Cervical Fascia Research Articles

Isolated right subclavian artery injury with fractured right first rib following blunt trauma chest

Blunt chest trauma uncommonly results in subclavian artery injuries which are protected by subclavius muscle, clavicle, first rib and deep cervical fascia. Subclavian artery injury presents early after trauma. It may rupture to cause haemorrhage, pseudo-aneurysm and brachial plexus compression. Careful physical evaluation of the upper limb is warranted to look for skin colour, temperature, sensation, motor function and radial artery pulses. Serious vascular injury should be suspected if there is presence of large hematomas or pulsatile mass in supraclavicular region. Contrast-CT represents a key diagnostic investigation, while arteriography offers both a diagnostic a therapeutic approach in case endovascular stenting could be contemplated. But surgical repair is preferred mode of management over endovascular stenting in children as it is difficult to manoeuvre a stent in small children and also because stent does not grow with the vessel leading to size mismatch. We report a case of traumatic 2 nd part of right subclavian arterial rupture after blunt trauma chest with fracture involving right first rib following a 10 meters fall from height, treated by open surgical repair of injured right subclavian artery with an interposition 5 mm PTFE graft.

Incomplete Ring of Cervical Abscesses

Cervical fascia and spaces can mobilize the spread of infections which are localized at first. Knowledge about these spaces and their relations are indispensable for the correct treatment of the abscesses in the deep neck spaces.

Re-visiting the Gordinsky and Holyoke anatomical model. Primary mediastinal pathology progressing to the deep cervical fascia. A unique clinical presentation

Introduction: The compartments and layers of the deep cervical fascia have been extensively described in well known anatomical models that correlate well with clinical practice. In the descriptions proposed by Gordinsky and Holyoke only the space that exists between the prevertebral and alar fascia is in potential continuity with the mediastinum. Cervicofacial infection may start in a retropharyngearl or paraphyrngeal compartment and is thought to gain access to the “danger space” through direct extension before progression down to the mediastinum.

Posterior stabilization of the cervical spine with lateral mass screws.

First we performed a closed reduction and ACDF C6–7. After a week, additional posterior stabilization and monosegmental fusion was indicated to provide optimal stability and a good restoration of cervical spine lordosis. Patient is placed in a prone position fixing the head with a Mayfield clamp. Lateral X-ray is helpful for confirming good alignment of the cervical spine. A posterior midline incision is performed down to cervical fascia. Fascia is opened and a subperiosteal exposure of posterior osseous structures C6–7 is performed with electrocautery. Staying in the midline within the ligamentum nuchae helps to avoid bleeding from neck muscles. Care has to be taken not to harm the facet joints that are not intended to be fused. Medial and lateral border of lateral masses are identified. C-arm is positioned laterally to visualize facet joints. Starting points for lateral mass screws are defined by Magerl [2, 3] 2 mm medial and 2 mm caudal to the center of the lateral mass. Cortex is opened by a 1–2 mm burr. The screw trajectory is about 25 –30 lateral and 20 –40 upwards, parallel to the orientation of the facet joint in the

Clavicle pain and reduction of incisional and fascial pain after posterior cervical surgery.

