Neck fascia according to international nomenclature. Fascia of the neck

SUPERFICIAL FASCIA OF THE NECK(fascia cervicalis superficialis) - the subcutaneous fascia forms a case for the subcutaneous muscle of the neck, upwards it passes into the superficial fascia of the head, downwards into the superficial fascia of the chest and back.

SUPERFICIAL PLATE OF THE PROPRIETARY FASCIA OF THE NECK(lamina superficialis fascia cervicalis propria) - forms cases for the sternocleidomastoid and trapezius muscles, gives spurs to the transverse processes of the cervical vertebrae and divides the neck into anterior and posterior sections. At the top it is attached to the lower edge of the lower jaw, at the bottom - to the anterior surface of the manubrium and clavicles.

DEEP PLATE OF PROPRIETARY FASCIA OF THE NECK(lamina profunda fascia cervicalis propria, Richet aponeurosis) - forms cases for the muscles lying below the hyoid bone. At the top it is attached to the hyoid bone, at the bottom - to the posterior surface of the manubrium of the sternum and clavicles. Along the midline, midway between the jugular notch of the sternum and the hyoid bone, it fuses with the superficial plate.

INTRACERVICAL FASCIA(fascia endocervicalis) - consists of parietal and visceral plates. The parietal plate forms cases for the neurovascular bundle of the neck. The visceral plate covers the organs of the neck (pharynx, esophagus, larynx, trachea, thyroid gland).

PRESPINAL FASCIA(fascia prevertebralis) - starts from the base of the skull and passes behind the pharynx. Attaches to the transverse processes of the cervical vertebrae and forms an osteofibrous sheath for the deep muscles of the neck. Below it reaches the level of the third thoracic vertebra.

NECK TOPOGRAPHY

MEDIAL TRIANGLE OF THE NECK(trigonum colli mediale) - part of the anterior region of the neck, limited by the midline, the anterior edge of the sternocleidomastoid muscle and the lower edge of the lower jaw. Includes the carotid, submandibular and scapulotracheal triangles.

SLEEPY TRIANGLE(trigonum caroticum) - limited by the anterior edge of the sternocleidomastoid muscle, the superior belly of the omohyoid muscle and the posterior belly of the digastric muscle.

Scapular-tracheal triangle(trigonum omotracheale) - limited by the midline, the anterior edge of the sternocleidomastoid muscle and the upper belly of the omohyoid muscle.

SUBMANDIBULAR TRIANGLE(trigonum submandibulare) - limited by the lower edge of the lower jaw, the anterior and posterior bellies of the digastric muscle.

PIROGOV TRIANGLE(trigonum linguale, syn. - lingual triangle) – a small triangle within the submandibular, bounded by the intermediate tendon of the digastric muscle, the posterior edge of the mylohyoid muscle and the hypoglossal nerve. The place of isolation and ligation along the lingual artery, described by N.I. Pirogov.

LATERAL TRIANGLE OF THE NECK(trigonum colli laterale) - limited by the edge of the trapezius muscle, the posterior edge of the sternocleidomastoid muscle and the clavicle. Includes the scapuloclavicular and scapuloclavicular triangles.

SCULA-TRAPEZIOUS TRIANGLE(trigonum omotraprzoideum) - limited by the edge of the trapezius muscle, the posterior edge of the sternocleidomastoid muscle and the lower belly of the omohyoid muscle.

SCULAVOCLAVICULAR TRIANGLE(trigonum omoclaviculare) - limited by the clavicle, the lower belly of the omohyoid muscle and the posterior edge of the sternocleidomastoid muscle.

WHITE LINE OF THE NECK(linea alba colli) - fusion of the deep and superficial layers of the neck's own fascia along the anterior midline from the hyoid bone to a point located 2-3 cm above the jugular notch of the sternum.

SUPRASTERAL INTERAPONEUROTIC SPACE(spatium interaponeuroticum suprasternale) - located above the jugular notch of the sternum between the superficial and deep layers of the own fascia of the neck. It rises up 2-3 cm, where the above-described leaves grow together. Laterally passes into the blind sac of Gruber. Contains loose tissue, lymph nodes and jugular venous arch. The latter may be damaged when performing a lower tracheotomy.

PRE-ORGAN SPACE(spatium previscerale) - located between the parietal and visceral plates of the intracervical fascia in front of the larynx and trachea. Below it passes into the tissue of the anterior mediastinum. Contains fiber, lymph nodes, isthmus of the thyroid gland, azygos thyroid veins and in 10-12% the azygos thyroid artery.

REPOSITORY ORGAN SPACE(spatium retroviscerale) - located between the parietal plate of the intracervical fascia and the prevertebral fascia, behind the pharynx and esophagus. Extends from the base of the skull to the tissue of the posterior mediastinum. The upper section is called the retropharyngeal space. Here are located the fiber, internal carotid arteries, initial segments of the glossopharyngeal, vagus, accessory and glossopharyngeal nerves.

PREVERTEBRAL SPACE(spatium prevertebrale) - located between the prevertebral fascia and the cervical vertebrae. Descends down to the third thoracic vertebra. Contains the long muscles of the head and neck, the anterior and lateral rectus capitis muscles and the cervical section of the borderline sympathetic trunk.

MANDIBULAR FOSSA(fossa retromandibularis) - a space limited behind by the mastoid process, above by the external auditory canal, in front by the posterior edge of the ramus of the mandible, the medial styloid process and the muscles starting from it. The fossa is filled with the parotid salivary gland.

The contours of the sternocleidomastoid muscle make it easy to determine the boundaries of the region of the same name, dividing the anterior region of the neck into medial and lateral triangles (Fig. 50). The medial triangle is formed by the midline, the base of the mandible and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the edge of the trapezius muscle. The lateral triangle is divided into the scapuloclavicular and scapular-trapezoid triangles. The terms are formed from the name of the omohyoid muscle, which forms one of the sides of the triangle, and the name of the muscle, which is involved in the formation of only one of the triangles.

By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior part of the neck is divided into the suprahyoid and infrahyoid regions. The muscles of the suprahyoid region are essentially the floor of the mouth. In the suprahyoid region, three triangles are distinguished: the unpaired mental triangle, the sides of which are formed by the hyoid bone and the two anterior bellies of the digastric muscles; paired submandibular triangle formed by the base of the lower jaw and both bellies of the digastric muscles. In the sublingual region, the scapular-tracheal and carotid triangles are distinguished.

