Superior cervical sympathetic ganglion. sympathetic trunk
SYMPATIC PART OF THE AUTONOMOUS (VEGETATIVE) NERVOUS SYSTEM
TO sympathetic part,pars sympathica (sympathetica), include: 1) lateral intermediate (gray) substance (vegetative nucleus) in the lateral (intermediate) columns from VIII cervical segment of the spinal cord to II lumbar; 2) nerve-
nye fibers and nerves running from the cells of the lateral intermediate substance (lateral column) to the nodes of the sympathetic trunk and autonomic plexuses; 3) right and left sympathetic trunks; 4) connecting branches; 5) nodes of autonomic plexuses located anterior to the spine in the abdominal cavity and pelvic cavity and nerves lying near large vessels (perivascular plexus); 6) nerves going from these plexuses to the organs; 7) sympathetic fibers that go as part of somatic nerves to organs and tissues.
Sympathetic preganglionic nerve fibers are usually shorter than postganglionic fibers.
Sympathetic trunk, truncus sympathicus-
a paired formation located on the sides of the spine. It consists of 20-25 knots connected internodal branches,rr. interganglionares.
nodes of the sympathetic trunk,ganglia trunci sympathici (sym-pathetici), spindle-shaped, ovoid and irregular (polygonal) shape. The sympathetic trunk is located on the anterior-lateral surface of the spine. Only one type of branches approaches the sympathetic trunk - the so-called white connecting branches, and gray connecting branches go out, as well as nerves to the internal organs, blood vessels and large prevertebral plexuses of the abdominal cavity and pelvis. White connecting branch, r . communicantalbus, called a bundle of preganglionic nerve fibers, branching off from the spinal nerve and entering into the nearby node of the sympathetic trunk.
As part of the white connecting branches, there are preganglionic nerve fibers, which are processes of neurons of the lateral columns of the spinal cord. These fibers pass through the anterior columns (horns) of the spinal cord and exit as part of the anterior roots, and then go to the spinal nerve, from which they branch off after it exits the spinal foramen. White connecting branches are present only in the VIII cervical, all thoracic and two upper lumbar spinal nerves and are suitable only for all thoracic (including cervicothoracic) and two upper lumbar nodes of the sympathetic trunk. The white connecting branches are not suitable for the cervical, lower lumbar, sacral and coccygeal nodes of the sympathetic trunk. Preganglionic fibers enter the named nodes along the internodal branches of the sympathetic trunk, passing without interruption through the corresponding thoracic and lumbar nodes.
Gray connecting branches emerge from the nodes of the sympathetic trunk along the entire length, rami communicantes gri-sei, that go to the nearest spinal nerve
Rice. 196. Cervical and thoracic sections of the sympathetic trunk; front view. 1 - gangl. cervicale superius; 2-gangl. cervical medium; 3 - gangl. cervi-cothoracicum; 4 - plexus subclavius; 5 - gangl. thora cica; 6-r. communicans griseus; 7-n. splanchnicus major; 8-n. splanchnicus minor.
woo. Gray connecting branches contain postganglionic nerve fibers - processes of cells lying in the nodes of the sympathetic trunk.
As part of the spinal nerves and their branches, postganglionic sympathetic fibers are sent to the skin, muscles, all organs and tissues, blood and lymphatic vessels, sweat and sebaceous glands, to the muscles that raise the hair, and carry out their sympathetic innervation. From the sympathetic trunk, in addition to the gray connecting branches, to the internal organs and vessels, nerves depart, containing postganglionic fibers, as well as nerves following to the nodes of the autonomic plexuses and containing preganglionic fibers that have passed through the nodes of the sympathetic trunk. Topographically, 4 sections are distinguished in the sympathetic trunk: cervical, thoracic, lumbar, sacral. The cervical region of the sympathetic trunk (Fig. 196) is represented by three nodes and internodal branches connecting them, which are located on the deep muscles of the neck behind the prevertebral plate of the cervical fascia. Preganglionic fibers approach the cervical nodes along the internodal branches of the thoracic sympathetic trunk, where they come from the autonomic nuclei of the lateral intermediate (gray) substance of the VIII cervical and six to seven upper thoracic segments of the spinal cord.
