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article-17473_14	Amoxapine -- Administration -- Specific Patient Populations	Breastfeeding considerations: Limited published data exist on amoxapine use during breastfeeding. Cases of galactorrhea have been observed in non-breastfeeding women using amoxapine. When nursing a newborn or preterm infant, it is advisable to explore alternative agents, such as sertraline, due to its more established safety profile in this context. [17] Pediatric patients: Amoxapine lacks FDA approval for use in pediatric patients.	Amoxapine -- Administration -- Specific Patient Populations. Breastfeeding considerations: Limited published data exist on amoxapine use during breastfeeding. Cases of galactorrhea have been observed in non-breastfeeding women using amoxapine. When nursing a newborn or preterm infant, it is advisable to explore alternative agents, such as sertraline, due to its more established safety profile in this context. [17] Pediatric patients: Amoxapine lacks FDA approval for use in pediatric patients.
article-17473_15	Amoxapine -- Administration -- Specific Patient Populations	Older patients: Clinical studies of amoxapine in individuals 65 and older did not establish whether they exhibit different responses compared to younger subjects. As amoxapine is metabolized by the liver and excreted by the kidney, healthcare providers should exercise caution when prescribing the medication to older patients, considering potential hepatic and renal impairments. According to the American Geriatrics Society (AGS) Beers Criteria, amoxapine is noted for its potent anticholinergic properties. Therefore, its use should be considered only after a meticulous risk-benefit assessment. [18]	Amoxapine -- Administration -- Specific Patient Populations. Older patients: Clinical studies of amoxapine in individuals 65 and older did not establish whether they exhibit different responses compared to younger subjects. As amoxapine is metabolized by the liver and excreted by the kidney, healthcare providers should exercise caution when prescribing the medication to older patients, considering potential hepatic and renal impairments. According to the American Geriatrics Society (AGS) Beers Criteria, amoxapine is noted for its potent anticholinergic properties. Therefore, its use should be considered only after a meticulous risk-benefit assessment. [18]
article-17473_16	Amoxapine -- Adverse Effects	The common adverse effects of amoxapine therapy include, but are not limited to, insomnia, palpitations, tachycardia, hypotension, and constipation. [19] [20] [2] Furthermore, research has indicated that amoxapine may trigger hypomanic states in individuals with underlying bipolar disorder. [19] Amoxapine has been observed to induce noradrenaline-mediated contraction of the urethra in guinea pigs and rats in various laboratory studies, leading to elevated urethral resistance. [21] [22] In addition, the drug has been associated with instances of painful ejaculations relieved by the administration of tamsulosin. [23] Notably, tricyclic antidepressants (TCAs), including amoxapine, are correlated with an increased risk of seizures, especially in older patients and those with epilepsy. [24] [25] Therefore, it is recommended to use SSRIs or SNRIs in patients with a history of epilepsy and seizures.	Amoxapine -- Adverse Effects. The common adverse effects of amoxapine therapy include, but are not limited to, insomnia, palpitations, tachycardia, hypotension, and constipation. [19] [20] [2] Furthermore, research has indicated that amoxapine may trigger hypomanic states in individuals with underlying bipolar disorder. [19] Amoxapine has been observed to induce noradrenaline-mediated contraction of the urethra in guinea pigs and rats in various laboratory studies, leading to elevated urethral resistance. [21] [22] In addition, the drug has been associated with instances of painful ejaculations relieved by the administration of tamsulosin. [23] Notably, tricyclic antidepressants (TCAs), including amoxapine, are correlated with an increased risk of seizures, especially in older patients and those with epilepsy. [24] [25] Therefore, it is recommended to use SSRIs or SNRIs in patients with a history of epilepsy and seizures.
article-17473_17	Amoxapine -- Adverse Effects	Amoxapine's anticholinergic properties can result in adverse effects such as sedation, dry mouth, delirium, and drug-induced Parkinsonism, particularly among older patients. [26] In a few cases, amoxapine has been associated with QTc interval prolongation. [27] Notably, as amoxapine may lead to urinary retention, it is important to exercise caution when prescribing the drug for patients with bladder outlet obstruction. [28]	Amoxapine -- Adverse Effects. Amoxapine's anticholinergic properties can result in adverse effects such as sedation, dry mouth, delirium, and drug-induced Parkinsonism, particularly among older patients. [26] In a few cases, amoxapine has been associated with QTc interval prolongation. [27] Notably, as amoxapine may lead to urinary retention, it is important to exercise caution when prescribing the drug for patients with bladder outlet obstruction. [28]
article-17473_18	Amoxapine -- Adverse Effects -- Drug-Drug Interactions	Amoxapine has the potential to enhance central nervous system depression caused by barbiturates and alcohol. Therefore, concurrent use of the drug with barbiturates and alcohol should be avoided. [29] In a subset of the Caucasian population who are poor metabolizers with reduced CYP2D6 activity, TCAs, such as amoxapine, have increased plasma concentrations. Dose reduction may be necessary when TCAs, such as amoxapine, are combined with CYP2D6-inhibiting drugs, including quinidine, cimetidine, phenothiazines, propafenone, and flecainide. [30]	Amoxapine -- Adverse Effects -- Drug-Drug Interactions. Amoxapine has the potential to enhance central nervous system depression caused by barbiturates and alcohol. Therefore, concurrent use of the drug with barbiturates and alcohol should be avoided. [29] In a subset of the Caucasian population who are poor metabolizers with reduced CYP2D6 activity, TCAs, such as amoxapine, have increased plasma concentrations. Dose reduction may be necessary when TCAs, such as amoxapine, are combined with CYP2D6-inhibiting drugs, including quinidine, cimetidine, phenothiazines, propafenone, and flecainide. [30]
