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The first exam is delayed to Sun. 18/03/12 and the second exam
to Tus. 17/4/12.
there will be a review lec. of the skull and the neck next week
Tus. 28/02/12 so plz study well in the weekend to be prepared.

In the previous lecture :
the muscles in the neck are divided according to its function and location into
3 groups:
The reference and superficial group: - 3 muscles (the superficial is the platezis,
and the reference are 2 the trapezius and SCM)
Hyoid related group :( 4 supra and 4 infra hyoid) we call the infra hyoid group
the strap muscles ( (
The final group is related to the vertebral column (cervical vertebral muscles):
consist of three groups:
-The anterior have 2 muscles (longus cavities and longus coli).
-Posterior group another 3 muscles (levator scapulae, splenius capitis and
semispinalis capitis) => just names.
-The lateral group have 3 scalenus muscles (scalenus anterior, medius, and
posterior) => we must know all details about them according the vertebral.

Posterior Triangle of The Neck

(Lateral Cervical Region)
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NOW, we will talk about the posterior triangle of the neck; we call it pos. Because
its behind the SCM but its actually representing at the lateral cervical region.
-GUYS, when we speak about any region in anatomy we look to the boundaries,
roof, floor and the contents of that area.
Lets start with boundaries:
Pos. triangle located behind the SCM so the first border which is the anterior
border of the triangle is SCM (sternocleidomastoid muscle) and the posterior
border is the trapezius muscle. Inferiorly you have the mid. third of the clavicle -
because the medial third is providing an attachment to SCM and the lateral third
of the clavicle is providing an attachment for trapezius ,and the mid. third which
is the inferior border of the posterior triangle.
The roof: is made by skin and fascia (superficial fascia, and the investing layer of
the deep fascia).
The floor: is made by prevertebral muscles (specifically the lateral and posterior
group) and the prevertebral fascia that cover them.
; the contents of posterior triangle are between the prevertebral fascia and
investing fascia.
-The prevertebral muscles which are the lateral and posterior group. The lateral
group which is:
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` The anterior scalenus, medius scalenus, ` posterior scalenus
-Between the anterior and medial scalene there is opening called scalene
hyeetus subclavian artery and brachial plexus pass through it.
So the floor starts from down up:
1- Anterior scalene.
2- Medius scalene.
3- Posterior scalene.
4- Elevator scapulae then the bandage () the first one in posterior group
5- Splenius capitis.
6-semispinales capitis (we can see small of semispinalis at the apex of pos.
triangle).
NOW; we can divide the pos. triangle to two smaller triangles to simplify studying
it by a specific muscle which is inferior belly of omohyoid
Omohyoid have superior and inferior belly and its call like that because the
omohyoid is one of the strap muscles it descend from the body of hyoid bone in
superior belly, it goes posterior to SCM since there is Intermediate tendon,
omohyoid inter these tendon => these called the anterior belly in anterior triangle
then the inferior belly goes posterior and attach to the upper border of the
scapula thats why called omo =>> omo means shoulder
As Inferior belly goes to pos. triangle we take an advantage to subdivide the
posterior triangle into two triangles:
The smaller one bellow the inferior belly of omohyoid called
omoclavicular or supraclavicular triangle another name for
this triangle subcalvian triangle because in its corner within
these triangle we can see the subclavian artery and vein.
3
So omoclavicular triangle
cuz its boundaries
Supraclavicular triangle
cuz its location; superior to
scapula
Subcalvian triangle cuz its
contents

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The other triangle which is the very larger one and above the omohyoid muscle
we call it occipital triangle >>why occipital?
Because its closer to occipital bone.