upper neck knot, ganglion cervicale superius, is the largest node of the sympathetic trunk. The node is fusiform, its length reaches 2 cm or more, thickness - 0.5 cm. The upper cervical node is located in front of the transverse processes of II - III cervical vertebrae. In front of the node are the carotid artery, laterally - the vagus nerve, behind - the long muscle of the head. Branches containing postganglionic fibers depart from the upper cervical node:
1) gray connecting branches, rr. communicntes grisei, co
unite the upper cervical node with the first three (sometimes IV)
cervical spinal nerves;
2) internal carotid nerve, n. caroticus internus, guide
from the upper pole of the node to the artery of the same name and along its
the course forms the internal carotid plexus, plexus caroticus
internus. Together with the internal carotid artery, this plexus
enters the carotid canal, and then into the cranial cavity. Sleepy
canal from the plexus depart carotid-tympanic nerves to the mucosa
that sheath of the middle ear. After the release of the internal carotid ar
the teri from the canal from the internal carotid plexus is separated
deep stony nerve, n. petrosus profundus. He
passes through the fibrocartilage of the torn hole and enters
pterygoid canal of the sphenoid bone, where it connects with pain
shim stony nerve, forming nerve of the pterygoid canal,
n. canalis pterygoidei. The latter, entering the pterygopalatine fossa,
joins the pterygopalatine node. Having passed through
pterygopalatine ganglion, sympathetic fibers along pterygopalatine nerves
enter the maxillary nerve and spread as part of
its branches, carrying out sympathetic innervation of blood vessels,
tissues, glands, oral and nasal mucosa,
conjunctiva of the lower eyelid and facial skin. Part of inner dream
foot plexus, located in the cavernous sinus, often
called the cavernous plexus plexus cavernosus. Into the eye
sympathetic fibers enter in the form of periarterial
leg plexus of the ophthalmic artery - branches of the internal carotid arte
rii. Branches from the ophthalmic plexus sympathetic kore
shock, radix sympathicus, to the eyelash. The fibers of this
the tails pass through the ciliary node in transit and as part of the co
short ciliary nerves reach the eyeball. pretty
sky fibers innervate the vessels of the eye and muscle, expanding
pupil. In the cranial cavity, the internal carotid plexus
should in the perivascular plexus branches of the internal sleep
noah artery;
3) external carotid nerves, pp. carotici externi, is 2-3
stem, they are sent to the external carotid artery and
peace along its course is the external carotid plexus, plexus caroticus
externus. This plexus spreads along the branches of the same name
noah artery, carrying out sympathetic innervation of blood vessels,
glands, smooth muscle elements and tissues of the organs of the head.
The internal and external carotid plexuses are connected at a common
carotid artery, where common carotid plexus,plexus caroticus communis;
4) jugular nerve, n. jugularis, climbs up the wall
jugular vein to the jugular foramen, where it divides into
branches leading to the superior and inferior nodes of the vagus nerve
to the inferior node of the glossopharyngeal nerve and to the hypoglossal nerve.
Due to this, sympathetic fibers spread in
the composition of the branches of the IX, X and XII pairs of cranial nerves;
5) laryngeal-pharyngeal branches, rr. laryngopharyngei /laryngo-
pharyngeales], participate in the formation of the laryngeal-pharyngeal
plexuses, innervate (sympathetic innervation) vessels,
mucous membrane of the pharynx and larynx, muscles and other tissues.
Thus, postganglionic nerve fibers
from the upper cervical node, carry out the sympathetic inner
vation of organs, skin and vessels of the head and neck;
6) superior cervical cardiac nerve, n. cardiacus cervicdtis superior, descends parallel to the sympathetic trunk anterior to the prevertebral plate of the cervical fascia. The right nerve runs along the brachiocephalic trunk and enters the deep part of the cardiac plexus on the posterior surface of the aortic arch. The left upper cervical cardiac nerve is adjacent to the left common carotid artery, descends into the superficial part of the cardiac plexus, located between the aortic arch and the bifurcation of the pulmonary trunk (Fig. 197).
middle neck knot,ganglion cervical, unstable, located anterior to the transverse process of the VI cervical vertebra, behind the inferior thyroid artery. The dimensions of the node do not exceed 5 mm. The middle cervical node is connected to the upper cervical node by one internodal branch, and to the cervicothoracic (stellate) node by two, less often three internodal branches. One of these branches passes in front of the subclavian artery, the other - behind, forming subclavian loop,dnsa subclavia. The following branches depart from the middle cervical node: 1) gray connecting branches to V and VI cervical spinal nerves, sometimes to VII;
2) middle cervical cardiac nerve, n. cardiacus cervicalis
medius. It runs parallel and lateral to the superior cervical
cardiac nerve. Right middle cervical cardiac nerve
relies along the brachiocephalic trunk, and the left - along the left
common carotid artery. Both nerves enter the deep part
cardiac plexus;
3) one or two thin nerves from the middle cervical node
participate in the formation of the common carotid plexus and plexus
inferior thyroid artery, innervating the thyroid and about
thyroid glands. In the absence of the middle cervical node, all
named branches depart from the internodal branches at the level of the pope
riverine process of the VI cervical vertebra, and postnodal fibers
these branches enter from the cervicothoracic node.
Cervical (stellate) node,ganglion cervicothoracicum,
Rice. 197. Cervical sympathetic trunk and cardiac plexus.