Incisional pain after posterior cervical spine surgery can be severe and very unpleasant to the patient. Ongoing incisional pain is one of the key disadvantages of posterior over anterior surgical approaches to the cervical spine. It prolongs hospital stays and delays return to work. In this study, the hypothesized that incisional pain in the immediate postoperative period is caused partially by tension on the skin as well as on the deep cervical fascia and the fascia overlying the trapezius, which are usually sewn together during closure. Reduction of this tension through retraction of the shoulders should therefore reduce pain as well as the amount of pain medication used in the early postoperative period. In this prospective randomized controlled study, 30 patients who had undergone posterior cervical spine surgery were randomized into 2 groups who either wore or did not wear a clavicle brace to retract the shoulders. Patients in the brace group began wearing the brace on postoperative day (POD) 4 and wore it continuously throughout the 30-day study period. Outcome was assessed by two measures: 1) the daily level of self reported pain according to the visual analog scale (VAS) and 2) the number of pain pills taken during the 30-day postoperative period. Wearing a clavicle brace in the immediate postoperative period significantly reduced incisional pain and the amount of pain medication that patients took. Beginning on POD 4 and continuing until day POD 13, the mean daily VAS score for pain was significantly lower in the brace group than in the control group. Furthermore, patients who wore the clavicle brace took less pain medication from POD 4 to POD 12. At this point the difference lost significance until the end of the study period. Four patients were randomized but did not tolerate wearing the brace. Patients who tolerated wearing the clavicle brace after posterior cervical spine surgery had reduced pain and used less pain medication.

교통 사고 10일 후 발생한 쇄골하 동맥 가성동맥류 1례

둔상에 의한 쇄골하 동맥 가성동맥류의 발생은 드물며, 관통상 이후에 이차적으로 발생하는 경우가 있다. 대게 쇄골하 동맥은 주변의 인대, 근막뿐만 아니라 쇄골, 첫 번째 갈비뼈, 심부 경부 조직들에 의해 보호받고 있어 둔상으로 의한 합병증으로 쇄골하 동맥의 손상이 발생하는 경우는 드물다. 쇄골하 동맥의 손상은 외상 초기에 나타나며, 동맥 파열은 생명을 위협할 수 있는 출혈, 가성동맥류 형성, 상완신경총 압박 등을 유발할 수 있다. 쇄골하 동맥 손상은 쇄골골절, 총상, 관통상이나 중심정맥삽관 같은 술기의 합병증으로 발생하는 것이 대부분이다. 쇄골 주변의 큰 혈종이나 맥박이 느껴지는 종괴가 있다면 심각한 혈관 손상 가능성이 높아지므로 이러한 소견이 있는지 이학적 검사를 통해 확인해야만 한다. 1993년에 외상성 혈관손상의 치료에 있어 혈관 내 스텐트 삽입 시술이 처음 발표된 이후 혈관내 스텐트 삽입 시술을 통해 외상성 혈관 손상을 치료하는 사례가 점차적으로 많아지고 있다. 이 연구는 교통사고 10일 후에 발생한 쇄골하 동맥 가성동맥류 환자에서 혈관내 스텐트 삽입을 통한 성공적 치료와 관련된 임상양상과 추정되는 병태생리에 대해 보고한 사례연구이다. The subclavian artery pseudoaneurysm in blunt trauma is uncommon and rarely occurs secondary to penetrating injury. Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-threatening hemorrhages, pseudoaneurysm formation and compression of brachial plexus. Most injuries were related to clavicle fracture, gunshot, other penetrating trauma, and complication of central line insertion. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury and these clinical evidences must be carefully worked out by physical examination of the upper limb. Since the first reports of endovascular treatment for traumatic vascular injuries in the 1993, an increasing number of vascular lesions have been treated this way. We report a case of subclavian artery pseudoaneurysm 10 days after blunt chest trauma due to traffic accident, treated by endovascular stent grafting.

Is the cervical fascia an anatomical proteus?

The cervical fasciae have always represented a matter of debate. Indeed, in the literature, it is quite impossible to find two authors reporting the same description of the neck fascia. In the present review, a historical background was outlined, confirming that the Malgaigne's definition of the cervical fascia as an anatomical Proteus is widely justified. In an attempt to provide an essential and a more comprehensive classification, a fixed pattern of description of cervical fasciae is proposed. Based on the morphogenetic criteria, two fascial groups have been recognized: (1) fasciae which derive from primitive fibro-muscular laminae (muscular fasciae or myofasciae); (2) fasciae which derive from connective thickening (visceral fasciae). Topographic and comparative approaches allowed to distinguish three different types of fasciae in the neck: the superficial, the deep and the visceral fasciae. The first is most connected to the skin, the second to the muscles and the third to the viscera. The muscular fascia could be further divided into three layers according to the relationship with the different muscles.