The practical significance of the neck triangles is obvious - in each of them certain surgically important elements are projected. However, the use of these triangles allows one to navigate only in two-dimensional (planimetric) space, and the surgeon must clearly understand the position of an organ or vessel in three-dimensional space. This is facilitated by knowledge of the location of the fascia. Fascia on the neck are well developed and quite numerous. Due to the complexity of their structure, the presence of numerous spurs and partitions, muscle receptacles, etc., the topography of the neck fascia is covered differently in different manuals. According to international anatomical nomenclature (PNA) on the neck there is one fascia, which splits into four leaves or plates: superficial, pretracheal, prevertebral plates and carotid vagina(Fig. 51).

Rice. 51. Classification of neck fascia.

More often, topographic anatomists use the classification of fascia by Academician V.N. Shevkunenko, which is based on a genetic approach to their study. By origin, fascia is divided into connective tissue, formed as a result of compaction of fiber around muscles, blood vessels and nerves; muscle, formed in place of reduced muscles; coelomics, which are formed from the internal lining of the embryonic cavity. In accordance with this classification V.N. Shevkunenko distinguishes five independent fasciae on the neck, which, for ease of presentation, he proposed to name by serial number: the first fascia of the neck ( superficial fascia), second fascia of the neck (superficial layer of own fascia), third fascia of the neck (deep layer of own fascia), the fourth fascia of the neck, which has parietal and visceral layers (intracervical fascia), the fifth fascia of the neck (prevertebral fascia) (Fig. 52).

The first and third fascia are of muscular origin, the second and fifth are of connective tissue origin, and the fourth fascia (intracervical) is of coelomic origin.

Rice. 52. Fascia of the neck on horizontal and sagittal sections (diagram). 1 – superficial fascia; 2 – superficial layer of the neck’s own fascia; 3 – trapezius muscle; 4 – sternocleidomastoid muscle; 5 – scapuloclavicular aponeurosis (Richet); 6 – neurovascular bundle of the neck (common carotid artery, internal jugular vein, vagus nerve); 7 – omohyoid muscle; 8 – intracervical fascia; 9 – prevertebral fascia; 10 – esophagus; 11 – subcutaneous muscle of the neck; 12 – thyroid gland; 13 – trachea; 14 – sternohyoid and sternothyroid muscles. A: 1 – sternum; 2 – superficial fascia; 3 – own fascia; 4 – suprasternal interaponeurotic space; 5 – scapuloclavicular aponeurosis; 6 – previsceral cellular space; 7 – isthmus of the thyroid gland; 8 – intracervical fascia; 9 – thyroid cartilage; 10 – epiglottis; 11 – hyoid bone; 12 – tongue; 13 – lower jaw; 14 – esophagus. Superficial fascia, or first fascia, represents part of the superficial fascia of the body. It is located deeper than the subcutaneous fatty tissue and in the anterolateral sections forms a sheath for the subcutaneous muscle, continuing along with its fibers onto the face, and below into the subclavian region. In the posterior part of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous fatty tissue into numerous cells, and therefore in this area the development of carbuncles with extensive necrosis of the tissue, reaching the fascial sheaths of the muscles, is possible.

Superficial layer of the cervical fascia, or the second fascia, in the form of a dense sheet, surrounds the entire neck and forms fascial sheaths for the sternocleidomastoid and trapezius muscles, as well as a capsule for the submandibular salivary gland. At the bottom it is attached to the sternum and clavicle, at the top - to the lower jaw, and from the sides - with frontally extending spurs - it is attached to the transverse processes of the cervical vertebrae and anatomically divides the neck into two sections, anterior and posterior. This is of great practical importance, since a dense fascial plate isolates purulent processes either only in the anterior or posterior sections of the neck. The same spurs connect this fascia with the prevertebral fascia and the sheath of the neurovascular bundle of the neck, which are also attached to the transverse processes of the cervical vertebrae.

Deep layer of the cervical fascia, or third fascia, covers only part of the neck. It has the shape of a trapezoid (or sail) and is stretched between the hyoid bone above and the posterior surface of the clavicles and sternum below and is also called the scapuloclavicular aponeurosis (Richet aponeurosis). Along the lateral borders, the third fascia forms a sheath for the omohyoid muscles, and near the midline of the neck, the second and third fascia (and sometimes the fourth) grow together, forming the so-called white neck line 2-3 mm wide. The supporting role of the white line of the neck for anatomical formations located along the midline is quite obvious.

Intracervical fascia, or the fourth fascia according to Shevkunenko, has two leaves: parietal and visceral. The visceral leaf forms fascial sheaths for the organs of the neck: larynx, trachea, esophagus, thyroid gland. The parietal layer surrounds the entire complex of organs of the neck and forms a fascial sheath for the main neurovascular bundle of the neck, consisting of the common carotid artery, internal jugular vein and vagus nerve. Inside this vagina, connected to the transverse processes of the cervical vertebrae, there are septa that form separate fascial sheaths for the artery, vein and nerve. In the vertical direction, the intracervical fascia continues upward to the base of the skull (along the walls of the pharynx), and descends downwards along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia.

prevertebral fascia, or fifth fascia, located on the spine behind all the organs of the neck. It is well developed and forms osteofascial sheaths for the long muscles of the head and neck. At the top, the fascia is attached in the region of the pharyngeal tubercle of the occipital bone on the outer base of the skull, and at the bottom, gradually thinning, it reaches the III-IV thoracic vertebrae. In the lateral region of the neck, this fascia forms sheaths for the scalene muscles, as well as fascial sheaths for the neurovascular formations located there (subclavian artery, vein and trunks of the brachial plexus). The phrenic nerve passes through the prevertebral fascia and the cervical sympathetic trunk is located.

Applied significance of fascia is determined not only by the fact that they limit the cellular spaces and crevices in which the suppurative process can develop and which will be described below, but also by their connection with the neurovascular formations. For penetrating chest wounds, to prevent pleuropulmonary shock, they often resort to a vagosympathetic blockade on the neck, the technique of which requires knowledge of the surgical anatomy of the fourth and fifth fascia in relation to the vagus nerve and sympathetic trunk. In addition, it should be recalled that the fascia of the neck is firmly connected to the walls of the veins, which does not allow the veins to collapse when injured. Therefore, damage to the veins of the neck is dangerous because, due to the proximity of the right atrium and the suction action of the chest, an air embolism may occur.