1 - gangl. cervicale superius; 2 - n. cardiacus cervicalis superior; 3 - gangl. cervicothoracicum; 4 - plexus cardiacus (superficial); 5 - plexus cardiacus (deep); 6 - n. cardiacus cervicalis inferior; 7 - years. cardiaci cervicales superiores; 8 - gangl. cervical medium; 9-n. vagus.
lies at the level of the neck of the 1st rib behind the subclavian artery, at the place where the vertebral artery originates from it. The node was formed as a result of the fusion of the lower cervical node with the first thoracic node. The cervicothoracic node is flattened in the anteroposterior direction, has an irregular (star-shaped) shape, its average diameter is 8 mm. The following branches depart from the node:
1) gray connecting branches, rr. communlcantes grisei, on
go to VI, VII, VIII cervical spinal nerves;
2) several branches, including from the subclavian loop,
form subclavian plexus,plexus subclavius,
continuing on the vessels of the upper limb. Together with branches
mi subclavian artery sympathetic fibers of this plexus
ion reach the thyroid gland, parathyroid glands,
organs of the upper and anterior mediastinum, and also innervate
branches of the subclavian artery;
3) several branches join the vagus nerve
and its branches, as well as to the phrenic nerve;
4) vertebral nerve, n. vertebralis, approaches the vertebral
arteries and participates in the formation of sympathetic spine
foot plexus,plexus vertebralis. Almost always at the entrance
da vertebral artery into the foramen of the transverse process VI
cervical vertebra along the course of the vertebral nerve, a small vertebrate knot, ganglion vertebrate. The vertebral plexus innervates the vessels of the brain and spinal cord and their membranes;
5) lower cervical cardiac nerve, n. cardiacus cervicatis inferior, passes on the right behind the brachiocephalic trunk, and on the left - behind the aorta. The right and left nerves enter the deep part of the cardiac plexus.
The thoracic region of the sympathetic trunk includes 10-12 chest nodes,ganglia thordcica, flattened, spindle-shaped or triangular. The dimensions of the nodes are 3-5 mm. The nodes are located anterior to the heads of the ribs on the lateral surface of the vertebral bodies, behind the intrathoracic fascia and parietal pleura. Behind the sympathetic trunk in the transverse direction are the posterior intercostal vessels. To the thoracic nodes of the sympathetic trunk from all the thoracic spinal nerves, white connecting branches containing pre-ganglionic fibers approach. Several types of branches depart from the thoracic nodes of the sympathetic trunk:
1) gray connecting branches, rr. comunicantes grisei, containing postganglionic fibers, join adjacent spinal nerves;
2) thoracic cardiac branches, pp. (rr.) cardiaci thoracici, from
go from the second, third, fourth, fifth chest nodes,
are directed forward and medially and participate in the formation
cardiac plexus;
3) thin
sympathetic nerves (pulmonary, esophageal, aortic) together
ste with branches of the vagus nerve form the right and left
pulmonary plexus,plexus pulmonalis,esophageal plexus,
plexus esophagedlis / oesophagedlis], And thoracic aortic spleen
shading,plexus aorticus thordcicus. Branches of the thoracic aortic
plexuses continue to intercostal vessels and other branches
thoracic aorta, forming along their course periarterial plexuses.
Sympathetic nerves also approach the walls of the unpaired and
semi-unpaired veins, thoracic duct and participate in their innervation
tions.
The largest branches of the sympathetic trunk in the thoracic region are the large and small splanchnic nerves;
4) large splanchnic nerve, n. splanchnicus major, It is formed from several branches extending from the 5th-9th thoracic node of the sympathetic trunk and consisting mainly of preganglionic fibers. On the lateral surface of the thoracic vertebral bodies, these branches are combined into a common nerve trunk, which goes down and medially, penetrates into the abdominal cavity between the muscle bundles of the lumbar diaphragm next to the unpaired vein on the right and the semi-unpaired vein on the left and ends at the nodes of the celiac plexus. At the level of the XII thoracic vertebra, along the course of the large internal nerve,
comes in small sizes [thoracic] splanchnic node,
ganglion spldnchnicum;
5) small splanchnic nerve, n. splanchnicus minor, nachi
comes from the 10th and 11th thoracic nodes of the sympathetic trunk and
also contains predominantly preganglionic
fibers. This nerve descends lateral to the greater
splanchnic nerve, passes between the muscle bundles
lumbar diaphragm (together with the sympathetic trunk)
and enters the nodes of the celiac plexus. From a small internal
nerve departs renal branch, r. renalis, ending in
aorto-renal node of the celiac plexus;
6) lower splanchnic nerve, n. splanchnicus imus, not
standing, goes next to the small splanchnic nerve. Nachi
originates from the 12th (sometimes the 11th) thoracic node of the sympathetic
trunk and ends at the renal plexus.
The lumbar section of the sympathetic trunk (Fig. 198) is represented by 3-5 lumbar nodes and internodal branches connecting them.
lumbar nodes,ganglia lumbalia, spindle-shaped, their dimensions do not exceed 6 mm. The nodes are located on the anterior-lateral surface of the bodies of the lumbar vertebrae medial to the psoas major muscle and are covered by the retroperitoneal fascia. The inferior vena cava adjoins the lumbar nodes of the right sympathetic trunk in front, the nodes of the left trunk are adjacent to the left semicircle of the abdominal aorta. The lumbar nodes of the right and left sympathetic trunks are connected by transversely oriented connecting branches lying on the anterior surface of the lumbar vertebrae, behind the aorta and inferior vena cava.