article-17473_19	Amoxapine -- Adverse Effects	All SSRIs exhibit varying degrees of CYP2D6 inhibition. Therefore, clinicians should exercise caution when combining TCAs with SSRIs or making transitions between these 2 classes of medications. In addition, when switching from fluoxetine to amoxapine, a substantial time interval is necessary due to the extended half-life of fluoxetine, which is at least 5 weeks. This precaution helps prevent potential interactions and ensures the safe use of medications. [31]	Amoxapine -- Adverse Effects. All SSRIs exhibit varying degrees of CYP2D6 inhibition. Therefore, clinicians should exercise caution when combining TCAs with SSRIs or making transitions between these 2 classes of medications. In addition, when switching from fluoxetine to amoxapine, a substantial time interval is necessary due to the extended half-life of fluoxetine, which is at least 5 weeks. This precaution helps prevent potential interactions and ensures the safe use of medications. [31]
article-17473_20	Amoxapine -- Contraindications	Amoxapine is contraindicated in patients with a known hypersensitivity to dibenzoxazepine compounds. The primary mechanism of action of amoxapine involves inhibiting the presynaptic reuptake of norepinephrine. Therefore, patients are advised against taking amoxapine concurrently with other antidepressants or medications, such as monoamine oxidase inhibitors (MAOIs), that produce similar effects. Patients should avoid taking the drug within a 14-day window of taking other antidepressants. This period allows the prior antidepressant to be eliminated from the system before initiating amoxapine or any other TCA. Furthermore, due to amoxapine's potential for QTc prolongation, it is not prescribed to patients with extended QTc intervals or those experiencing acute myocardial infarction, as it may worsen their symptoms. [27]	Amoxapine -- Contraindications. Amoxapine is contraindicated in patients with a known hypersensitivity to dibenzoxazepine compounds. The primary mechanism of action of amoxapine involves inhibiting the presynaptic reuptake of norepinephrine. Therefore, patients are advised against taking amoxapine concurrently with other antidepressants or medications, such as monoamine oxidase inhibitors (MAOIs), that produce similar effects. Patients should avoid taking the drug within a 14-day window of taking other antidepressants. This period allows the prior antidepressant to be eliminated from the system before initiating amoxapine or any other TCA. Furthermore, due to amoxapine's potential for QTc prolongation, it is not prescribed to patients with extended QTc intervals or those experiencing acute myocardial infarction, as it may worsen their symptoms. [27]
article-17473_21	Amoxapine -- Contraindications -- Box Warning	Amoxapine has an FDA black box warning for increased suicidality risk in individuals aged 24 and younger and aged 65 and older. Amoxapine is not recommended for the treatment of pediatric depression. [32]	Amoxapine -- Contraindications -- Box Warning. Amoxapine has an FDA black box warning for increased suicidality risk in individuals aged 24 and younger and aged 65 and older. Amoxapine is not recommended for the treatment of pediatric depression. [32]
article-17473_22	Amoxapine -- Contraindications -- Warnings and Precautions	Although amoxapine is effective for certain conditions, it demands vigilant consideration of particular concerns to mitigate potential risks and adhere to essential safety measures associated with its usage. Extrapyramidal adverse effects: Amoxapine's ability to block dopamine receptors increases the risk of experiencing extrapyramidal adverse effects and tardive dyskinesia.	Amoxapine -- Contraindications -- Warnings and Precautions. Although amoxapine is effective for certain conditions, it demands vigilant consideration of particular concerns to mitigate potential risks and adhere to essential safety measures associated with its usage. Extrapyramidal adverse effects: Amoxapine's ability to block dopamine receptors increases the risk of experiencing extrapyramidal adverse effects and tardive dyskinesia.
article-17473_23	Amoxapine -- Contraindications -- Warnings and Precautions	Angle-closure glaucoma: Amoxapine's potential for inducing pupillary dilation is a crucial concern, especially for patients with anatomically narrow angles, as it heightens the risk of angle-closure glaucoma.	Amoxapine -- Contraindications -- Warnings and Precautions. Angle-closure glaucoma: Amoxapine's potential for inducing pupillary dilation is a crucial concern, especially for patients with anatomically narrow angles, as it heightens the risk of angle-closure glaucoma.
article-17473_24	Amoxapine -- Contraindications -- Warnings and Precautions	Seizures: TCAs are also contraindicated in patients with a history of epilepsy or seizures. Instead, individuals who are at risk of seizures should consider taking SSRIs or SNRIs instead of amoxapine, as research indicates that amoxapine may slightly increase the risk of seizures. [25]	Amoxapine -- Contraindications -- Warnings and Precautions. Seizures: TCAs are also contraindicated in patients with a history of epilepsy or seizures. Instead, individuals who are at risk of seizures should consider taking SSRIs or SNRIs instead of amoxapine, as research indicates that amoxapine may slightly increase the risk of seizures. [25]
article-17473_25	Amoxapine -- Contraindications -- Warnings and Precautions	Hepatic impairment: As amoxapine is metabolized in the liver, it is imperative to exercise extreme caution when prescribing this medication to patients with hepatic impairment or active liver disease. [11] Electroconvulsive therapy: The concurrent administration of amoxapine and electroshock therapy may heighten the associated risks of electroconvulsive therapy.	Amoxapine -- Contraindications -- Warnings and Precautions. Hepatic impairment: As amoxapine is metabolized in the liver, it is imperative to exercise extreme caution when prescribing this medication to patients with hepatic impairment or active liver disease. [11] Electroconvulsive therapy: The concurrent administration of amoxapine and electroshock therapy may heighten the associated risks of electroconvulsive therapy.