The contents of pos.triangle
The contents of pos.triangle are artery, vein and nerve.
There are four important artery:
Ooccipital arteryOtransverse cervical arteryOsuprascapular arteryOthird part of
subclavian artery.
-occipital artery: its abranch of exernal carotid artery(ECA) in the apex of pos.
triangle, it pass over the holl pos. aspect of the head broviding the blood supply to
pos. half of the skull
WNote:the main blood supply into the head and neck region comes from
common carotid artery .
The common carotid at the level of adams apple divides into two arteries one
continue to the brain calledinternal carotid the other one leaves the carotid
sheet to provide blood supply to most of the structures outside the skull
external carotid one of the branches of external carotid is the occipital.
The other two important arterys we will see them running transversely through
the triangle; the superior one usually call ittransverse cervical artery the other
The posterior triangle is subdivided by inf. belly of omohyoid muscle to two
triangles:
1 Omoclavicular triangle
2 Occipital triangle
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name is superfacial cervical artery defferent names depends on its story; the
transverse cervical arise from subclavian artery, as it arise it goes and inter to pos.
triangle posteriorly providing blood supply to superfascial structure in
superfacial fascia and any structure there, then it disapper by getting deep to
trapezius muscle then it desend down to medine border of scapula, there its name
become dorsal scapular artery- it provides blood supply to romboid muscle-;
now in other cases the dorsal scapula artery will arise directly from another
origin of the subclavian and go all the way across the medine border of the
scapula so its name dorsal scapula as it arise ,and the transverse cervical just arise
passing through pos. triangle and terminate deep to the trapezius in these case no
longer called transverse cervical; since its providing blood supply to superfacial
part of the neck => we call it superfacial cervical artery ,and if its continue to
become dorsal scapular we will name it transverse cervical artery , superfacial
cervical artery.
ones it arises it will pass superfacialy to the most of the structure there ;when it
arise anteriorty to phrenic nerve and scalenus anterior muscle then it will pass
above the trunks of bracial plexus all the way to disapper deep to the trapezius
muscle .
+suprascapulaer artery always inferior the transverse cervical also pass
transversly all the way to the posterior aspect, in the posterior aspect it will go to
posterior surface of the scapula it pass through suprascapular notch => all the
way to the back to pos. surface of the scapula since there is two muscles(
supraspinatus and infraspinatus) providing blood supply to these.
Another branch from subclavian artery in the anteroinf. angle of the triangle is
the third part of subclavian artery
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And now since we talk about it we have to know the story of
subclavian artery:
firstly the subclavian artery divides into different parts Once it's
originate from its origin it will go to the superior thoracic opening
through the scalene hiatus behind the scalenus anterior muscle
arching over the first rip on the outer border of the 1st rip it
becomes the axillary artery and on the lower border of teres
major becomes the brachial artery so this is the subclavian from
its origin - brachiocephalic- to the outer border of the 1st rip.
the subclavian artery divides into 3 parts based on the scalenus anterior
muscle the 1st part is from its origin to the medial border of
scalenus anterior the 2nd part is the one that located behind the
scalenus anterior "which we can't see in the drawing" the 3rd
part from the lateral surface of scalenus anterior to the outer
border of the first rip.

THE BRANCHES
1st --> 3 brances , 2nd --> 1 branch & 3rd --> no branches or
sometimes it gives one branch which is "dorsalscapular artery"
WHEN dorsalscapular artery is there the transverse cervical
artery b9er 2smo super facial cervical artery BUT when there is
no branches from the 3rd part "there is no dorsalscapular artery"
bekon 2smo transvers servical artery most commonly there are
no branches from the 3rd part
First part branches :
Remember them in a clock wise manner
the 1st the most medial goes superiorly "vertebral artery" it
goes between the scalenus anterior and longus colli (longus
surfaces) then inter into the transverse foramina of C6 - C1 then
Where does the
subclavian artery
originate from?
the right subclavian from
the brachiocephalic
behind the
sternoclavicular joint
while the left one from
the arch of the aorta
directly
So the subclavian is
three parts :
1st one Extension is
from its origin to the
scalenus anterior
2nd one extension is
posterior to scalenus
anterior
3rd one extension is
from scalenus anterir to
the outer border of the
first rip
Branches from the first
part of the subclavian
artery :
vertebral artery
superiorly to the brain
thyrocervical trunk
anteriorly to the thyroid
& structures of the neck
internal thoracic artery
to the thorax
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inter the foramen magnum to supply the brain the inferior
posterior part of it 'hai Rabe3 mrra bne7keha !!' .

the 2nd one is more lateral goes anteriorly it's short but wide so
it's "thyrocervical trunk" cuz it gives arteries to the thyroid and
the structures of the neck.
it gives three main branches the first and largest one that goes
superiorly to the thyroid gland it is the inferior thyroid artery cuz
it reaches the thyroid gland from inf. the remaining two arteries
goes transversely cross the posterior triangle to the back the
upper on is the transverse cervical artery "2smo eltaney
superficial depending on the 3rd part branches!!" and the lower
is the supra scapular artery 'that the ones we just spoke about :)'

the 3rd one the most lateral goes inferior to the thorax along
with the sternum gives the anterior intercostals arteries we will
name it "internal thoracic artery" which descends down passing
along the margins of the sternum providing the anterior
intercostals arteries for the upper 6 spaces then it divides into
two arteries superior epigastric to the abdomen the other goes
with the costal margin the musculophrenic which provide the
remaining intercostals spaces."u've studied it the last sem. so its
good to know just the internal thoracic"

NOW the subclavian artery goes behind the SCM so now we are
in the Second part of the subclavian.


Second part branches :
from the second part there is one branch only this time it arising
:
what is the largest
branch from
thyrocervical trunk ?
ans. : inferior thyroid
artery
the transverse cervical
artery and the supra
scapular artery arise
from the thyrocervical
trunk which is from the
first part of subclavian
artery
Notice the order of the
branches the 1st branch
of the first part goes
sup. then the 2nd
branch goes ant. then
the 3rd goes inf. and
now the second part
branch goes post.
"clock wise manner":D

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posteriorly "the costocervical trunk" cuz its a large artery divides
above the neck of the first rip and gives two branches :
1- Deep cervical artery : go superiorly to supply the deep muscles
of the posterior neck "Semispinalis, Splenius, Levator Scapulae".