From the I and II lumbar spinal nerves belonging to the corresponding segments of the spinal cord (L I - L II), white connecting branches approach the upper two lumbar nodes of the sympathetic trunk. The remaining lumbar nodes do not have white connecting branches.
Two types of branches depart from each lumbar node: 1) gray connecting branches, containing postganglionic fibers heading to the lumbar spinal nerves; 2) lumbar splanchnic nerves, nervi splanchnici lumbales, which are sent to the celiac plexus and organ (vascular) autonomic plexuses: splenic, hepatic, gastric, renal, adrenal. These nerves have both preganglionic and postganglionic nerve fibers.
The pelvic section of the sympathetic trunk is formed by four sacral nodes. sacral nodes,ganglia sacralia, spindle-shaped, about 5 mm in size each, connected by internodal branches. These nodes lie on the pelvic surface of the sacrum medially to the pelvic sacral foramen. Below, the right and left sympathetic trunks converge and end
Rice. 198. Lumbar and sacral sections of the sympathetic trunk. 1 - gangll. lumbalia; 2-rr. communicantes (transverse); 3 - gangll. sa cralia; 4-gang], impar; 5-r. communicans (griseus); 6 - nn. splanchnici lumbales.
V unpaired node,ganglion impar, which lies on the anterior surface of the I coccygeal vertebra. As in the lumbar region, there are transverse connections between the nodes of the sympathetic trunks of the right and left sides. Branches depart from the sacral nodes:
1) gray connecting branches go to the sacral spinal nerves, which include postnodal sympathetic
skee fibers are sent to innervate blood vessels, glands, organs and tissues in those areas where the somatic sacral nerves branch;
2) sacral splanchnic nerves, nervi splanchnici sacra-les, follow to the upper and lower hypogastric (pelvic) vegetative plexuses.
sympathetic trunk(truncus sympathicus), paired, located on the sides of the spine, consists of 20-25 nodes connected internodal branches(rr. interganglionares), . Connecting branches extending from all the thoracic and upper two lumbar spinal nerves approach the sympathetic trunk. Gray connecting branches emerge from the sympathetic trunk to all spinal nerves, as well as nerves to the internal organs, blood vessels and large plexuses of the abdominal cavity and pelvis.
Topographically, the sympathetic trunk is divided into four sections: cervical, thoracic, lumbar, sacral.
The cervical region of the sympathetic trunk is formed by three nodes and internodal branches connecting them, which are located on the deep muscles of the neck behind the prevertebral plate of the cervical fascia. Preganglionic fibers approach the cervical nodes along the internodal branches from the thoracic sympathetic trunk, where they come from the vegetative nuclei of the lateral intermediate (gray) substance of the 8th cervical and six to seven upper thoracic segments of the spinal cord. Upper cervical knot(ganglion cervicale superius), the largest, its length reaches 2 cm or more. Branches containing postganglionic sympathetic fibers depart from the upper cervical node to the upper spinal and nearby cranial nerves (glossopharyngeal, vagus, accessory, hypoglossal), as well as to the external and internal carotid arteries and other nearby blood vessels.
Internal carotid nerve(n. caroticus internus), goes to the artery of the same name and forms along its course internal carotid plexus(plexus caroticus internus). Together with the internal carotid artery, this plexus enters the carotid canal, and then into the cranial cavity. From this plexus depart carotid nerves(nn. caroticotympanic!) to the mucous membrane of the middle ear, then - deep stony nerve(n. petrosus profundus). This nerve passes into the pterygoid canal of the sphenoid bone, where it joins with the greater petrosal nerve to form pterygoid canal nerve(n. canalis pterygoidei), which approaches the pterygopalatine node. After passing through the pterygopalatine ganglion, sympathetic fibers enter the maxillary nerve and spread as part of its branches, carrying out sympathetic innervation of blood vessels, tissues, glands of the oral mucosa and walls of the nasal cavity, conjunctiva of the lower eyelid and facial skin. Sympathetic fibers enter the orbit in the form of the periarterial plexus of the ophthalmic artery, a branch of the internal carotid artery. Branches from the ophthalmic plexus sympathetic spine(radix sympathicus) to the ciliary node. The fibers of this root pass through the ciliary ganglion and, as part of short ciliary nerves, reach the eyeball, where they innervate the vessels of the eye and the muscle that dilates the pupil. In the cranial cavity, the internal carotid plexus continues into the circumvascular plexus of the branches of the internal carotid artery.
External carotid nerves(nn. carotid externi), 2-3 stems, go to the external carotid artery and form along its course external carotid plexus(plexus caroticus externus), which continues along the branches of this artery, carrying out sympathetic innervation of blood vessels, glands, smooth muscle elements, organs and tissues of the head.
jugular nerve(n. jugularis) rises along the wall of the internal jugular vein to the jugular foramen, where it is divided into branches that go to the pharyngeal, vagus, and hypoglossal nerves. Laryngo-pharyngeal nerves(nn. laryngopharyngei) innervate blood vessels, the mucous membrane of the pharynx and larynx, muscles and other tissues. Superior cervical cardiac nerve(n. cardiacus cervicalis superior) descends anterior to the prevertebral plate of the cervical fascia and enters the cardiac plexus.