article-17473_26	Amoxapine -- Contraindications -- Warnings and Precautions	Neuroleptic malignant syndrome (NMS): NMS can arise as a result of antipsychotic drugs, including amoxapine. Clinical manifestations of NMS encompass hyperpyrexia, muscle rigidity, altered mental status, and signs of autonomic instability, such as irregular pulse or labile blood pressure, diaphoresis, and cardiac dysrhythmias. The management of NMS entails the immediate discontinuation of causative medications, including amoxapine, along with vigilant medical supervision and the prompt implementation of supportive care measures. [33] [34]	Amoxapine -- Contraindications -- Warnings and Precautions. Neuroleptic malignant syndrome (NMS): NMS can arise as a result of antipsychotic drugs, including amoxapine. Clinical manifestations of NMS encompass hyperpyrexia, muscle rigidity, altered mental status, and signs of autonomic instability, such as irregular pulse or labile blood pressure, diaphoresis, and cardiac dysrhythmias. The management of NMS entails the immediate discontinuation of causative medications, including amoxapine, along with vigilant medical supervision and the prompt implementation of supportive care measures. [33] [34]
article-17473_27	Amoxapine -- Contraindications -- Warnings and Precautions	Bipolar disorder: The initial manifestation of bipolar disorder can often resemble a major depressive episode. However, a concern prevails that using antidepressant monotherapy, such as amoxapine, can trigger a manic episode in individuals with a predisposition to bipolar disorder. Therefore, it is essential to conduct a thorough assessment of the patient's personal and family history of bipolar disorder and suicide before initiating antidepressant treatment. [35] [36]	Amoxapine -- Contraindications -- Warnings and Precautions. Bipolar disorder: The initial manifestation of bipolar disorder can often resemble a major depressive episode. However, a concern prevails that using antidepressant monotherapy, such as amoxapine, can trigger a manic episode in individuals with a predisposition to bipolar disorder. Therefore, it is essential to conduct a thorough assessment of the patient's personal and family history of bipolar disorder and suicide before initiating antidepressant treatment. [35] [36]
article-17473_28	Amoxapine -- Monitoring	Patients taking amoxapine should undergo regular monitoring for resolution or reduction of symptoms, withdrawal symptoms from abrupt discontinuation, changes in body weight and BMI, blood pressure and blood glucose levels, worsening of depression, the emergence of suicidal thoughts, or unusual behavior at the onset of therapy or during dose adjustments. Older individuals and those with preexisting cardiac disease or hyperthyroidism should undergo a 12-lead electrocardiogram as part of their evaluation. As the older population faces an elevated risk of hyponatremia, necessitating electrolyte monitoring in patients 65 and older is important. [37] Clinicians can monitor patient responses using validated questionnaires such as the patient health questionnaire (PHQ-9) and the Hamilton Rating Scale for Depression. Furthermore, it is crucial to remain vigilant for signs of suicidal ideation. [38] [39]	Amoxapine -- Monitoring. Patients taking amoxapine should undergo regular monitoring for resolution or reduction of symptoms, withdrawal symptoms from abrupt discontinuation, changes in body weight and BMI, blood pressure and blood glucose levels, worsening of depression, the emergence of suicidal thoughts, or unusual behavior at the onset of therapy or during dose adjustments. Older individuals and those with preexisting cardiac disease or hyperthyroidism should undergo a 12-lead electrocardiogram as part of their evaluation. As the older population faces an elevated risk of hyponatremia, necessitating electrolyte monitoring in patients 65 and older is important. [37] Clinicians can monitor patient responses using validated questionnaires such as the patient health questionnaire (PHQ-9) and the Hamilton Rating Scale for Depression. Furthermore, it is crucial to remain vigilant for signs of suicidal ideation. [38] [39]
article-17473_29	Amoxapine -- Toxicity -- Signs and Symptoms of Overdose	The primary concern for TCA toxicity is the potential development of serotonin syndrome, particularly when the medication is combined with other antidepressants such as SSRIs or SNRIs. Serotonin syndrome is characterized by symptoms such as hyperthermia, hypertension, muscle rigidity, and delirium.	Amoxapine -- Toxicity -- Signs and Symptoms of Overdose. The primary concern for TCA toxicity is the potential development of serotonin syndrome, particularly when the medication is combined with other antidepressants such as SSRIs or SNRIs. Serotonin syndrome is characterized by symptoms such as hyperthermia, hypertension, muscle rigidity, and delirium.