Depending on the direction of the fascial sheets, the formation of spurs by them and connections with bones or adjacent fascial sheets cellular spaces on the neck divided into two groups: closed and unclosed.

To the closed cellular spaces of the neck include the suprasternal interaponeurotic space, the sheath of the submandibular gland and the sheath of the sternocleidomastoid muscle. To open cellular spaces include: previsceral, retrovisceral, prevertebral, carotid vagina, cellular space of the lateral neck.

Suprasternal interaponeurotic space- the middle cellular space in the sublingual region of the neck, formed by the second and third fascia of the neck, attached to the outer and inner edges of the manubrium of the sternum (Fig. 53). This space contains a large amount of fiber and a jugular venous arch, on the sides it communicates with the paired blind sac (Gruber's pouches), lying behind the sternocleidomastoid muscle. The cecum contains the terminal section of the anterior jugular vein, lymphatic vessels and sometimes lymph nodes. If there is pus in this space, an “inflammatory collar” is observed. Drainage of the suprasternal interaponeurotic space can be carried out by a longitudinal or transverse incision directly above the upper edge of the manubrium of the sternum.

Case of the submandibular gland– a fascial receptacle formed by splitting the second fascia of the neck, one of the leaves of which is attached to the base of the jaw, the second to the mylohyoid line. This case contains the submandibular salivary gland, submandibular lymph nodes, facial artery and vein. Purulent processes (lymphadenitis) usually do not spread to adjacent areas due to the density of the walls of the fascial sheath. However, it should be borne in mind that there is a weak spot in the posterior part of the case, as a result of which, if surgical intervention is delayed, pus breaks through into the deep peripharyngeal cellular space.

Sheath of the sternocleidomastoid muscle also formed by splitting the second fascia of the neck. Phlegmons developing within this case are characterized by a form of infiltration corresponding to the contours of the sternocleidomastoid muscle, as well as muscle rigidity, manifested by torticollis. Due to compression of the vessels supplying the muscle, the process may transition to a necrotic form.

Previsceral cellular space located between the parietal and visceral leaves of the fourth fascia (Fig. 54). Its lower part, corresponding to the trachea, is called the pretracheal cellular fissure. In this space, in addition to fiber, there are the unpaired thyroid venous plexus, lymph nodes and, in 5-10% of cases, the inferior thyroid artery.

Cellulitis of the previsceral cellular space is observed as a consequence of injury or damage to the larynx and trachea (for example, cartilage fractures), as well as inflammatory processes in the thyroid gland. Below, at the level of the manubrium of the sternum, the pretracheal cell gap is separated from the anterior mediastinum by a fragile septum formed by the transition of the parietal layer of the fourth fascia from the posterior surface of the sternum to the visceral layer of the trachea. In purulent processes, this septum cannot serve as a serious obstacle to the spread of pus into the anterior mediastinum (anterior mediastinitis develops). When a tracheostomy is performed and the cannula is not tightly inserted into the trachea, air may enter the previsceral space (mediastinal emphysema).

Retrovisceral cellular space located between the visceral layer of the fourth fascia, surrounding the pharynx and esophagus, and the prevertebral fascia. This space communicates freely above with the retropharyngeal space, and below with the posterior mediastinum. When the esophagus is injured or its wall is perforated by a foreign body, the infection penetrates into the retrovisceral space and can descend into the posterior mediastinum, with the development of posterior mediastinitis. Pus accumulating in the pre- and retrovisceral cellular spaces can perforate the trachea, pharynx, and esophagus.

Prevertebral cellular space– deep osteofibrous space located between the cervical vertebrae and the prevertebral fascia. In this space lie the long muscles of the neck and the sympathetic trunk. Abscesses developing under the prevertebral fascia are usually a consequence of tuberculous lesions of the cervical vertebrae (strain abscesses) and can spread down into the retropleural tissue. Having destroyed the leaves of the prevertebral fascia, pus can penetrate into the lateral region of the neck and further along the subclavian artery and brachial plexus to reach the axilla.

Cellular space of the neurovascular bundle is a powerful fascial sheath with a large amount of loose connective tissue enveloping the main neurovascular bundle of the neck (common carotid artery, internal jugular vein and vagus nerve). This fascial sheath contains lymph nodes and reaches at the top to the base of the skull, and at the bottom it passes into the anterior mediastinum. Phlegmon of the cellular space of the neurovascular bundle is usually observed when the infection passes from neighboring parts of the neck, often through the lymphatic vessels, while the spread of pus occurs up and down the course of the vessels and nerves. A serious complication with these phlegmons is the melting of the vessel wall with subsequent bleeding.

Cellular space of the lateral neck enclosed between the superficial layer of the proper fascia and the prevertebral fascia, i.e. between the second and fifth fascia according to Shevkunenko (there is no fourth fascia in the lateral region of the neck, and the third is located only within the scapuloclavicular triangle). Medially this space is limited by the carotid sheath, and laterally by the edge of the trapezius muscle. It is separated from the axillary fossa by numerous jumpers that connect the second fascia of the neck with the heel in the clavicle area. In addition to fatty tissue, in the lateral space of the neck there are lymph nodes, blood and lymphatic vessels, and nerves, along which this space communicates with the scapular and axillary regions and with the deep sections of the anterior neck.

The fifth fascia of the neck forms fascial sheaths around the subclavian artery and brachial plexus. Surrounded by a fascial sheath, the subclavian neurovascular bundle penetrates the interscalene space and is further directed to the subclavian and axillary regions. It should be recalled that the subclavian vein is separated from the artery by the anterior scalene muscle. Phlegmon of paravasal tissue along the subclavian vessels and brachial plexus can be complicated by leakage into the armpit.

When large vessels are injured, the gushing blood exfoliates the paravasal tissue along with the fascia, resulting in the formation of a blood-filled pulsating hematoma, and then the formation of a false aneurysm. Thus, phlegmons of the neck, developing both in superficial and deep cellular spaces, pose a serious danger. They are characterized, as a rule, by severe intoxication, up to a septic state, and may also be accompanied by the spread of purulent leaks along interfascial gaps and cellular spaces into adjacent anatomical areas (anterior and posterior mediastinum, subclavian and axillary regions, etc.) (Fig. 55) . Inflammatory infiltrates and tissue swelling often lead to compression of the trachea, narrowing of the lumen of the larynx, and the development of suffocation. Purulent melting of the artery wall can cause fatal bleeding.