Middle neck knot(ganglion cervicale medium), unstable, located anterior to the transverse process of the VI cervical vertebra. Connecting branches depart from the middle cervical node to the 5th and 6th cervical spinal nerves, as well as middle cervical cardiac nerve(n. cardiacus cervicalis medius). 2-3 thin nerves depart from the middle cervical node, which participate in the formation of the common carotid plexus and innervate the thyroid and parathyroid glands.
Cervicothoracic (stellate) node(ganglion cervicothoracicum) is formed by the fusion of the lower cervical node with the first thoracic node. Connecting branches of the cervical spinal nerves depart from the node, to the subclavian artery, where they form subclavian plexus(plexux subclavius), continuing on the vessels of the shoulder girdle and the free part of the upper limb. Vertebral nerve(n. vertebralis) approaches the vertebral artery and participates in the formation of the sympathetic plexus, from which the vessels of the brain and spinal cord are innervated. Inferior cervical cardiac nerve(n. cardiacus cervicalis inferior) passes into the deep part of the cardiac plexus.
The thoracic section of the sympathetic trunk includes 9-12 thoracic nodes, to which connecting branches containing preganglionic fibers come from all thoracic spinal nerves. Gray connecting branches containing postganglionic fibers depart from the thoracic nodes of the sympathetic trunk to the adjacent spinal nerves.
Thoracic cardiac nerves(nn. cardiaci thoracici) depart from the second to fifth thoracic nodes, participate in the formation of the cardiac plexus. Thin sympathetic nerves depart from the thoracic nodes (pulmonary, esophageal, aortic), which, together with the branches of the vagus nerve, form pulmonary plexus(plexus pulmonalis) esophageal plexus(plexus esophagealis), as well as thoracic aortic plexus(plexus aorticus thoracicus), whose branches continue to the intercostal vessels and other branches of the thoracic aorta, forming periarterial plexuses, and also approach the walls of the unpaired and semi-unpaired veins, the thoracic lymphatic duct. Large branches of the sympathetic trunk in the thoracic region are the large and small splanchnic nerves, formed mainly by preganglionic sympathetic fibers.
sympathetic trunk (truncus sympathicus) - a paired formation located on the side of the spine (Fig. 9-67, 9-68). Of all the organs of the posterior mediastinum, it is located most laterally and corresponds to the level of the heads of the ribs. Consists of nodes of the sympathetic trunk (nodi trunci sumpathici), connected by internodal branches (rami interganglionares).
Each node of the sympathetic trunk (ganglion trunci sympathici) gives off a white connecting branch (ramus communicans albus) and gray connecting branch (ramus communicans griseus). In addition to the connecting branches, a number of branches depart from the sympathetic trunk, which take part in the formation of reflexogenic zones - autonomic plexuses on the vessels and organs of the chest and abdominal cavities.
Great splanchnic nerve (p. splan-chnicus major) begins with five roots from V to IX thoracic nodes. Having connected into one trunk, the nerve goes to the diaphragm, penetrates into the abdominal cavity between the legs of the diaphragm and takes part in the formation of the celiac plexus (Plexus coeliacus).
Small splanchnic nerve (n. splanchnicus
minor) starts from the tenth-eleventh thoracic sympathetic nodes and penetrates along with the large splanchnic nerve into the abdominal cavity, where it is partly part of the celiac plexus (Plexus coeliacus), superior mesenteric plexus (plexus mesentericus superior) and forms the renal plexus (plexus renalis).
inferior splanchnic nerve (n. splanchnicus imus s. minimus s. tertius) starts from the twelfth thoracic sympathetic node and also enters the renal plexus.
Thoracic cardiac nerves (pp. cardiaci thoracici) depart from the second-fifth thoracic sympathetic nodes, pass forward and medially, take part in the formation of the aortic plexus (plexus aorticus). Branches of the thoracic aortic plexus on the arteries extending from the thoracic aorta form the periarterial plexuses.
Numerous subtle sympathetic non-
ditches extending from the thoracic nodes of the sympathetic trunk - esophageal branches (rami esophagei), pulmonary branches (ramipulmonales)-
734 <■ TOPOGRAPHICAL ANATOMY AND OPERATIONAL SURGERY « Chapter 9
Rice. 9-67. Sympathetic trunk. 1 - celiac plexus, 2 - small splanchnic nerve, 3 - large splanchnic nerve, 4 - thoracic nodes of the sympathetic trunk, 5 - unpaired vein, 6 - right superior intercostal vein, 7 - subclavian loop, 8 - subclavian artery, 9 - brachial plexus , 10 - anterior scalene muscle, 11 - phrenic nerve, 12 - anterior branches of the cervical nerves, 13 - superior cervical node of the sympathetic trunk, 14 - hypoglossal nerve, 15 - vagus nerve, 16 - middle cervical node of the sympathetic trunk, 17 - common carotid artery, 18 - cervicothoracic node, 19 - brachiocephalic trunk, 20 - esophagus, 21 - lung, 22 - thoracic aorta, 23 - celiac trunk. (From: Sinelnikov V.D.