article-17473_30	Amoxapine -- Toxicity -- Management of Overdose	In case of TCA or amoxapine overdose, there is no particular antidote available. The primary concern in cases of TCA overdose is ensuring proper respiration and delivering cardiovascular support to patients. Research has demonstrated that, in certain instances, sodium bicarbonate can reduce the incidence of QRS widening. [40] This treatment requires vigilant monitoring of sodium plasma concentrations, as there is a possibility of hypernatremia in patients receiving sodium bicarbonate. However, in the absence of immediate electrolyte changes, the standard protocol involves close monitoring of the patient in the intensive care unit to detect any cardiac abnormalities and ensure adequate hydration to facilitate drug elimination from the system. Analysis of U.S. Poison Control Center data from 2000 to 2014 reveals that amoxapine toxicity may lead to severe complications, including cardiac arrest, renal failure, and intractable seizures. [41]	Amoxapine -- Toxicity -- Management of Overdose. In case of TCA or amoxapine overdose, there is no particular antidote available. The primary concern in cases of TCA overdose is ensuring proper respiration and delivering cardiovascular support to patients. Research has demonstrated that, in certain instances, sodium bicarbonate can reduce the incidence of QRS widening. [40] This treatment requires vigilant monitoring of sodium plasma concentrations, as there is a possibility of hypernatremia in patients receiving sodium bicarbonate. However, in the absence of immediate electrolyte changes, the standard protocol involves close monitoring of the patient in the intensive care unit to detect any cardiac abnormalities and ensure adequate hydration to facilitate drug elimination from the system. Analysis of U.S. Poison Control Center data from 2000 to 2014 reveals that amoxapine toxicity may lead to severe complications, including cardiac arrest, renal failure, and intractable seizures. [41]
article-17473_31	Amoxapine -- Toxicity -- Management of Overdose	In a recent case report, intractable seizures were observed following an amoxapine overdose resulting from a suicide attempt involving the consumption of 3 g of the drug. Despite the administration of intravenous diazepam, levetiracetam, and phenobarbital, the seizures remained uncontrolled. However, the seizures ceased just within 2 minutes of initiating intravenous lipid emulsion (ILE). Although a seizure recurrence occurred 30 minutes after the initial ILE treatment, these seizures were effectively managed through the re-administration of ILE. Therefore, ILE should be considered as a potential intervention for managing severe amoxapine overdose. [42] The prevailing mechanism of lipid emulsion treatment as adjunctive therapy in cases of drug toxicity is based on the hypothesis of lipid shuttling. ILE administration establishes a substantial lipid compartment that efficiently absorbs highly lipid-soluble drugs such as amoxapine, aiding in their removal from the system. [43]	Amoxapine -- Toxicity -- Management of Overdose. In a recent case report, intractable seizures were observed following an amoxapine overdose resulting from a suicide attempt involving the consumption of 3 g of the drug. Despite the administration of intravenous diazepam, levetiracetam, and phenobarbital, the seizures remained uncontrolled. However, the seizures ceased just within 2 minutes of initiating intravenous lipid emulsion (ILE). Although a seizure recurrence occurred 30 minutes after the initial ILE treatment, these seizures were effectively managed through the re-administration of ILE. Therefore, ILE should be considered as a potential intervention for managing severe amoxapine overdose. [42] The prevailing mechanism of lipid emulsion treatment as adjunctive therapy in cases of drug toxicity is based on the hypothesis of lipid shuttling. ILE administration establishes a substantial lipid compartment that efficiently absorbs highly lipid-soluble drugs such as amoxapine, aiding in their removal from the system. [43]
article-17473_32	Amoxapine -- Enhancing Healthcare Team Outcomes	As TCAs, such as amoxapine, are typically reserved as third-line treatments for depression, patients who receive them or are being considered for their use typically exhibit recurrent or reactive depression. This suggests that other medication and treatment approaches have proven ineffective in managing the symptoms of these patients. Consequently, these patients are at an elevated risk of engaging in self-harming and suicidal behaviors. To address these concerns effectively, it is imperative to assemble a cohesive interprofessional healthcare team to oversee their treatment. This team should encompass regular coordination between the patient's primary physician, psychiatrist, and counselors, ensuring adherence to the medication regimen and monitoring the response to treatment. At every office visit, comprehensive assessments for suicidal ideations, plans, or tendencies should be conducted. Appropriate overdose precautions should be initiated if there is any indication that patients pose a risk to themselves or others. [44]	Amoxapine -- Enhancing Healthcare Team Outcomes. As TCAs, such as amoxapine, are typically reserved as third-line treatments for depression, patients who receive them or are being considered for their use typically exhibit recurrent or reactive depression. This suggests that other medication and treatment approaches have proven ineffective in managing the symptoms of these patients. Consequently, these patients are at an elevated risk of engaging in self-harming and suicidal behaviors. To address these concerns effectively, it is imperative to assemble a cohesive interprofessional healthcare team to oversee their treatment. This team should encompass regular coordination between the patient's primary physician, psychiatrist, and counselors, ensuring adherence to the medication regimen and monitoring the response to treatment. At every office visit, comprehensive assessments for suicidal ideations, plans, or tendencies should be conducted. Appropriate overdose precautions should be initiated if there is any indication that patients pose a risk to themselves or others. [44]
article-17473_33	Amoxapine -- Enhancing Healthcare Team Outcomes	Treatment with amoxapine and other antidepressant medications is most effective when managed by an interprofessional healthcare team responsible for all aspects of the patient's case. This team comprises physicians who prescribe and make regimen-related decisions, specialists who provide in-depth condition-specific expertise, specialized nursing staff who oversee care, ensure patient adherence, and assist with monitoring patient symptoms, and pharmacists who conduct medication reconciliation and dosage verification. A retrospective analysis of data from hospitalized patients with poisoning indicates significant reductions in hospitalization duration, healthcare costs, and mortality rates when medical toxicologists actively participate in patient care. [45] All interprofessional team members, including clinicians (MD, DO, NP, and PA), nurses, specialists, toxicologists, and pharmacists, should collaborate and maintain open communication to ensure optimal care and outcomes related to amoxapine therapy.	Amoxapine -- Enhancing Healthcare Team Outcomes. Treatment with amoxapine and other antidepressant medications is most effective when managed by an interprofessional healthcare team responsible for all aspects of the patient's case. This team comprises physicians who prescribe and make regimen-related decisions, specialists who provide in-depth condition-specific expertise, specialized nursing staff who oversee care, ensure patient adherence, and assist with monitoring patient symptoms, and pharmacists who conduct medication reconciliation and dosage verification. A retrospective analysis of data from hospitalized patients with poisoning indicates significant reductions in hospitalization duration, healthcare costs, and mortality rates when medical toxicologists actively participate in patient care. [45] All interprofessional team members, including clinicians (MD, DO, NP, and PA), nurses, specialists, toxicologists, and pharmacists, should collaborate and maintain open communication to ensure optimal care and outcomes related to amoxapine therapy.