The main principle of treatment of neck abscesses is a timely incision, ensuring a wide opening of all pockets in which pus can accumulate. The incision should be made strictly in layers, be atraumatic and, if possible, cosmetic. When choosing the direction of the incision, it is necessary to take into account the location of large vessels, the course of fascial sheets, and skin folds. After dissecting the superficial tissues, blunt instruments should be used to open the pockets to avoid damage to blood vessels, especially veins, the walls of which become loose and sometimes thin when inflamed. It must be remembered that the walls of the neck veins are connected to the fascia, so when damaged, the veins do not collapse, which contributes to air embolism.

Rice. 56. Topography of anatomical formations in the submandibular and carotid triangles. 1 – posterior belly of the digastric muscle; 2 – internal carotid artery; 3 – external carotid artery; 4 – stylohyoid muscle; 5 – submandibular vein; 6 – facial artery and vein; 7 – submandibular lymph nodes; 8 – mental vein; 9 – submandibular gland; 10 – mylohyoid muscle; 11 – anterior belly of the digastric muscle; 12 – lingual artery; 13 – anterior jugular vein; 14 – hyoid bone; 15 – sternohyoid muscle; 16 – upper belly of the omohyoid muscle; 17 – thyrohyoid muscle; 18 – thyrohyoid membrane; 19 – thyroid gland; 20 – sternocleidomastoid muscle; 21 – common carotid artery; 22 – neck loop; 23 – superior thyroid artery and vein; 24 – superior laryngeal nerve; 25 – facial vein; 26 – deep cervical lymph nodes; 27 – upper root of the cervical loop; 28 – vagus nerve; 29 – hypoglossal nerve; 30 – internal jugular vein; 31 – external jugular vein and accessory nerve; 32 – parotid gland. Surgical anatomy of the triangles of the neck

The applied significance of the neck triangles described above is obvious, since each of them projects certain surgically important anatomical objects that are directly related to the surgeon’s activities. For a more detailed understanding of the topography of the neck, it is necessary to consider certain areas separately.

Suprahyoid region in clinical practice it is better known as submandibular. The area consists of paired submandibular triangles and an unpaired mental triangle, bounded by the digastric muscle. Since the muscles of the suprahyoid region are essentially the floor of the mouth, this region is functionally connected with the head region, in particular with the maxillofacial region. The skin of this area is mobile, easily stretchable and has almost the same color as the skin of the face. These skin qualities, which also have hair, are widely used in plastic surgery on the face.

The submandibular triangle is used for more precise orientation in the topography of the submandibular gland and its excretory duct (Fig. 56).

Submandibular salivary gland fills the gap between the bellies of the digastric muscle and the lower jaw. The bed of the gland is formed by the muscles that form the bottom of the submandibular triangle (mylohyoid and hyoid-lingual) and the lower jaw. The capsule of the gland is formed by the second fascia of the neck, which is divided into two sheets: the superficial one is attached to the base of the lower jaw, and the deep one to the mylohyoid line; below, at the level of the hyoid bone, both sheets are connected. Thus, the upper part of the gland is adjacent directly to the periosteum of the lower jaw in the region of the submandibular fossa. Around the gland and in its thickness there are lymph nodes, the presence of which necessitates the removal of not only the submandibular lymph nodes, but also the salivary gland itself during metastases of cancerous tumors (for example, the lower lip and tongue). The excretory duct of the gland (Whartonov) starts from its inner surface and penetrates into the gap between the mylohyoid and mylohyoid muscles and further under the mucous membrane of the floor of the mouth, where it opens on the sublingual papilla. The lingual artery penetrates into the same gap above the duct, and below the duct the hypoglossal nerve, accompanied by the lingual vein. The blood vessels of the tongue and the intermuscular gap may be the anatomical route through which pus from phlegmon of the floor of the mouth descends into the area of ​​the submandibular triangle.

The relationship between the gland and the facial vessels is very important from a practical point of view. The facial artery and vein cover the gland on both sides: in this case, the artery passes through the bed of the gland, adjacent to its inner surface, and the vein – to the outer surface. Both vessels can also become an anatomical route for the transfer of pus from the neck to the lateral area of ​​the face.

Sometimes exposure and ligation of the lingual artery is required to stop bleeding in case of damage to the tongue or as a preliminary step for its removal (for a tumor). To find the lingual artery, use it as a guide Pirogov triangle, the boundaries of which are above and laterally - the hypoglossal nerve, below - the intermediate tendon of the digastric muscle, medially - the edge of the mylohyoid muscle. The bottom of the triangle is formed by the hyoglossus muscle. The lingual artery is located between the hyoglossus muscle and the deeper middle pharyngeal constrictor. Behind the middle constrictor of the pharynx is the mucous membrane of the pharynx, so when trying to expose the artery, great care is necessary, since it is possible, through the mucous membrane, to penetrate into the pharyngeal cavity and infect the surgical field.

Currently, ligation of the lingual artery is preferred not in Pirogov's triangle, but at the place where it originates from the external carotid artery behind the posterior belly of the digastric muscle.

When a purulent focus is localized in the bed of the submandibular gland, the incision is made parallel to the edge of the lower jaw, 3-4 cm below. After dissecting the skin, subcutaneous tissue and the first fascia of the neck, the surgeon penetrates deep into the gland case in a blunt manner. The cause of such phlegmon can be carious teeth, the infection from which penetrates into the submandibular lymph nodes. Within the mental triangle, incisions are made for phlegmon of the floor of the mouth in order to drain pus and to remove the mental lymph nodes for a malignant tumor of the tongue (lip). The safest cut in this triangle is considered to be the midline incision between the two anterior bellies of the digastric muscle.

The lateral triangle of the neck is divided into the scapuloclavicular and scapuloclavicular triangles.