2-Superior intercostals artery : go inferiorly gives the posterior
intercostals arteries of the first two intercostals spaces.
We have 11 intercostals spaces the first 2 spaces get blood
supply from the Superior intercostals artery which come from the
costocervical trunk which arise from subclavian and the
remaining spaces get blood supply from the descending thoracic
aorta which was a Q in the previous term ;)
Third part :
the third part of subclavian has no branches But SOMETIMES the
dorsalscapular artery arise from it , if that happened the
transverse cervical artery becomes superficial cervical. so it
depending on the presence or absence of the dorsal scapular
artery.








To remember:
the costocervical trunk
arise from the posterior
aspect of the second
part of the subclavian !!
you have to know about the subclavian branches but When we are talking about the posterior
triangle you have to know exactly what arteries are present which is the 3rd part only cuz the 1st is
medial to the Scalenus anterior and the 2nd is behind the scalenus anterior so only the 3rd part
present in the posterior triangle
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So till now we have 4 arteries we will go to the veins which are 5
veins :
Veins in Post. Triangle
the veins are two systems :deep and superficial ,the deep ones
are the same as the deep arteries we've studied later Occipital
v., Transverse cervical v., Suprascapular v. & Subclavian v.

The superficial vein within the posterior triangle is called
external jugular vein (EJV) it is usually formed at the angle of the
mandible by the union of two veins( posterior oracular vein &
posterior division of retromandibular vein) now its superficial or
external to the SCM then it descend down, when it reach deeper
it will appear in the posterior triangle within the superficial facia
its deep to the platysma muscle and superficial to the SCM,
after leaving the SCM it will get into the lower part of the
posterior triangle in the subclavian triangle (omoclavicular
triangle), now it tears the investing layer deep facia and go deep
to drain into the deep veins whether the EJV or the subclavian
vein.
Nerves in Post. Triangle
we can divide them into 3 groups :
1- Cutaneous Nerves:
they are four arising from the midpoint of posterior border of
SCM go through the investing layer of deep facia to the
superficial facia from there they will go to the skin so they are
sensory cutaneous nerves.
lesser occipital nerve: from anterior ramous of C2
Retromandibular vein
descend behind the
mandible at the angle of
the mandible divide into:
1- ant. division of
retromandibular vein: it
will drain into the facia.
2- post. division of retro
mandibular vein: it will
unite with the posterior
oracular vein to form the
EJV.
To remember :
EJV
extension: from the
angle of the mandible to
the middle 3rd of the
clavicle
muscle relations : deep
to the platysma muscle
superficial to SCM.
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the great auricular nerve : cuz there is no lesser only great
one, from the anterior ramie of C2,C3. innervate the skin over
the angle of the mandible which is part of the face not the neck
so in the facial surgeon after anesthetizing the sensation of the
face from the trigeminal nerve (V) we have to anesthetize this
location cuz it has a different nerve. and innervate the skin
over the parotid gland (the larges salivary gland ) then
to the lower part of the auricle especially the lobule where U
put the ear rings ;)
transverse cervical or Cutaneous nerve to the anterior triangle
supra clavicular nerve to the upper half of the shoulderand
skin over the clavicle
2- Brachial Plexus
Roots and trunks arising from C5-T1 passing through the scalene
hiatus btween scalenus anterior and scalenus medius to go to the
axilla as it passing there you can see the trunks of the brachial
plexus mainly the upper ,the middle and the lower trunks.
3- Spinal accessory n.
the eleventh cranial nerve (XI) arises from the spinal cord
from the upper five segments it goes up and enter inside
the skull through foramen magnum and get out from the jugular
foramen as it leaves it is classify as cranial nerve. then it goes
deep to the SCM it gives a branch to the SCM , after that it leaves
the SCM to appears at the posterior triangle of the neck.then it
goes deep to the trapezius muscle and innervate it.

the accessory n. is a land mark it helps to know the muscle that
located under it which is levator scapulae muscle
You have to know those
4 nerves , their origins
and what area they give
sensation to !!
All of them have been
discussed in previous
lec. in details :)
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so as a quick revision the posterior triangle contents are :
4 arteries:
3
rd
part of subclavian --> anteroinf. angle
Transverse cervical a.(superficial cervical)
Suprascapular a. --> inf. to transverse cervical
Occipital a. --> at apex of triangle
5 veins :
EJV
Occipital v.
Transverse cervical v.
Suprascapular v.
Subclavian v.
3 types of nerves :
Cutaneous Nerves --> 4 nerves
Spinal accessory n.( XI)
Brachial Plexus THE END

Baraah Al-Salamat , Asmaa Al-Mawas
If U find any mistake plz forgive us, but we will NOT if U dont tell us about it
plz correct the name of the third group in the slides "slide #13" to become Spinal accessory n.
instead of spinal division of accessory n. ,if u asked why?!
previously we used to classify accessory n. ( the cranial nerve XI) into two parts one arising from
the spinal cord "spinal root" and the other arising from the brain "cranial root" BUT in the
recent years this is wrong bcuz the cranial root is now part of the vagus n. (X) so we dont have
cranial and spinal we just name it accessory or spinal accessory.
BTW , this nerve changed the definition of the cranial nerves they are NO more the nerves that
arise from the brain because the XI arising from the spinal cord so to redefine the cranial nerves:
Cranial nerves : any nerve passing through skull foramina or cranial openings