The Disposition of Radiocontrast in the Interscalene Space in Healthy Volunteers.

We measured the spread of radiocontrast in the interscalene space after injection under low (<15 psi) and high (>20 psi) pressures. Nine healthy volunteers received ultrasound-guided injections of 10 mL radio-opaque NaCl 0.9% in both interscalene spaces. Spread of injectate as assessed by computed tomography scan and discomfort on injection were recorded. Under both opening pressure conditions, injectate contacted 3 brachial plexus roots and spilled over the surface of the anterior and/or middle scalene muscles underneath the cervical fascia. Regardless of injection pressure, the interscalene space was filled with 10 mL of radiocontrast injectate.

Level IIb CTV delineation based on cervical fascia anatomy in nasopharyngeal cancer

We carefully reviewed magnetic resonance (MR) images from 100 consecutive NPC patients and analyzed the lymph node distribution status at level IIb. We proposed several modifications of the existing consensus guidelines for determining the level IIb clinical target volume (CTV) in NPC patients.

Anaesthetic management of Ludwig's angina with comorbidities.

Ludwig's angina is a rapidly progressing necrotising cellulitis affecting the posterior oropharynx, submaxillary and sublingual spaces. It can cause elevation and displacement of the tongue resulting in airway obstruction. Death in such cases occurs due to airway compromise.[1] The most common cause is tooth extraction or dental infection. It can be complicated by airway compromise or extension into the mediastinum or extension into deeper soft tissues like cervical fascia.[2] The treatment involves appropriate antibiotics, airway control and surgical intervention (incision and drainage).

Postburn neck anterior contracture treatment in children with scar-fascial local trapezoid flaps: a new approach.

One of the dramatic consequences of burns is scar contracture and deformities of the neck. Cervical contracture in children is especially dangerous, leading to face disfigurement and kyphosis; therefore, early reconstruction is indicated. Despite the existence of many various surgical techniques, the successful neck contracture treatment in pediatric patients remains a challenge for surgeons. Eleven children (aged 5 to 14 years) with postburn neck anterior contractures were studied to develop a new approach for reconstruction that would employ the use of local scar-fascial flaps. The new approach and technique for postburn pediatric contracture treatment was developed which is especially effective in the treatment of children who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration. The technique consists of two trapezoid scar-fascial flaps mobilization which includes all the anterior neck surfaces and consists of scars, fat layer, platysma, and deep cervical fascia. Counter transposition of flaps with tension elongated neck anterior surface was 100 to 200%. The contracture was fully eliminated, and neck contours, mentocervical angle, and head movement were restored. In case of severe contracture, residual wound in submandibular region and above clavicles were skin-grafted. The full range of head motion (functional results) was achieved in all the 11 patients. The flaps continued to grow and the skin grafts shrinkage was moderate. Local trapeze-flap plasty allows neck contracture elimination in children in the cases when a more complex technique is impossible or undesirable to use. Early surgical intervention prevents secondary complications, allotting enough time for patients to mature and be ready for more complex procedures.