Topographic anatomy of the chest
Rice. 9-68. The course of the fibers of the spinal nerves, their connection with the sympathetic trunk (diagram). 1 - anterior branch (spinal nerve), 2 - posterior branch (spinal nerve), 3 - gray connecting branch, 4 - somatic sensory nerve fibers of cells of the spinal node, 5 - trunk of the spinal nerve, 6 - white connecting branch, 7 - spinal node , 8 - posterior root, 9 - posterior horn, 10 - posterior cord, 11 - lateral cord, 12 - white matter, 13 - lateral horn, 14 - gray matter, 15 - central canal, 16 - central intermediate gray matter, 17- node of the autonomic plexus, 18 - anterior median fissure, 19 - anterior cord, 20 - anterior horn, 21 - sympathetic prenodal nerve fibers of the cells of the lateral horn of the spinal cord, 22 - sympathetic postnodal nerve fibers of the cells of the nodes of the autonomic plexuses, 23 - sympathetic postnodal fibers to the spinal nerve, 24 - anterior root, 25 - motor fibers of the cells of the anterior horn of the spinal cord, 26 - sympathetic post-nodal nerve fibers of the cells of the nodes of the sympathetic trunk, 27 - nodes of the sympathetic trunk. (From: Sinelnikov V.D. Atlas of human anatomy. - M., 1974. - T. III.)
take part in the formation of the esophageal plexus (plexus esophageus) and pulmonary plexus (plexus pulmonalis).
Cellular spaces of the mediastinum
Intrathoracic fascia (fascia endothoracica) lines the inner surface of the chest and below passes to the diaphragm, pre-
rotating into the diaphragmatic-pleural fascia (fascia phrenicopleuralis). The spurs of the intrathoracic fascia cover the mediastinal pleura, and also approach the organs and neurovascular formations of the mediastinum, forming fascial sheaths. Fascial spurs limit the following interfascial spaces.
The prepericardial space is located posterior to the sheet of intrathoracic fascia lining the transverse muscle of the chest.
736 ♦ TOPOGRAPHIC ANATOMY AND OPERATIONAL SURGERY ♦ Chapter 9
(i.e. transversus thoracis). Posteriorly, this space is limited by the fascial sheaths of the thymus gland and vessels located anterior to the trachea, and the pericardium. From below, the prepericardial space is limited by the diaphragmatic-pleural fascia, communicating with the preperitoneal tissue through the sternocostal triangle. From above, this space communicates with the pre-visceral space of the neck.
The pretracheal space is limited on the left by the aortic arch and the initial sections of its branches, and on the right by the mediastinal pleura and azygous vein. In front, this space is limited by the fascial sheath of the thymus gland and the posterior wall of the pericardium, A behind - a trachea and a fascial sheet stretched between the main bronchi.
The periesophageal space in the upper mediastinum is separated laterally and posteriorly by sheets of the intrathoracic fascia adjacent to the mediastinal pleura and the prevertebral fascia, and in front by the trachea, to which the esophagus is directly adjacent. In the posterior mediastinum, the periesophageal space is located between the posterior wall of the pericardium and the intrathoracic fascia lining the aorta. The lower part of the periesophageal space is divided by fascial spurs connecting the side walls of the fascial sheath of the esophagus with the mediastinal pleura below the roots of the lungs, into the anterior and posterior sections. The periesophageal space communicates from above with the retrovisceral space of the neck, and from below through the aortic opening of the diaphragm and the lumbocostal triangle - with the retroperitoneal space.
In the chest cavity, purulent inflammation of the mediastinal tissue can occur - media stinitis. There are anterior and posterior media-astinitis.
With anterior purulent mediastinitis, purulent fusion of tissues along the intercostal space, destruction of the pericardium - purulent pericarditis or empyema of the pleural cavity are observed.
With posterior mediastinitis, pus penetrates the subpleural tissue and can go down into the retroperitoneal tissue through the openings of the diaphragm - the lumbocostal triangle, the aortic or esophageal openings. Sometimes pus breaks into the trachea or esophagus. Factors contributing to the spread of purulent inflammatory processes in the mediastinum:
Uneven development of fascial bundles and fiber, as a result of which the various sections of the mediastinum are not delimited from each other.
Mobility of the pleural sheets and diaphragm, constant spatial and volumetric changes in the organs and vessels of the mediastinum. /
The disease has different names: with the defeat of one node - sympathoganglionitis, with the defeat of several nodes - polyganglionitis, or truncitis Sometimes they talk about ganglioneuritis, since it is very difficult to determine which structures are affected mainly by nodes or nerves. It should not be confused with lesions of the spinal ganglia, which are also diagnosed as ganglionitis or ganglioneuritis.
