Semispinalis capitis Longissimus capitis Longissimus cervicis

Iliocostalis cervicis O: angles of 3rd to 6th ribs I: PT of TP of C4 to C6

21 Muscle layers Spinalis capitis

Semispinalis capitis Splenius capitis Splenius cervicis: PT of C1 to C3 (under levator scapulae C1 to C4) Serratus posterior superior (under rhomboidues)

Middle scalene: O: TP of C1, C2, anterior aspect of PT of TP of C1 to C7 I: 1st rib

23 Splenius cervicis, Splenius capitis

Mastoid procss, TP of C1 to C occipital bone u 3, just anterio nder SCM r to LS (C1 to C4)

SP of C7 to T4 SP of T3 to T6

Action Acting individually, splenius cervicis laterally flexes Action and slightly rotates the neck to the same side. Acti extends the head and neck, lateral flexion of the ne ng together the muscles extend the neck. ck and rotation of the face to the same side

Third occipital nerve/C3 MB/GON

OCI, semispinalis capitis, splenius capitis

30 Cho, Sonography of the normal greater occipital nerve and obliquus capitis inferior muscle, J Clin Ultrasound; 2010 ①

From the top: ɡ Inferior oblique capitis & C1 transverse proce e àC2/3 facet joint ①

ɡ Inferior oblique capitis muscle

① ①

ɡ ① ① ɡ

ɡ ① ①

ɡ ①

① ɡ ɡ

US anatomy Typical Cervical vertebrae(C3-5)

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the ﬁle again. If the red x still appears, you may have to delete the image and then insert it again. Medial branches (C3 ~ C5) Ultrasound anatomy C 6,7 vertebra & medial branch

Landmark for C6 MBB Landmark for C7 MBB

Semispinalis muscle

• Semispinalis capitis – deep to the splenius, and medial to the longissim us cervicis and longissimus capitis – arises by a series of tendons from the tips of the t ransverse processes of the upper six or seven tho racic and the seventh cervical vertebrae, and fro m the articular processes of the three cervical vert ebrae above this (C4-C6). • Semispinalis cervicis • Semispinalis thoracis

Erector spinal muscles

Lateral column Intermediate colum Medial column Iliocostalis n Spinalis Longissimus Lower thoracic Lumborum Upper thoracic Thoracis Thoracis Thoracis Cervical Cervicis Cervicis Cervicis Skull Capitis Capitis

Contents

• 1st layer: trapezius, sternocleidomastoideus • 2nd layer: – Upper neck and middle: splenius capitis and cervicis – Lower neck and interscapular region: levator scapula r, rhomboideus • 3rd layer: – semispinalis capitis, spinalis cervicis – Longissimus capitis & cervicis, iliocostalis cervicis, se rratus posterior superior • 4th layer – Inferior oblique capitis muscle, Multifidius Intervertebral foramen/roots Intervertebral foramen

• Bony canal (internal intervertebral foramen ) • Fibrous osseous canal( external interverte bral foramen) formed by intertubercular gr oove

* Fibromuscular tunnel for brachial plexus Bony canal 1) Midsagittal plane ɠ upper and middle cervical IVFs – about 45 degree, anterior direction ɡ lower cervical IVFs – about 55 degree

2) Horizontal plane ; About 10 degree, inferior direction

3) Dimension ɠ length ; 4 to 6 mm ɡ average height ; 8.1 mm average width ; 5.6 mm

(Ebraheim,,biyani, Salpietro,1996)

Bony canal

4) Dorsal & ventral roots (medially) or the spinal nerve (laterally)

; occupy about 30-50 % of space(Sunderland, 1974)

ɠ dorsal & ventral roots VA ; place inferior aspect of bony canal (Pech et al.,1985)

ɡ epidural fat and blood vessels

; place superior aspect of bony canal C6 root External intervertebral foramen

• Consist of fibro-osseous tunnel • Floor – Intertubercular sulcus • Anterior inferior: anterior tubercle • Postero inferior: posterior tubercle • Connecting intertubercular lamella

• Roof – Free space

Transverse process (ant & post tubercle)

• C1, C2: single blunt tip of tr ansverse process • C3,4: small rudimentary an terior tubercle • C5: small, similar size of a nterior & posterior tubercle • C6: tallest, anterior protrusi on of anterior tubercle • C7: rudimentary or no ante rior tubercle Characteristics of each C. vertebrae

(1) (2) (3)

(4) (5)

C7 root

• No or tiny anterior tubercle • V1 segment of vertebral artery is located medial to C7 root

C6 root C 5 root C3,4 roots

• Tiny anterior tubercle • Small nerve roots • Contributes to cervical plexus with C1,2 ro ot, C5 roots Brachial plexus Brachial plexus

Cervical plexus

Fascial layers of neck

• Superficial cervical layer • Deep cervical layer – Superficial cervical fascia ( investing fascia) – Pretrachial fascia – Carotid sheath – Preverebral fascia

Muscle layers of anterior neck

• Platysma • Sternocleidomastoideus muscle • Omohyoid muscle • Scalene muscles • Longus colli and longus capitis

Nerves

• Cervical plexus – Arise from C1 to C5 – No intervertebral foramen at C0-C1, C1-2, pie rce interlaminar space • Spinal acessory nerve • Brachial plexus – Roots, trunks, divisions, cords – Branches • Sympathetic chain and ganglion

SUPRASCAPULAR NERVE

• follow the brachial plexus up the neck until yo u see it emerging between the anterior and m iddle scalene muscles, together with the subc lavian artery. • Trace the suprascapular nerve (accompanied by the suprascapular artery on its way to sup raspinatus and infraspinatus muscles) as it br anches from the plexus and runs back across the neck parallel to the transverse cervical ar tery. Sympathetic chain and ganglion

chain Muscle and fascia of neck

• Skin and subcutaneous tissue • Superficial cervical fascia • Sternocleidomastoideus & Trapezius • Splenius capitis • Posterior tubercles of transverse process or transverse proces s of upper cervical vertebrae • Muscles attaches to posterior tubercle or transverse process o f C1 : inferior oblique capitus, levator scapulae, splenius cervi cis, longisimus cervicis • Muscles attaches to anterior tubercle: scalene muscle, longus colli and longus capitis • Semispinalis cervicis • Multifidus Insonation angle of lower cervical Thank you for your attention