article-17473_34	Amoxapine -- Review Questions	Access free multiple choice questions on this topic. Comment on this article.	Amoxapine -- Review Questions. Access free multiple choice questions on this topic. Comment on this article.
article-32313_0	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Introduction	The cervical plexus is a complex neurologic structure located within the head and neck. The large portion of the cervical plexus is the communication between the anterior divisions of C1 through C4 nerves. While the plexus itself can be complex, it is essential for practitioners to understand the significant motor and sensory functions of the cervical plexus as this information can provide valuable information when treating a patient with a possible insult to this area.	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Introduction. The cervical plexus is a complex neurologic structure located within the head and neck. The large portion of the cervical plexus is the communication between the anterior divisions of C1 through C4 nerves. While the plexus itself can be complex, it is essential for practitioners to understand the significant motor and sensory functions of the cervical plexus as this information can provide valuable information when treating a patient with a possible insult to this area.
article-32313_1	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Structure and Function	The function of the cervical plexus is to provide a network of branches that give sensory and muscular innervation to structures within the head, neck, and trunk. Some branches also receive contributions from cranial nerves as they innervate their corresponding tissues. The cervical plexus is more specifically two separate plexuses, one superficial, and the other deep. The superficial plexus is made up of the lateral terminal branches which turn into loops that give the sensory branches of the cervical plexus and become the great auricular nerve, the external acoustic meatus, the transverse cervical nerve, the lesser occipital and supraclavicular nerves. The deep plexus then becomes the muscular branches which include the ansa cervicalis, the phrenic nerve, and various segmental branches. [1]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Structure and Function. The function of the cervical plexus is to provide a network of branches that give sensory and muscular innervation to structures within the head, neck, and trunk. Some branches also receive contributions from cranial nerves as they innervate their corresponding tissues. The cervical plexus is more specifically two separate plexuses, one superficial, and the other deep. The superficial plexus is made up of the lateral terminal branches which turn into loops that give the sensory branches of the cervical plexus and become the great auricular nerve, the external acoustic meatus, the transverse cervical nerve, the lesser occipital and supraclavicular nerves. The deep plexus then becomes the muscular branches which include the ansa cervicalis, the phrenic nerve, and various segmental branches. [1]
article-32313_2	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Embryology	The ventral roots of the spinal nerves are derived originally from the mantle layer of the neural tube. The processes from the neuroblasts in this mantle layer assemble into rootlets that exit in a continuous longitudinal series on the ventrolateral border of the neural tube. The direction taken by the ventral root fibers as they emerge from the tube varies according to the size and position of the ganglion crest. The superficial cervical plexus originally forms by the anterior branch fusion of C2 andC3 which forms the descendens cervicalis; this then unites in a loop with the hypoglossal nerve and together with the first cervical nerve, is incorporated into the plexus. The deep plexus is made up of the lateral terminal branches. [2] While the development of the cervical plexus is a complex process, there has been one major branch of the deep cervical plexus accurately detailed during development, this being the phrenic nerve. During development, the diaphragm develops near the newly developing nerves. Some literature describes the phrenic nerve developing directly ventral to the diaphragm during development. As the fetus continues to grow, the points of origin and insertion of the phrenic nerve draw gradually apart due to the descent of the diaphragm and the elevation of the cervical nerves as it accompanies the development of other structures in the neck. [3]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Embryology. The ventral roots of the spinal nerves are derived originally from the mantle layer of the neural tube. The processes from the neuroblasts in this mantle layer assemble into rootlets that exit in a continuous longitudinal series on the ventrolateral border of the neural tube. The direction taken by the ventral root fibers as they emerge from the tube varies according to the size and position of the ganglion crest. The superficial cervical plexus originally forms by the anterior branch fusion of C2 andC3 which forms the descendens cervicalis; this then unites in a loop with the hypoglossal nerve and together with the first cervical nerve, is incorporated into the plexus. The deep plexus is made up of the lateral terminal branches. [2] While the development of the cervical plexus is a complex process, there has been one major branch of the deep cervical plexus accurately detailed during development, this being the phrenic nerve. During development, the diaphragm develops near the newly developing nerves. Some literature describes the phrenic nerve developing directly ventral to the diaphragm during development. As the fetus continues to grow, the points of origin and insertion of the phrenic nerve draw gradually apart due to the descent of the diaphragm and the elevation of the cervical nerves as it accompanies the development of other structures in the neck. [3]