Etiology and pathogenesis
Sympathetic ganglionitis often occurs in acute infectious diseases (flu, measles, diphtheria, pneumonia, tonsillitis, scarlet fever, dysentery, sepsis, erysipelas) and chronic infections (tuberculosis, syphilis, brucellosis, rheumatism). Probably, primary viral lesions are also possible. Metabolic disorders, intoxications, neoplasms (both primary ganglioneuromas and metastatic ones) matter.
Clinical picture
Sympathoganglionitis is distinguished: cervical, upper and lower thoracic, lumbar, sacral. The main symptom is a periodically aggravated pain of a burning nature, which does not have precise boundaries. Paresthesias, hypoesthesias or hyperesthesias, pronounced disorders of pilomotor, vasomotor, secretory and trophic innervation are detected
A special clinic has lesions of four cervical sympathetic nodes: upper, middle, accessory and stellate (not all people have middle and accessory nodes).
Damage to the upper cervical node manifested by a violation of the sympathetic innervation of the eye (Bernard-Horner syndrome). Often, vasomotor disturbances are observed in the same half of the face. When this node is irritated, pupil dilation (mydriasis), expansion of the palpebral fissure, exophthalmos (Pourfure du Petit syndrome) occur. The main feature of lesions of the upper cervical sympathetic ganglion is that the localization of painful manifestations does not correspond to the zone of innervation of any somatic nerve. Pain can spread to half of the face and even the entire half of the body (according to the hemitype), which is explained by the involvement of the entire sympathetic chain in the process. With very severe pain in the face and teeth, the defeat of this node can cause the erroneous extraction of several teeth. One of the provoking factors is hypothermia, however, various inflammatory processes, surgical interventions on the neck, etc. can play a role. With a long duration of the disease, patients become emotionally labile, explosive, sleep is disturbed. A change in the psyche often develops according to the type of asthenohypochondriac syndrome.
Prosopalgia with sympathetic truncitis differs from other forms of facial sympathology by significant irradiation: increasing in intensity, pain in the face radiates throughout the entire half of the body.
Star node lesion characterized by pain and sensory disturbances in the upper limb and upper chest.
At damage to the upper thoracic nodes pain and skin manifestations are combined with vegetative-visceral disorders (difficulty breathing, tachycardia, pain in the heart). More often such manifestations are more pronounced on the left.
Damage to the lower thoracic and lumbar nodes leads to a violation of the vegetative skin innervation of the lower part of the trunk, legs and vegetative-visceral disorders of the abdominal organs.
Treatment
During the period of exacerbation, analgesics (paracetamol), as well as tranquilizers, are prescribed. In the case of a pronounced pain syndrome, novocaine is administered intravenously or a preganglionic novocaine blockade is performed (50-60 ml of a 0.5% solution of novocaine is injected paravertebral at the level of II and III thoracic vertebrae; for a course of 8-10 blocks in 2-3 days). Tegretol is effective. In acute cases, anti-infective treatment is carried out simultaneously. If the lesion of the sympathetic trunk is due to influenza infection, gamma globulin is prescribed. In cases of bacterial infection (tonsillitis, pneumonia, rheumatism), a course of antibiotic treatment is carried out. With an increase in the tone of the sympathetic part of the autonomic nervous system, anticholinergic, ganglioblocking, neuroplegic and antispasmodic drugs are indicated. Some antihistamines have anticholinergic properties, therefore diphenhydramine, diprazine, etc. are also prescribed. In case of inhibition of sympathetic structures, cholinomimetic agents (ephedrine, glutamic acid), as well as calcium gluconate, calcium chloride, are prescribed. Electrophoresis of novocaine, amidopyrine, ganglerone, potassium iodide is used on the area of the affected areas of the sympathetic trunk. UV irradiation (erythemal doses), diadynamic or sinusoidal modulated currents, cold mud applications, radon baths, massage are shown. Assign difenin, multivitamins, preparations of phosphorus, iron, lecithin, aloe, vitreous body. Rarely, with pain that is not amenable to drug therapy, sympathectomy is performed.
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(plexus cervicalis) is formed by the anterior branches of the 4 upper cervical spinal nerves (C I -C IV), which have interconnections. The plexus lies on the side of the transverse processes between the vertebral (back) and prevertebral (front) muscles (Fig. 1). The nerves emerge from under the posterior edge of the sternocleidomastoid muscle, slightly above its middle, and fan out upward, forward, and downward. The following nerves depart from the plexus:
Rice. 1.