Extraskeletal Ewing Sarcoma in a Young Patient During Pregnancy

Background: Ewing’s sarcoma is usually identified as a primary malignancy of the bone affecting children and young adults. It is associated with soft tissue extension in 90% of cases. Primarily extraskeletal Ewing’s sarcoma is a rare subtype, and very few data are available concerning optimal treatment modalities. Case Presentation: We report a case of an 18 year-old female from Cabo Verde in her 34th week of pregnancy presenting with a rapid growing cervical tumor. It had initially started as an indolent swelling at the left cervico-posterolateral region. CT had shown involvement of both superficial and deep cervical fascia. At time of presentation, the histologic diagnosis of a peripheral Primitive Neuroectodermal Tumor/Extraskeletal Ewing’s sarcoma had already been provided. To reduce risk of fetal metastasis, the child was delivered by caesarean section. A chest CT of the patient revealed pulmonary metastasis and compressive atelectasis of the left lung caused by the tumor. Three weeks post partum, she presented with loss of muscular function of the extremities as well as parestesia and bladder dysfunction. A repeat CT confirmed medullar compression at the level of C5-C6, C6-C7 and C7-D1 by the tumor without signs of bone metastasis. 5 sessions of palliative radiotherapy were performed that led to parcial recovery of muscular function of the upper right extremity. Palliative chemotherapy was refused, so that the patient was released from hospital. No metastasis had been detected in the child so far. Conclusion: Extraskeletal Ewing’s sarcoma can manifest as a rapidly growing localized mass causing local compression symptoms. Palliative radiotherapy can achieve local tumor reduction and symptom relief.

Treatment and prognosis of deep neck infections.

Deep neck infections could have serious threats for life of patients, if not noticed adequately. Early diagnosis and correct treatment planning can save the patient's lives and prevent complications of disease extension and also surgical procedures that in some instances may be performed in an emergent situation with higher complication rates. Herein, we have studied 815 cases of deep neck abscesses and infections with especial consideration to treatment and prognosis. In a retrospective case review, we studied 815 cases admitted in our medical center from 1998 until the year 2013. Only patients with abscesses or infections deeper than superficial layer of deep cervical fascia were included in this study, based on the review of their medical records. From 815 cases (485 males and 330 females) surgery was indicated and performed in 428 cases and the rest were treated medically. In cases with dental infections as the etiologic factor, dental procedures were performed as early as possible (extraction in almost all cases). Tracheostomy was performed in five cases. All of the patients in medical treatment group and most of the surgically managed patients were discharged while were stable with relative or complete resolution of their symptoms. One of our patients, a 15year old boy died with symptoms suggestive for mediastinitis and air way compromise. Early diagnosis and medical management can be effective in treating deep neck infections. Dental infections and also procedures are the major cause in our patients, although tonsillitis and peritonsillar abscess also were important leading causes with almost equal numbers in our series. Extraction of the infected tooth as early as possible while medical treatment is continued can be very helpful. In some cases it may be necessary to perform surgical exploration of the neck more than once, and finally, malignant neoplasia, somewhere in the head and neck should be considered in some cases, as in one of our patients with left side submandibular abscess whose underlying disorder was tongue SCC with neck metastasis. Prognosis can be excellent in both medically and surgically managed groups if started and designed early and promptly.

Esthetic and functional surgery and reconstruction after oral cancer ablation

Oral cancer ablation surgery results in tissue defects with functional loss. Accompanying neck dissection results in facial nerve weakness and dysmorphic changes. To minimize the complications after oral cancer surgery, accurate dissection without damaging facial nerve and vital structures are mandatory. Marginal mandibular branch of facial nerve should be dissected or contained in the superficial layer of deep cervical fascia to minimized facial palsy after operation. Reconstruction after cancer ablations is routine procedures and free flap reconstruction is the most commonly used. Radial forearm free flap is the most versatile flap to reconstruct soft tissue defects and it is easy to design according to the defect size and shape. However, donor site scar and secondary skin graft from thigh result in unesthetic and cumbersome wounds. Double layered collagen graft in the donor site could reduce secondary donor site for skin graft. In conclusion, oral and maxillofacial surgeon should know the exact anatomy of the face and neck during neck dissection. Radial forearm free flap is most versatile flap for soft tissue reconstruction and double collagen graft can reduce postoperative scar and there is no need for secondary skin graft.