Scapuloclavicular triangle bounded anteriorly by the posterior edge of the sternocleidomastoid muscle, posteriorly by the anterior edge of the lower belly of the omohyoid muscle, and inferiorly by the clavicle. In the area of ​​the scapuloclavicular triangle, the external jugular vein passes superficially in a vertical direction, flowing into the jugular venous angle, and the subcutaneous supraclavicular nerves from the cervical plexus. Deeper in the triangle is prescaler interval, located between the anterior scalene and sternocleidomastoid muscles and containing the subclavian vein, phrenic nerve and lymphatic duct. Between the anterior and middle scalene muscles, located interstitial space, which is of great practical importance, since the subclavian artery and brachial plexus pass through it. Moreover, below, adjacent to the first rib, there is first an artery, and above it are the trunks of the brachial plexus. Therefore, when ligating the subclavian artery in the supraclavicular fossa, at the exit of the vessel from the interscalene space, one should carefully differentiate the elements of the neurovascular bundle, since there are known cases of erroneous ligation of one of the trunks of the brachial plexus instead of the artery. To temporarily stop bleeding from the arteries of the upper limb in the supraclavicular fossa, you can press the subclavian artery to the tubercle of the anterior scalene muscle on the first rib.

Thus, in the scapuloclavicular triangle there are a number of important anatomical objects on which surgical interventions are performed. Here the subclavian artery is accessed, but ligating it often causes disruption of the blood supply to the upper limb due to insufficient development of collateral circulation. Anesthesia of the brachial plexus using the Kulenkampff method is performed during operations on the upper limb. For this purpose, the needle is inserted one transverse finger above the middle of the clavicle (downwards, medially and back) until pain appears, which indicates that the tip of the needle has reached the brachial plexus. When paresthesia appears, 10-20 ml of a 2% novocaine solution is injected, after 20 minutes the operation can be performed. In addition, in the left scapuloclavicular triangle, the thoracic duct is ligated for lymphorrhea, or it is catheterized for lymphosorption.

Scapular-trapezoid triangle bounded anteriorly by the sternocleidomastoid muscle, posteriorly by the edge of the trapezius muscle, and inferiorly by the lower belly of the omohyoid muscle. In this triangle is held vagosympathetic blockade according to Vishnevsky, which aims to prevent or relieve developing pleuropulmonary shock that occurs with injuries to the chest wall (with the presence of pneumothorax) and complex operations on the organs of the chest cavity. With the head turned in the opposite direction, the needle is inserted at the level of the hyoid bone at the intersection of the posterior edge of the sternocleidomastoid muscle with the external jugular vein. The muscle, together with the vessels located under it, is moved inward with the left index finger. The long corner is injected upward and inward to the front surface of the spine, adding a solution of novocaine along the way. Then the needle is pulled away from the spine by 0.5 cm so that the solution does not get under the prevertebral fascia (bursting pain) and 40-50 ml of a 0.25% novocaine solution is injected. Spreading in the form of a creeping infiltrate along the prevertebral fascia, the novocaine solution comes into contact with the epineurium of the vagus nerve and sympathetic trunk, and often the phrenic nerve. The higher the novocaine solution is distributed, the more reliably the nerve blockade is achieved. The effectiveness of the vagosympathetic blockade according to Vishnevsky is judged by the appearance of Horner-Claude Bernard syndrome in patients (retraction of the eyeball, narrowing of the pupil and palpebral fissure, as well as hyperemia with increased skin temperature of the face on the side of the blockade).

Anesthesia of the branches of the cervical plexus is carried out behind the middle of the sternocleidomastoid muscle, since in this place the main cutaneous nerves of the plexus enter the subcutaneous tissue: the great auricular nerve, which goes up to the region of the external ear and mastoid process; supraclavicular nerves innervating the inferolateral region of the neck; the small occipital nerve, which goes back and up to the occipital region and the transverse cervical nerve - to the midline of the neck.

Sternocleidomastoid region corresponds to the projection of the muscle of the same name. Behind the sternocleidomastoid muscle in the lower half of the region is located scalene-vertebral triangle, which is limited medially by the longus colli muscle, laterally by the anterior scalene muscle, below by the dome of the pleura, and the apex of the triangle is the transverse process of the VI cervical vertebra (Chassaignac's carotid tubercle). The staircase-vertebral triangle contains a segment of the subclavian artery with the beginning of its branches: the thyrocervical trunk, the vertebral and internal thoracic arteries, the vertebral vein, the arch of the thoracic duct on the left, as well as the parasympathetic and sympathetic nerves and sympathetic ganglia connecting the thoracic cavity with the neck area. In front of the formations lying in the scalene-vertebral triangle, the neurovascular bundle of the medial triangle of the neck passes. The internal jugular vein, which is part of it, forms an extension - the lower bulb of the internal jugular vein and connects with the subclavian vein to form the venous angle. A number of lymphatic trunks flow into each of the venous angles (Pirogov), and the thoracic duct flows to the left.

Sublingual area divided into carotid and scapulotracheal triangles.

Sleepy triangle bounded above by the posterior belly of the digastric muscle, externally by the anterior edge of the sternocleidomastoid muscle and below by the superior belly of the omohyoid muscle. Within the carotid triangle, the location of the exit of the main neurovascular bundle of the neck from under the anterior edge of the sternocleidomastoid muscle is determined. In addition, the bifurcation of the common carotid artery is located in it, and here several large arterial branches depart from the external carotid artery. The practical significance of the carotid triangle is associated with the possibility of digitally pressing the carotid artery to the transverse process of the VI cervical vertebra, if necessary, to stop bleeding and expose in this area both the main trunk of the common carotid artery, its bifurcation, and the first large branches of the external carotid artery. From the point of view of clinical anatomy, it is important to know the relationship of the neck organs to the main neurovascular bundle. The lateral lobes of the thyroid gland cover it almost completely, and sometimes only partially. The edges of the esophagus and trachea are 1.0-1.5 cm away from the neurovascular bundle.

Inside the neurovascular bundle, the common carotid artery is located medially. Outside the artery lies the internal jugular vein, which has a significantly larger diameter. Between these vessels and behind, in the groove between them, lies the vagus nerve. The superior root of the hypoglossal nerve lies on the anterior surface of the common carotid artery, along which it descends to the infrahyoid muscles of the neck, innervating them. In the carotid triangle, forced ligation of all three carotid arteries is performed when they are injured or, only the external carotid, as a preliminary step to prevent bleeding during operations on the face or tongue.