article-32313_3	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Blood Supply and Lymphatics	While the nerves receive their blood supply through various tributaries throughout their course, the vessels that course near the cervical spinal cord are the vertebral arteries. Additionally, there is one anterior spinal artery, two posterior spinal arteries, an anterior and posterior radicular artery, and an arterial vasocorona. This arterial vasocorona is an anastomosis between the spinal arteries. It consists of the anterior and two posterior spinal arteries, which are direct branches of the two vertebral arteries which form the basilar artery. The anterior spinal artery runs along the anterior median fissure while the two posterior spinal arteries run along the posterolateral sulcus bilaterally. These posterior spinal arteries run along the line of attachment of the dorsal nerve roots. The anterior spinal artery does give off branches that enter the spinal cord through the anterior median fissure. [4]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Blood Supply and Lymphatics. While the nerves receive their blood supply through various tributaries throughout their course, the vessels that course near the cervical spinal cord are the vertebral arteries. Additionally, there is one anterior spinal artery, two posterior spinal arteries, an anterior and posterior radicular artery, and an arterial vasocorona. This arterial vasocorona is an anastomosis between the spinal arteries. It consists of the anterior and two posterior spinal arteries, which are direct branches of the two vertebral arteries which form the basilar artery. The anterior spinal artery runs along the anterior median fissure while the two posterior spinal arteries run along the posterolateral sulcus bilaterally. These posterior spinal arteries run along the line of attachment of the dorsal nerve roots. The anterior spinal artery does give off branches that enter the spinal cord through the anterior median fissure. [4]
article-32313_4	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves	The cervical plexus lies deep to the internal jugular vein and the sternocleidomastoid muscle and on the surface of the scalenus medius and levator scapulae muscle. The nerves are also located laterally to the transverse processes between prevertebral muscles on the medial side and other vertebral muscles from the lateral side. The primary rami, besides C1, divides into two. C1 joins the upper branch of C2, and the adjacent upper and lower branches of C2 and C3, as well as C3 and C4, fuse. The lower branch of C4 joins C5 and contributes to the brachial plexus. The branches emerge from the posterior border of the sternocleidomastoid muscle. [5]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves. The cervical plexus lies deep to the internal jugular vein and the sternocleidomastoid muscle and on the surface of the scalenus medius and levator scapulae muscle. The nerves are also located laterally to the transverse processes between prevertebral muscles on the medial side and other vertebral muscles from the lateral side. The primary rami, besides C1, divides into two. C1 joins the upper branch of C2, and the adjacent upper and lower branches of C2 and C3, as well as C3 and C4, fuse. The lower branch of C4 joins C5 and contributes to the brachial plexus. The branches emerge from the posterior border of the sternocleidomastoid muscle. [5]
article-32313_5	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves	The cutaneous branches of the cervical plexus all emerge near the midpoint of the posterior border of the sternocleidomastoid muscle. One of those nerves, the lesser occipital nerve, originates from C2 and ascends the posterior border of the sternocleidomastoid muscle to supply the skin of the upper neck and the scalp behind the auricle. The great auricular nerve gains innervation from both C2 and C3 ascends across the sternocleidomastoid to reach the skin of the parotid gland on the lateral part of the face just anterior to the auricle. The transverse cervical nerve also has roots from C2 and C3, but it crosses the sternocleidomastoid horizontally, deep to the platysma to supply the skin along the anterior triangle of the neck. Lastly, the supraclavicular nerves, which come from C3 and C4 descend initially as one trunk behind the sternocleidomastoid and then divide near the clavicle to supply the skin over the shoulder and the upper pectoral region. [6] [7]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves. The cutaneous branches of the cervical plexus all emerge near the midpoint of the posterior border of the sternocleidomastoid muscle. One of those nerves, the lesser occipital nerve, originates from C2 and ascends the posterior border of the sternocleidomastoid muscle to supply the skin of the upper neck and the scalp behind the auricle. The great auricular nerve gains innervation from both C2 and C3 ascends across the sternocleidomastoid to reach the skin of the parotid gland on the lateral part of the face just anterior to the auricle. The transverse cervical nerve also has roots from C2 and C3, but it crosses the sternocleidomastoid horizontally, deep to the platysma to supply the skin along the anterior triangle of the neck. Lastly, the supraclavicular nerves, which come from C3 and C4 descend initially as one trunk behind the sternocleidomastoid and then divide near the clavicle to supply the skin over the shoulder and the upper pectoral region. [6] [7]
article-32313_6	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves	The muscular branches pass deeply from the plexus to supply the rhomboids, the serratus anterior, the sternocleidomastoid, the trapezius, levator scapulae, and the scalenus medius. There are also branches that supply the muscles of the suboccipital triangle.	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves. The muscular branches pass deeply from the plexus to supply the rhomboids, the serratus anterior, the sternocleidomastoid, the trapezius, levator scapulae, and the scalenus medius. There are also branches that supply the muscles of the suboccipital triangle.
article-32313_7	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves	The communicating branches contributing to the plexus from the sympathetic nervous system are from the gray ramus communicantes from the superior cervical sympathetic ganglion. The plexus also gives a communicating branch from C1 to the hypoglossal nerve which then almost immediately leaves to supply the geniohyoid and thyrohyoid muscles.	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves. The communicating branches contributing to the plexus from the sympathetic nervous system are from the gray ramus communicantes from the superior cervical sympathetic ganglion. The plexus also gives a communicating branch from C1 to the hypoglossal nerve which then almost immediately leaves to supply the geniohyoid and thyrohyoid muscles.
