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2021 KSRA clavicle innervation
- 1. Innervation of the Clavicle and Implications for Regional Anesthesia Boohwi Hong koho0127@gmail.com 2021. 8.
- 2. UNIV. PROF. Bernhard Moriggl Innsbruck, Austria Department Division of Clinical and Functional Anatomy Position Vice Director Division of Clinical and Functional Anatomy CLAVICLE INNERVATION AND IMPLICATIONS FOR REGIONAL ANAESTHESIA RAPM 2019;44(Suppl 1):A1–A276
- 3. 1.Concept of periosteum innervation 2.Innervation of clavicle 3.Which block technique is BEST? Contents
- 4. KJA 2018 August 71(4): 274-288 Cervical plexus
- 5. C5 C7 C8 C6 T1 Trunk Division Root Cord MC Ax R M U Suprascapular n. Subclavius n. Subscapular n. MBCN, MABCN LPN MPN PC LC MC ST MT IT PD AD AD Brachial plexus
- 6. • 관절의 신경 지배 • 어느 한 관절에 분포되는 신경은 동시에 그 관절을 움직이는 근육에도 분포되어 있고 또한 이 근육이 뼈에 붙는 곳(insertions) 의 표면에 있는 피부에도 분포되고 있는 규칙성을 가짐 Hilton's law
- 7. Reg Anesth Pain Med 2013;38: 539–
- 9. • 1. Terminal branches of motor nerves • (“Muscle-Areas” of periosteum). • 2. Terminal branches of joint nerves • (“Capsule-Adjacent-Areas”) • 3. Branches of cutaneous nerves • (“Muscle-Free-Areas”) • 4. Branches of nerves following nutrient arteries • (“Nutrient-Foramina-Areas”). Innervation of Periosteum
- 10. 1. Terminal branches of motor nerves (“Muscle-Areas” of periosteum) Deltoid: Axillary nerve & Lateral pectoral nerve Trapezius: Spinal accessory nerve & Cervical plexus br. to trapezius Pectoralis M: Pectoral nerve SCM: Spinal accessory nerve, Medial supraclavicular nerve Subclavian: Subclavian nerve Platysma: Facial nerve(?), Cervical plexus
- 11. 2. Terminal branches of joint nerves (“Capsule-Adjacent-Areas”) Lateral pectoral nerves BP (C 5,6,7) Suprascapular nerve BP (C 5,6) Medial supraclavicular nerve Subclavian nerve BP (C 5,6)
- 12. Anesth Analg 2016;122:1704–6 3. Branches of cutaneous nerves (“Muscle-Free-Areas”)
- 13. 3. Branches of cutaneous nerves (“Muscle-Free-Areas”) Medial and Intermediate supraclavicular nerves, CP (C4) (Lateral ?)
- 14. • Lateral pectoral nerve 4. Branches of nerves following nutrient arteries (“Nutrient-Foramina-Areas”).
- 15. a) Medial and Intermediate supraclavicular nerves, CP (C4) (Lateral ?) b) Subclavian nerve, BP (C 5,6) c) Lateral pectoral nerves, BP (C 5,6,7) d) Trapezius branch of cervical plexus, CP (C 3,4) e) Spinal Accessory nerve CN XI SCP Plane f) Suprascapular nerve. BP (C 5,6) Axillary nerve? (C 5,6) Lateral supraclavicular nerve? CP (C4) Innervation of Clavicle periosteum
- 17. • Medial supraclavicular nerves • anterior supraclavicular nerves, suprasternal nerves • Skin as far as the middle line. • Sternoclavicular joint (superficial part) • One or two filaments to Intermediate supraclavicular nerve • Intermediate supraclavicular nerve • middle supraclavicular nerves, supraclavicular nerves • Cross the clavicle, and supply the skin over the pectoralis major and deltoid • Communicating with the cutaneous branches of the upper intercostal nerves. • Lateral supraclavicular nerve • posterior supraclavicular nerves, supra-acromial nerves • Pass obliquely across the outer surface of the trapezius and the acromion • Skin of the upper and posterior parts of the shoulder. Supraclavicular nerves
- 18. • Lateral supraclavicular nerve • Supra-acromial nerves • Under platysma • Did not supply trapezius • AC joint • Before branching or Seperately Surg Radiol Anat (2007) 29:605–610
- 19. 초음파
- 20. Subclavian nerve • Nerve to the Subclavius • Small filament • Arises from the point of junction of the fifth and sixth cervical nerves • The subclavian nerve may give off an accessory phrenic nerve. • Sternoclavicular joint (Deep part)
- 22. Int. J. Morphol., 36(3):817-820, 2018. Subclavian nerve
- 23. Accesspry Phrenic Nerve Acta Medica (Hradec Kralove). 2008;51(3):181-4.