The esthetic surgical management of a submandibular fascial space infection of odontogenic origin

Background Odontogenic infections are common complications in dental practice and can sometimes spread through the cervical fascia and cause abscesses of the deep fascial spaces. Some of these abscesses can be life threatening. Early diagnosis of these deep fascial abscesses and aggressive antimicrobial and surgical treatment with extensive drainage are of utmost importance. The aim of this presentation is to show the clinical characteristics of a submandibular fascial space abscess and its esthetic, minimally-invasive surgical management.

Deep plane facelifting for facial rejuvenation.

The purpose of this article is to provide the facial plastic surgeon with anatomical and embryologic evidence to support the use of the deep plane technique for optimal treatment of facial aging. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented. The following points will be further elucidated in the article. The platysma muscle/submuscular aponeurotic system/galea are the continuous superficial cervical fascia encompassing the majority of facial fat, and this superficial soft tissue envelope is poorly anchored to the face. The deep cervical fascia binds the structural aspects of the face and covers the facial nerve and buccal fat pad. Facial aging is mainly due to gravity's long-term effects on the superficial soft tissue envelope, with more subtle effects on the deeper structural compartments. The deep plane is the embryologic cleavage plane between these fascial layers, and is the logical place for facial dissection. The deep plane allows access to the buccal fat pad for treatment of jowling. Soft tissue mobilization is maximized in deep plane dissections and requires careful hairline planning. Flap advancement creates tension only at the fascia level allowing natural, tension-free skin closure, and long-lasting outcomes. The deep plane advancement flap is well vascularized and resistant to complications.

Lymph node metastasis in the suprasternal space from thyroid papillary cancer

The suprasternal space is a narrow space between the superficial and deep layers of the investing layers of the deep cervical fascia above the manubrium of the sternum. The suprasternal space has been paid little attention as a space with the potential for lymph node metastasis from both thyroid cancer and head and neck cancer. We experienced 2 patients who were found to have a lymph node in the suprasternal space preoperatively. Both of them had well-differentiated thyroid papillary carcinomas and level III and IV lymph node metastases as well as metastasis in the suprasternal space. We have not previously dissected the suprasternal space prophylactically in other patients with thyroid papillary cancer, but no patient has developed metastasis in this space to date. The suprasternal space is not usually dissected in patients with thyroid cancer. However, suprasternal space metastasis has been reported to occur occasionally in patients with lymph node metastases in levels III and IV. We consider that dissection of the suprasternal space, which is not routinely performed, should be done when preoperative examination suggests lymph node metastasis in the suprasternal space as dissection of this space is less invasive, easy to achieve, and is not time consuming. Greater attention should be paid to the suprasternal space as an area with the potential for lymph node metastasis from thyroid cancer.

AB0856 Ultra Sonographic Confirmation of Enthesitis in Patients with Fibromyalgia

BackgroundAiming to evaluate whether the clinical overlap identified and presented before [1] between enthesitis sites (ES) and Fibromyalgia (FM) tender points (TeP) in patients with Inflammatory back pain corresponds to...

AB0878 Heterotopic Ossifications after Cervical Fasciitis: about 26 Cases

BackgroundHeterotopic ossifications are lamellar bone formations within soft tissues. They can occur after trauma, orthopedic surgery, neurologic injuries, burns, hematoma, necrosis or even spontaneously. They can have major functional consequences....

The spread of infection through the danger space to the mediastinum case report

Abstract Deep neck infection is an infection in the potential space and fascial planes of the neck, either with abscess formation or cellulitis. Cervical fascias create space and plane, which define and limit the spread of infection. Danger space is the area of thin connective tissue extending from the skull base down to the diaphragm. This space is enclosed on all sides, therefore inflammation in this area arises from penetration and spreads of infection from surrounding structures. This risk is in the rapid spread of infection in the chest, due to the low resistance of thin connective tissue. Formation of the descending necrotizing mediastinitis is the most common and most feared complication of danger space. Authors describe a case of extensive dental infection that despite intensive surgical and antibiotic treatement spread to other anatomical areas and caused descending necrotizing mediastinitis.