The bifurcation of the common carotid artery is most often located at the level of the upper edge of the thyroid cartilage (in 48% of cases). However, you need to know that with a short and wide neck, the level of division of the common carotid artery into external and internal is above the upper edge of the thyroid cartilage, and with a long and narrow neck, it is lower. To identify the external and internal carotid arteries, the following signs are used: the topography of the arteries is “reverse” to the name (the internal carotid artery is usually located outward); branches arise from the external carotid artery, while the internal carotid artery in the neck does not give branches; temporary ligation of the external carotid artery leads to the disappearance of pulsation of the superficial temporal and facial arteries, which is easily determined by palpation. Forced ligation of the common or internal carotid artery when injured leads to death in 30% of cases due to severe cerebrovascular accidents (insufficiency of anastomoses in the area of ​​the large arterial circle of the brain), while ligation of the external carotid artery is safer.

Scapulotracheal triangle bounded superiorly and laterally by the superior belly of the omohyoid muscle, inferiorly and laterally by the sternocleidomastoid muscle, and medially by the midline of the neck. Within the triangle lies a number of vital organs: the larynx, trachea, thyroid and parathyroid glands, and blood vessels. The following surgical interventions are performed here: partial or complete removal of the larynx; tracheostomy or conicotomy - dissection of the cricothyroid ligament (it is performed if it is necessary to urgently open the larynx in the absence of instruments intended for tracheostomy); resection of the thyroid gland, etc.

The upper border of the neck runs along the lower edge of the lower jaw, the apex of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra.

The most important organs - the trachea, esophagus, thyroid gland, neurovascular bundles, thoracic duct - are located in the anterior part of the neck, separated from the posterior by a frontal plane passing through the transverse processes of the cervical vertebrae. In the back of the neck there are only muscles enclosed in dense fascial sheaths and adjacent to the cervical vertebrae.

The neck is divided into anterior, lateral, posterior and sternocleidomastoid (within the boundaries of the muscle of the same name) regions.

Anterior neck area(regio colli anterior) is limited: from above - by the lower edge of the lower jaw, from below - by the upper edge of the manubrium of the sternum, from the sides - by the anterior edges of the sternocleidomastoid muscles. The horizontal plane passing through the hyoid bone divides the region into the suprahyoid and subhyoid regions. In the lateral upper parts of the anterior neck, between the suprahyoid and subhyoid regions, there are carotid triangles.

Suprahyoid region(regio suprahyoidea) is bounded above by the lower edge of the lower jaw, below by the hyoid bone, and on the sides by the posterior bellies of the digastric muscles. Within the region, two paired submandibular triangles and the submental triangle located between them are distinguished.

Submandibular triangle(trigonum submandibulare) is limited by the lower edge of the lower jaw and the bellies of the digastric muscle. Within this triangle is Pirogov’s triangle, bounded in front by the posterior edge of the mylohyoid muscle, above by the hypoglossal nerve, below and behind by the tendon and posterior belly of the digastric muscle.

Submental triangle(trigonum submentale) is limited laterally by the anterior bellies of the digastric muscles, in front by the lower jaw, and behind by the hyoid bone.

Sublingual area(regio infrahyoidea) is bounded above by the hyoid bone, below by the jugular notch of the manubrium of the sternum, and on the sides by the anterior edges of the sternocleidomastoid muscles and the omohyoid muscles. The anterior midline divides the subhyoid region into two scapular-tracheal triangles (trigonum omotracheale).

Carotid or omohyoid triangle(trigonum caroticum) is limited by the posterior belly of the digastric and stylohyoid muscles, the anterior edge of the sternocleidomastoid muscle and the superior belly of the omohyoid muscle.

Lateral neck area(regio colli lateralis) is limited: in front by the posterior edge of the sternocleidomastoid muscle, behind by the anterior outer edge of the trapezius muscle, below by the clavicle. The scapulohyoid muscle divides the area into two triangles: the scapular-clavicular (trigonum omoclaviculare), or supraclavicular fossa (fossa supraclavicularis major) and the scapular-trapezoid (trigonum omotrapezoideum).

Posterior neck area(regio colli posterior) is limited: from above - by the superior nuchal line and the external occipital tubercle; from below – a line passing through the acromial processes of the scapula and the spinous process of the VII cervical vertebra; from the sides by the edges of the trapezius muscles.

The practical significance of the triangles is obvious - in each of them certain surgically important elements are projected, for example, in the scapuloclavicular triangle - the subclavian artery and brachial plexus, in the lower part of the sternocleidomastoid region - the common carotid artery, the vagus nerve and the internal jugular vein, here is the cervical part of the thoracic duct, in the carotid triangle - the common carotid artery and its bifurcation, etc. However, the use of these triangles allows one to navigate only in two-dimensional (planimetric) space, and the surgeon must clearly understand the position of an organ or vessel in three-dimensional space. This is facilitated by knowledge of the location of the fascia.

Fascia

The fascia of the neck has a complex structure, different origins and individual expression. On the one hand, they envelop the muscles, vessels, nerves and organs of the neck, forming fascial bags and vaginas for them, on the other hand, they limit the cellular spaces, preventing or facilitating the spread of purulent-inflammatory processes within the neck and into neighboring areas.

There are several classifications of neck fascia. For surgical purposes, the description of the neck fascia according to V.N. Shevkunenko, which is based on a genetic approach, is most convenient.

According to their origin, all fascia are divided into three groups:

Fascia of connective tissue origin, formed as a result of compaction of loose connective tissue and fiber around muscles, blood vessels and nerves;

Fascia of muscular origin, formed in place of reduced muscles or flattened and stretched tendons (aponeuroses);

Fascia of coelomic origin, which is formed from the internal lining of the primary embryonic cavity or from the reducing layers of the primary mesenteries.

In accordance with this classification, V.N. Shevkunenko distinguishes 5 fascia on the neck.

Superficial fascia of the neck(fascia colli superficialis) is of muscular origin. It is formed in place of the reduced subcutaneous muscle, which is well developed in many mammals. This fascia is found in all parts of the neck. On the front surface of the neck, this fascia can be separated by accumulations of adipose tissue into several plates, especially in the presence of the so-called double and triple chin in obese people. In the anterolateral sections, the superficial fascia forms a sheath for the subcutaneous muscle. In the posterior part of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous adipose tissue into numerous cells. Due to this structural feature of the subcutaneous fat layer, the development of carbuncles in this area is (sometimes) accompanied by extensive necrosis of the tissue, reaching the fascial sheaths of the muscles. The fascia is part of the general superficial (subcutaneous) fascia of the body and passes without interruption from the neck to neighboring areas.