- 24. • Two independent branches enter the lateral surface of the muscle in the posterior triangle. • Join with the spinal accessory nerve • A branch from the second cervical nerve to the sterno-mastoid joins the accessory nerve beneath that muscle • Branches to the trapezius from the third and fourth nerves are connected with the accessory nerve in the posterior triangle • Branches from the same nerves join the nerve beneath the trapezius muscle Trapezius branch of cervical plexus Cunningham's Text-book of anatomy
- 26. C2 and C3 usually joined the spinal accessory nerve prior to its penetration of the trapezius muscle. Fibers containing just C-3 and C-4 innervations generally entered trapezius muscle separately. 3 sides derived from C2 to C4 2 sides had fibers derived from C2 to C3 25 sides had fibers derived from C3 to C4 Motor axons Trapezius branch of cervical plexus J Neurosurg Spine 14:626–629, 2
- 27. Korean J Radiol 2015;16(4):749- Spinal accessory nerve
- 29. Medial Clavicle: SCM 1. Beneath SCM 2. Clavipectoral plane block or Infiltration Lateral Clavicle: Trapezius m. with Trapezius branch of cervical plexus Journal of Clinical Anesthesia 58 (2019) 125–127
- 30. Surg Radiol Anat (2016) 38:917–922 Spinal accessory nerve & N. to Trapezius SAN communicating branch
- 31. ORL 2014;76:8–12 Ann Otol Rhinol Laryngol. 2015 Nov;124(11):881-5.
- 32. SAN n. to Tr Supraclavicular nerve Medial
- 33. Suprascapular nerve J Neurosurg 125:350–354, 2016
- 34. Reg Anesth Pain Med 2019;44:1038. Reg Anesth Pain Med 2019;44:561–564. Lateral Suprascapular nerve
- 35. SUIT • Suprascapular nerve 빠져나오는 동영상 A P S MT 1st rib
- 37. J Shoulder Elbow Surg. 2019 Sep;28(9):1788-1794. Suprascapular nerve 3 sensory br. ① MSAb (medial subacromial branch) • proximal to the suprascapular notch • conoid (*) and trapezoid (**) ligament • subacromial bursa ② LSAb (lateral subacromial branch) • at the level of the suprascapular notch • subacromial bursa ③ PGHb (posterior glenohumeral branch) • distal to the spinal glenoid notch • posterior glenohumeral capsule
- 39. The ACJ was innervated in all 15 specimens by 1–2 articular branches of LPN and by the acromial branch of SSN. Reg Anesth Pain Med 2019;44:452–458. Motor br. : Pectoralis major muscle Pure sensory br. : Continues superior to the acromial branch of the thoracoacromial artery to innervate the anterior superior GHJ and coracoacromial ligament. Reg Anesth Pain Med 2017;42: 564–570
- 40. Clin Anat 2020 Nov;33(8):1152-1158. The clavicular portion of the deltoid muscle received a deltoid branch from the lateral pectoral nerve in 86.2% of cases. Distal splitting Proximal splitting Classic-Ax. n. D br. P br. LPN LPN P br. D br.