article-32313_8	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves	The phrenic nerve deserves careful consideration due to its motor, sensory, and sympathetic nerve fibers to the diaphragm. It originates at the lateral border of the scalenus anterior at the level of the upper border of the thoracic cavity and passes anterior to the subclavian artery. [8]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Nerves. The phrenic nerve deserves careful consideration due to its motor, sensory, and sympathetic nerve fibers to the diaphragm. It originates at the lateral border of the scalenus anterior at the level of the upper border of the thoracic cavity and passes anterior to the subclavian artery. [8]
article-32313_9	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Surgical Considerations	Cervical plexus blocks are commonly used in this region to promote anesthesia and regional pain block for surgical procedures in the neck region. Such procedures include cervical fat pad biopsy, lymph node biopsy, or other superficial surgical procedures in the neck. If done correctly, this type of block produces anesthesia over the neck, occipital region, the shoulder region, and the upper pectoral region. Firstly, to achieve this nerve block correctly, it is necessary to inject an analgesic solution subcutaneously around the midpoint of the posterior border of the sternocleidomastoid. It is through this anesthetized skin that the areas lateral to the transverse processes of the second, third, and fourth cervical vertebrae should be infiltrated. Avoiding intrathecal and intravascular injection during this approach is essential. One case study also reported injections into the phrenic and vagus nerves while another showed a Horner syndrome following this procedure. [9]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Surgical Considerations. Cervical plexus blocks are commonly used in this region to promote anesthesia and regional pain block for surgical procedures in the neck region. Such procedures include cervical fat pad biopsy, lymph node biopsy, or other superficial surgical procedures in the neck. If done correctly, this type of block produces anesthesia over the neck, occipital region, the shoulder region, and the upper pectoral region. Firstly, to achieve this nerve block correctly, it is necessary to inject an analgesic solution subcutaneously around the midpoint of the posterior border of the sternocleidomastoid. It is through this anesthetized skin that the areas lateral to the transverse processes of the second, third, and fourth cervical vertebrae should be infiltrated. Avoiding intrathecal and intravascular injection during this approach is essential. One case study also reported injections into the phrenic and vagus nerves while another showed a Horner syndrome following this procedure. [9]
article-32313_10	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Surgical Considerations	If more radical surgical interventions are required, such as dissections of the neck, excision of masses, thyroglossal cysts, operations on the trachea and larynx and even carotid endarterectomy, then local anesthetic must be administered under the carotid sheath. This injection must be under the adventitia of the carotid bifurcation and into the superior angle of the incision. Unfortunately, thyroidectomies are usually not performed using this method as the bilateral blockade gives a choking sensation to the patient and the potential for a bilateral phrenic blockade. [10]	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Surgical Considerations. If more radical surgical interventions are required, such as dissections of the neck, excision of masses, thyroglossal cysts, operations on the trachea and larynx and even carotid endarterectomy, then local anesthetic must be administered under the carotid sheath. This injection must be under the adventitia of the carotid bifurcation and into the superior angle of the incision. Unfortunately, thyroidectomies are usually not performed using this method as the bilateral blockade gives a choking sensation to the patient and the potential for a bilateral phrenic blockade. [10]
article-32313_11	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Clinical Significance	The triangles of the neck are commonly an interest to various surgical subspecialties. Of the triangles of the neck, the posterior triangle is the location of the posterior cervical plexus. It is vital for professional medical staff to be familiar with these structures and their respective functions. Ultrasound is used to identify the cervical plexus during such nerve blocks. As noted above, the most common indications for these blocks is a carotid endarterectomy and also superficial neck surgery.	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Clinical Significance. The triangles of the neck are commonly an interest to various surgical subspecialties. Of the triangles of the neck, the posterior triangle is the location of the posterior cervical plexus. It is vital for professional medical staff to be familiar with these structures and their respective functions. Ultrasound is used to identify the cervical plexus during such nerve blocks. As noted above, the most common indications for these blocks is a carotid endarterectomy and also superficial neck surgery.
article-32313_12	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Review Questions	Access free multiple choice questions on this topic. Comment on this article.	Anatomy, Head and Neck, Posterior Cervical Nerve Plexus -- Review Questions. Access free multiple choice questions on this topic. Comment on this article.
article-24455_0	Lumbar Facet Arthropathy -- Continuing Education Activity	The lumbar zygapophysial joint, otherwise known as facet joint, is a common generator of lower back pain. The facet joint is formed via the posterolateral articulation connecting the inferior articular process of a given vertebra with the superior articular process of the below adjacent vertebra. The facet joint is a true synovial joint, containing a synovial membrane, hyaline cartilage surfaces, and surrounded by a fibrous joint capsule. There is a meniscoid structure formed within the intra-articular folds. The facet joint is dually innervated by the medial branches arising from the posterior ramus at the same level and one level above the joint. This activity describes the pathophysiology, evaluation, and management of lumbar facet arthropathy and highlights the role of the interprofessional team in improving care for affected patients.	Lumbar Facet Arthropathy -- Continuing Education Activity. The lumbar zygapophysial joint, otherwise known as facet joint, is a common generator of lower back pain. The facet joint is formed via the posterolateral articulation connecting the inferior articular process of a given vertebra with the superior articular process of the below adjacent vertebra. The facet joint is a true synovial joint, containing a synovial membrane, hyaline cartilage surfaces, and surrounded by a fibrous joint capsule. There is a meniscoid structure formed within the intra-articular folds. The facet joint is dually innervated by the medial branches arising from the posterior ramus at the same level and one level above the joint. This activity describes the pathophysiology, evaluation, and management of lumbar facet arthropathy and highlights the role of the interprofessional team in improving care for affected patients.