Superficial layer of the fascia propria of the neck(lamina superficialis fasciae colli propriae) covers the entire neck, covers the muscles above and below the hyoid bone, salivary glands, blood vessels and nerves. At the top it is attached to the upper nuchal line, the mastoid process of the temporal bone, the angle and lower edge of the lower jaw and passes on the face into the parotid-masticatory fascia. Below, the fascia attaches to the anterior edge of the manubrium and the clavicle. In front, along the midline, the superficial fascial layer fuses with the deep layer of the neck's own fascia, forming the so-called linea alba. The superficial layer on each half of the neck runs from the linea alba back to the spinous processes of the cervical vertebrae. Bifurcating, it forms separate fascial sheaths for the sternocleidomastoid and trapezius muscles and a capsule (vagina) of the submandibular salivary gland. The fascia of the neck is of connective tissue origin, since loose connective tissue becomes denser during development around the powerful sternocleidomastoid and trapezius muscles, which are in constant tone. The spurs of the second fascia extending in the frontal direction are attached to the transverse processes of the cervical vertebrae and anatomically divide the neck into two sections - anterior and posterior. This has important practical significance: due to the presence of a dense fascial plate, purulent processes develop in isolation either only in the anterior or only in the posterior sections of the neck.

Deep layer of the cervical fascia(lamina profunda fasciae colli propriae) is of muscular origin. The fascia develops in place of the muscle, which in some animals is located between the hyoid bone, the jugular notch of the sternum and the clavicles (m. cleidohyoideus). During the reduction process, this muscle turned into a thin but dense connective tissue plate stretched between the hyoid bone and the clavicles. The fascia is expressed only in the middle part of the neck, where it is stretched in the form of a trapezoid between the hyoid bone at the top, the posterior edge of the manubrium of the sternum and the clavicles at the bottom, laterally it is limited by the omohyoid muscles and covers only the scapulotracheal, scapuloclavicular triangles and the lower part of the sterno- cleidomastoid region. The leaf forms fascial sheaths for the muscles lying below the hyoid bone, and unites these muscles into a connective tissue-muscular plate, for them it is like an aponeurosis (aponeurosis omoclavicularis) (cervical sail), which stretches with contraction of the omohyoid muscles and promotes venous outflow along the neck veins passing through it and merging with it.

Internal cervical fascia(fascia endocervicalis) is of coelomic origin, encircles the cervical internal organs (pharynx, larynx, trachea, thyroid gland, esophagus, blood vessels). It consists of two layers: visceral, which, covering each of the organs, forms a capsule for them, and parietal, which covers all organs together and forms a sheath for the neurovascular bundle of the neck. The fascia, surrounding the organs of the neck, does not topographically extend beyond the median triangle of the neck and the region of the sternocleidomastoid muscle. In the vertical direction, it continues upward to the base of the skull (along the walls of the pharynx), and descends downward along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia. This leads to an important practical conclusion about the possibility of spread (formation of a leak) of a purulent process from the tissue spaces of the neck into the tissue of the anterior and posterior mediastinum and the development of anterior or posterior mediastinitis.

Prevertebral fascia(fascia prevertebralis) is of connective tissue origin and is a compaction of loose connective tissue around the long muscles of the neck. The fascia covers the prevertebral and scalene muscles in front and, fused with the transverse processes of the vertebrae, forms the vagina for these muscles. Superiorly, the prevertebral fascia begins at the base of the skull behind the pharynx, descends down through the neck and into the posterior mediastinum. Continuing laterally, the fascia forms a sheath (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles.

According to the Paris anatomical nomenclature, all fascia of the neck are united under the name fascia cervicalis, which is divided into three plates:

Superficial plate(lamina superficialis) corresponds to the 2nd fascia according to V.N. Shevkunenko.

Pretracheal plate(lamina pretrachealis) muscles and other formations in front of the trachea and corresponds to the 3rd fascia according to V.N. Shevkunenko.

Prevertebral plate(lamina prevertebralis) corresponds to the 5th fascia according to V.N. Shevkunenko.

The superficial fascia of the neck (according to V.N. Shevkunenko) is considered the epimysium of the subcutaneous muscle. The internal cervical fascia (according to V.N. Shevkunenko) is considered the adventitia of the internal organs.

On the neck there are (according to V.N. Shevkunenko) 5 fascia 1. Superficial fascia(fascia superficialis) is part of the general superficial fascia of the body, forms the fascial sheath of the subcutaneous muscle of the neck. 2. Proprietary fascia of the neck(fascia colli propria) covers the entire neck in the form of a sheath and forms a fascial sheath for the sternocleidomastoid and trapezius muscles. In the lateral sections of the neck, a frontally located plate extends from it deeper, to the transverse processes of the vertebrae, which divides the common fascial sheath into anterior and posterior sections. Above the hyoid bone, the proper fascia of the neck is divided into two layers, forming a fascial sheath for the submandibular salivary gland. The deep layer of this vagina is attached to the mylohyoid line of the lower jaw, and the superficial layer is attached to the base of the lower jaw and passes to the masticatory muscle. At the anterior pole of the gland, these layers grow together, and then the second fascia passes forward over the muscles lying above the hyoid bone. Below the latter, along the midline of the neck, it fuses with the third fascia lying in a deeper layer, forming the linea alba of the neck, and below it attaches to the anterior edge of the manubrium of the sternum and to the anterior superior edge of the clavicle. 3. Scapoclavicular fascia(fascia omoclavicularis). This fascia has the form of a trapezoid: it is attached to the hyoid bone from above, covers both omohyoid muscles from the sides, and below is attached to the posterior edge of the manubrium of the sternum and the posterior edge of the clavicle. The third fascia covers the muscles lying below the hyoid bone, forming a fascial sheath for them. Between the second and third fascia, at the manubrium of the sternum, a suprasternal space (spatium suprasternale), Where is the jugular venous arch located? On the sides, behind the lower end of the sternocleidomastoid muscle, this space becomes blind lateral pockets. 4. Intracervical fascia(fascia endocervicalis) lines the organs of the neck. It distinguishes between two plates: parietal (parietal), which covers the organs of the neck from the outside, lining the cavity of the neck, forms the vagina for the common carotid artery and internal jugular vein, and visceral, forming fascial sheaths for the organs of the neck. Between the parietal and visceral plates a cellular space is formed, in which the anterior section is distinguished - previsceral space (spatium previscerale) and rear - retrovisceral space (spatium retroviscerale). These spaces communicate, respectively, with the anterior and posterior mediastinum.