- 41. Two pectoral nerves, Three terminal branches LPN, Subpectoral plexus
- 43. Superior branch travelled in a straight course to the pectoralis major to innervate the clavicular aspect. Middle branch coursed on the under- surface of the pectoralis major near the pectoral branch of the thoraco- acromial artery to innervate the muscle’s sternal aspect. Inferior branch passed beneath the pectoralis minor muscle to innervate the pectoralis minor muscle and the costal aspect of the pectoralis major muscle. LPN, Subpectoral plexus
- 44. a) Medial and Intermediate supraclavicular nerves CP (Selcetive) b) Subclavian nerve BP (C5,6) c) Lateral pectoral nerves BP (C5,6,7) d) Trapezius branch of cervical plexus CP (C3,4) e) Spinal Accessory nerve CN XI CP Plane f) Suprascapular nerve BP (C 5,6) Axillary nerve? (C 5,6) Lateral supraclavicular nerve? CP (Selecetive) Innervation of Clavicle periosteum
- 45. Technique • Selective Trunk Block or C5,6,7 RAPM 2021;46:376–378. • Superior trunk block C5,6 • Middle trunk block C7 • Suprascapular n. • Lateral pectoral n. • Subclavian n. • Axillary n. • Supraclavicular nerve block + Infiltration • Medial, Middle, Lateral • N. to Trapezius • Spinal accessory nerve block
Editor's Notes
- 관절에는 많은 감각신경종말(sensory nerve ending)이 분포되어 있다. 이 종말은 관절 주머니와 인대에 주로 퍼져 있으며 관절면을 덮고 있는 연골에는 그 주변인 윤활막에만 약간 있다. 이 종말에서는 관절주머니나 인대가 얼마나 늘어나 있는지 그 상태를 알리는 신호를 끊임없이 중추신경으로 보내 만약 너무 늘어났다고 판단되면 그 관절을 안정시키는 근육을 수축시킬 운동신경 자극을 내려보냄으로써 관절주머니나 인대는 더 이상 늘어나지 않게 하고 이러한 관절주머니나 인대의 늘어남이 도를 넘게 되면 통증을 느끼게 함으로써 휴식을 하도록 유도한다. 관절에서의 이러한 신호는 근육이나 힘줄에서 보내오는 감각 신호와 함께 우리 몸을 능동적으로 움직이게 하거나 몸의 자세를 유지시키는 일을 돕게 된다.
- Skin Muscle free area Sternoclavicular joint Superficial part
- Two independent branches enter the lateral surface of the muscle in the posterior triangle. (4) To the scaleni (medius and posterior), from the third and fourth cervical nerves. The communicating branches are three in number. They join the accessory nerve in three situations:â(a) A branch from the second cervical nerve to the sterno-mastoid joins the accessory nerve beneath that muscle, (b) Branches to the trapezius from the third and fourth nerves are connected with the accessory nerve in the posterior triangle, (c) Branches from the same nerves join the nerve beneath the trapezius muscle.
- These findings support surgical and clinical experiences in which partial or complete trapezius function is maintained after injury to the spinal accessory nerve.
- Most texts will still refer to the accessory nerve as having two components. The fibers arising from the intracranial component is known as the cranial accessory nerve, while those fibers arising from the spinal nucleus are called the spinal accessory nerve. Medial side 수술일때 SCM 을 자극한다면 차단필요 이때는 매우 상위레벨에서 블럭,,,, 하지만 Clavipectorla block이나 소량 injection해주면.. Medial side에
- The sensory branch of the suprascapular nerve, which passed through the scapular notch inferior to the transverse scapular ligament, was found in 100% of the study specimens. J Shoulder Elbow Surg (2011) 20, e13-e17
- Lateral pectoral은 medial에 위치… lateral cord에서 오니까. Pure motor nerve들로 알려져있지만, pectoralis m. 들 주변 관절들(ac joint, sholder joint, clavicle periosteum 등등 ) afferent nociception)이 이 신경들을 통해 전달된다고 함
- Deltoid도 lateral pectral nerve 가 메인 Most standard anatomy books state that the axillary nerve is the exclusive supplier of innervation to the deltoid.
- Spinal origin도 다양 Lateral은 절반은 C 567 절반은 C 67이라고 하고 그 터미널은 두 갈래로… subpectoral plexus를 이룸 Medial pectoral nerve는 pec m. 를 뚫고 나온다고 하지만, 일부 minor 마진을 돌아서 majorfh 들어오기도
- CIBA처럼 알고 있었지만… 실제로는 그 origin 이 매우 다양…lateral은 주로 anterior division(upper middle trunk),, lateral cord는 23퍼센트 정도 나오기도.. Medial pectoral은 medial cord에선 반정도… 나머지는 anterior division level (lower trunk)
- SB는 PM의 clavicle쪽 MB는 우리가 알던 thoracoacromial artery근처에서 같이가는 신경이고 sternal aspect를 담당 IB는 minor 밑에서 가다가 costal 측면을 담당