article-24455_1	Lumbar Facet Arthropathy -- Continuing Education Activity	Objectives: Describe the pathophysiology of lumbar facet arthropathy. Outline the components of a proper evaluation and assessment of a patient presenting with lumbar facet arthropathy, including any indicated imaging studies. Explain treatment and management options available for lumbar facet arthropathy. Review the role of improving coordination amongst the interprofessional team to streamline diagnosis, joint reduction, and/or surgery for patients with lumbar facet arthropathy. Access free multiple choice questions on this topic.	Lumbar Facet Arthropathy -- Continuing Education Activity. Objectives: Describe the pathophysiology of lumbar facet arthropathy. Outline the components of a proper evaluation and assessment of a patient presenting with lumbar facet arthropathy, including any indicated imaging studies. Explain treatment and management options available for lumbar facet arthropathy. Review the role of improving coordination amongst the interprofessional team to streamline diagnosis, joint reduction, and/or surgery for patients with lumbar facet arthropathy. Access free multiple choice questions on this topic.
article-24455_2	Lumbar Facet Arthropathy -- Introduction	The lumbar zygapophysial joint, otherwise known as facet joint, is a common generator of lower back pain. The facet joint is formed via the posterolateral articulation connecting the inferior articular process of a given vertebra with the superior articular process of the below adjacent vertebra. The facet joint is a true synovial joint, containing a synovial membrane, hyaline cartilage surfaces, and surrounded by a fibrous joint capsule. [1] There is a meniscoid structure formed within the intra-articular folds. The facet joint is dually innervated by the medial branches arising from the posterior ramus at the same level and one level above the joint.	Lumbar Facet Arthropathy -- Introduction. The lumbar zygapophysial joint, otherwise known as facet joint, is a common generator of lower back pain. The facet joint is formed via the posterolateral articulation connecting the inferior articular process of a given vertebra with the superior articular process of the below adjacent vertebra. The facet joint is a true synovial joint, containing a synovial membrane, hyaline cartilage surfaces, and surrounded by a fibrous joint capsule. [1] There is a meniscoid structure formed within the intra-articular folds. The facet joint is dually innervated by the medial branches arising from the posterior ramus at the same level and one level above the joint.
article-24455_3	Lumbar Facet Arthropathy -- Introduction	The facet joints play an important role in load transmission, assisting in posterior load-bearing, stabilizing the spine in flexion and extension, and restricting excessive axial rotation. Studies before and after facetectomy have shown that the facet joint may support up to 25% of axial compressive forces and 40% to 65% of rotational and shear forces on the lumbar spine. [2] [3] [4]	Lumbar Facet Arthropathy -- Introduction. The facet joints play an important role in load transmission, assisting in posterior load-bearing, stabilizing the spine in flexion and extension, and restricting excessive axial rotation. Studies before and after facetectomy have shown that the facet joint may support up to 25% of axial compressive forces and 40% to 65% of rotational and shear forces on the lumbar spine. [2] [3] [4]
article-24455_4	Lumbar Facet Arthropathy -- Introduction	Facet joint arthrosis is a pathological process involving the failure of the synovial facet joints. [5] Degenerative changes begin with cartilage degradation, leading to the formation of erosions and joint space narrowing, and eventually sclerosis of subchondral bone. Risk factors include advanced age, a sagittal orientation of the facet joint, and concomitant intervertebral disk degeneration. [6]	Lumbar Facet Arthropathy -- Introduction. Facet joint arthrosis is a pathological process involving the failure of the synovial facet joints. [5] Degenerative changes begin with cartilage degradation, leading to the formation of erosions and joint space narrowing, and eventually sclerosis of subchondral bone. Risk factors include advanced age, a sagittal orientation of the facet joint, and concomitant intervertebral disk degeneration. [6]
article-24455_5	Lumbar Facet Arthropathy -- Etiology	Facet joint arthrosis is a degenerative syndrome that typically occurs secondary to age, obesity, poor body mechanics, repetitive overuse and microtrauma. Numerous studies have linked facet joint degeneration to degeneration of intervertebral disks, showing that intervertebral disk degeneration likely occurs before facet joint arthrosis. [7] One explanation for these findings is the increased mechanical changes in the loading of the facet joints following intervertebral disk degeneration. Other studies have demonstrated an increased propensity for facet joint degeneration with a more sagittal orientation of the facet joint. [6]	Lumbar Facet Arthropathy -- Etiology. Facet joint arthrosis is a degenerative syndrome that typically occurs secondary to age, obesity, poor body mechanics, repetitive overuse and microtrauma. Numerous studies have linked facet joint degeneration to degeneration of intervertebral disks, showing that intervertebral disk degeneration likely occurs before facet joint arthrosis. [7] One explanation for these findings is the increased mechanical changes in the loading of the facet joints following intervertebral disk degeneration. Other studies have demonstrated an increased propensity for facet joint degeneration with a more sagittal orientation of the facet joint. [6]