5. Prevertebral plate(lamina prevertebral) attaches to the transverse processes of the cervical vertebrae. Forms bone-fibrous sheaths of the deep muscles of the neck and fascial sheaths of the scalene muscles.

Fascia of the neck according to V.N. Shevkunenko (horizontal cut; diagram): 1 - trapezius muscle; 2 - posterior scalene muscle; 3 - neurovascular bundle of the neck; 4 - omohyoid muscle; 5 - sternocleidomastoid muscle; 6 - thyrohyoid muscle; 7 - sternothyroid muscle; 8 - subcutaneous muscle of the neck; 9 - larynx; 10 - thyroid gland; 11 - esophagus; 12 - fascial plate separating the anterior section of the neck from the posterior one; fascial leaves: a - I; b - II; c - III; g - IV; d - V

Fascia of the neck (according to International Anatomical Terminology), right view: 1 - chewing fascia; 2, 7 - subcutaneous muscle of the neck (cut and turned away); 3 - submandibular salivary gland; 4 - superficial plate of the fascia of the neck; 5 - suprasternal interaponeurotic space; 6 - clavipectoral fascia; 8, 12 - fascia of the neck; 9 - pretracheal plate of the fascia of the neck; 10 - trapezius muscle; 11 - sternocleidomastoid muscle

42925 0

On the neck there are (according to V.N. Shevkunenko) 5 fascia (Fig. 1).

Rice. 1. Fascia of the neck according to V.N. Shevkunenko (horizontal cut; diagram):

1— trapezius muscle; 2—posterior scalene muscle; 3—neurovascular bundle of the neck; 4 - omohyoid muscle; 5 - sternocleidomastoid muscle; 6—thyrohyoid muscle; 7 - sternothyroid muscle; 8 - subcutaneous muscle of the neck; 9 - larynx; 10 - thyroid gland; 11 - esophagus; 12 - fascial plate separating the anterior section of the neck from the posterior one; fascial leaves: a - I; b - II; c - III; g - IV; d—V

1. Superficial fascia(fascia superficialis) is part of the general superficial fascia of the body, forms the fascial sheath of the subcutaneous muscle of the neck.

2. Proprietary fascia of the neck(fascia colli propria) covers the entire neck in the form of a sheath and forms a fascial sheath for the sternocleidomastoid and trapezius muscles (Fig. 2). In the lateral sections of the neck, a frontally located plate extends from it deeper, to the transverse processes of the vertebrae, which divides the common fascial sheath into anterior and posterior sections. Above the hyoid bone, the proper fascia of the neck is divided into two layers, forming a fascial sheath for the submandibular salivary gland. The deep layer of this vagina is attached to the mylohyoid line of the lower jaw, and the superficial layer is attached to the base of the lower jaw and passes to the masticatory muscle. At the anterior pole of the gland, these layers grow together, and then the second fascia passes forward over the muscles lying above the hyoid bone. Below the latter, along the midline of the neck, it fuses with the third fascia lying in a deeper layer, forming the linea alba of the neck, and below it is attached to the anterior edge of the manubrium of the sternum and to the anterior superior edge of the clavicle.

Rice. 2. Fascia of the neck (according to International Anatomical Terminology), right view:

1 - chewing fascia; 2.7 - subcutaneous muscle of the neck (cut and turned away); 3 - submandibular salivary gland; 4 - superficial plate of the fascia of the neck; 5— suprasternal interaponeurotic space; 6—clavipectoral fascia; 8.12 - fascia of the neck; 9 - pretracheal plate of the fascia of the neck; 10 - trapezius muscle; 11 - sternocleidomastoid muscle

3. Scapoclavicular fascia(fascia omoclavicularis). This fascia has the form of a trapezoid: it is attached to the hyoid bone from above, covers both omohyoid muscles from the sides, and below is attached to the posterior edge of the manubrium of the sternum and the posterior edge of the clavicle. The third fascia covers the muscles lying below the hyoid bone, forming a fascial sheath for them (Fig. 3).

Between the second and third fascia at the manubrium of the sternum is formed suprasternal space(spatium suprasternale), where the venous jugular arch is located. On the sides, behind the lower end of the sternocleidomastoid muscle, this space becomes blind lateral pockets.

4. Intracervical fascia(fascia endocervicalis) lines the organs of the neck (see Fig. 3). It distinguishes between two plates: parietal (parietal), which covers the organs of the neck from the outside, lining the cavity of the neck, forms a vagina for the common carotid artery and internal jugular vein, and visceral, forming a fascial sheath for the organs of the neck. Between the parietal and visceral plates a cellular space is formed, in which the anterior section is distinguished - previsceral space(spatium previscerale) and rear - retrovisceral space(spatium retroviscerale). These spaces communicate, respectively, with the anterior and posterior mediastinum.

5. Prevertebral plate(lamina prevertebralis) is attached to the transverse processes of the cervical vertebrae (see Fig. 3). Forms bone-fibrous sheaths of the deep muscles of the neck and fascial sheaths of the scalene muscles.

Rice. 3.

1 - posterior scalene muscle; 2 - middle scalene muscle; 3 - longus colli muscle; 4 - sternocleidomastoid muscle; 5 - sleepy vagina; 6—lower belly of the omohyoid muscle; 7 - scapuloclavicular fascia; 8—subcutaneous muscle and superficial fascia of the neck; 9 - prevertebral fascia and retrovisceral space; 10 - sternothyroid muscle; 11—sternohyoid muscle; 12— suprasternal interaponeurotic space; 13 - previsceral space; 14—thyroid gland; 15—own fascia of the neck; 16— trachea; 17—esophagus; 18— common carotid artery; 19— internal jugular vein; 20 - vagus nerve; 21 - vertebral artery and veins

Human anatomy S.S. Mikhailov, A.V. Chukbar, A.G. Tsybulkin