1 - hypoglossal nerve; 2 - accessory nerve; 3, 14 - sternocleidomastoid muscle; 4 - a large ear nerve; 5 - small occipital nerve; 6 - large occipital nerve; nerves to the anterior and lateral rectus muscles of the head; 8 - nerves to the long muscles of the head and neck; 9 - trapezius muscle: 10 - connecting branch to the brachial plexus; 11 - phrenic nerve: 12 - supraclavicular nerves; 13 - lower belly of the scapular-hyoid muscle; 15 - neck loop; 16 - sternohyoid muscle; 17 - sternothyroid muscle; 18 - upper abdomen of the scapular-hyoid muscle: 19 - transverse nerve of the neck; 20 - lower spine of the neck loop; 21 - the upper root of the neck loop; 22 - thyroid-hyoid muscle; 23 - chin-hyoid muscle
1. Lesser occipital nerve(n. occipitalis mino) (from C I -C II) extends upward to the mastoid process and further to the lateral sections of the occiput, where it innervates the skin.
2. Great ear nerve(n. auricularis major) (from C III -C IV) goes along the sternocleidomastoid muscle up and anteriorly, to the auricle, innervates the skin of the auricle (posterior branch) and the skin above the parotid salivary gland (anterior branch).
3. Transverse nerve of the neck(n. transverses colli) (from C III -C 1 V) goes anteriorly and at the anterior edge of the sternocleidomastoid muscle is divided into upper and lower branches that innervate the skin of the anterior neck.
4. Supraclavicular nerves(pp. supraclaviculares) (from C III -C IV) (numbering from 3 to 5) spread downward fan-shaped under the subcutaneous muscle of the neck; branch in the skin of the back of the neck (lateral branches), in the region of the collarbone (intermediate branches) and the upper front of the chest up to the III rib (medial branches).
5. Phrenic nerve(n. phrenicis) (from C III -C IV and partly from C V), predominantly a motor nerve, goes down the anterior scalene muscle into the chest cavity, where it passes to the diaphragm in front of the lung root between the mediastinal pleura and pericardium. Innervates the diaphragm, gives sensitive branches to the pleura and pericardium (rr. pericardiaci), sometimes to the cervicothoracic nerve plexus. In addition, it sends diaphragmatic-abdominal branches (rr. phrenicoabdominales) to the peritoneum covering the diaphragm. These branches contain nerve nodes ( ganglii phrenici) and connect to the celiac plexus. Especially often, the right phrenic nerve has such connections, which explains the phrenicus symptom - irradiation of pain in the neck with liver disease.
6. Lower spine of the neck loop (radix inferior ansae cervicalis) is formed by nerve fibers from the anterior branches of the second and third spinal nerves and goes anteriorly to connect with top spine (radix superior) arising from the hypoglossal nerve (XII pair of cranial nerves). As a result of the connection of both roots, a cervical loop is formed ( ansa cervicalis), from which branches extend to the scapular-hyoid, sternohyoid, thyroid-hyoid and sternothyroid muscles.
7. Muscular branches (rr. musculares) go to the prevertebral muscles of the neck, to the muscle that lifts the scapula, as well as to the sternocleidomastoid and trapezius muscles.
Lies in front of the transverse processes of the cervical vertebrae on the surface of the deep muscles of the neck (Fig. 2). In each cervical region there are 3 cervical nodes: upper, middle ( ganglia cervicales superior et media) and cervicothoracic ( stellate ) ( ganglion cervicothoracicum (stellatum)). The middle cervical node is the smallest. The stellate node often consists of several nodes. The total number of nodes in the cervical region can vary from 2 to 6. Nerves depart from the cervical nodes to the head, neck and chest.
Rice. 2.
1 - glossopharyngeal nerve; 2 - pharyngeal plexus; 3 - pharyngeal branches of the vagus nerve; 4 - external carotid artery and nerve plexus; 5 - upper laryngeal nerve; 6 - internal carotid artery and sinus branch of the glossopharyngeal nerve; 7 - sleepy glomus; 8 - carotid sinus; 9 - the upper cervical cardiac branch of the vagus nerve; 10 - the upper cervical cardiac nerve: 11 - the middle cervical node of the sympathetic trunk; 12 - middle cervical cardiac nerve; 13 - vertebral node; 14 - recurrent laryngeal nerve: 15 - cervicothoracic (stellate) node; 16 - subclavian loop; 17 - vagus nerve; 18 - lower cervical cardiac nerve; 19 - chest cardiac sympathetic nerves and branches of the vagus nerve; 20 - subclavian artery; 21 - gray connecting branches; 22 - the upper cervical node of the sympathetic trunk; 23 - vagus nerve
1. gray connecting branches(rr. communicantens grisei) - to the cervical and brachial plexuses.
2. Internal carotid nerve(p. caroticus internus) usually departs from the upper and middle cervical nodes to the internal carotid artery and forms around it internal carotid plexus(plexus caroticus internus), which also extends to its branches. Branches from the plexus deep stony nerve (p. petrosus profundus) to the pterygoid node.
3. The jugular nerve (n. jugularis) starts from the upper cervical node, within the jugular opening is divided into two branches: one goes to the upper node of the vagus nerve, the other to the lower node of the glossopharyngeal nerve.
4. Vertebral nerve(n. vertebralis) departs from the cervicothoracic node to the vertebral artery, around which it forms vertebral plexus.
5. Cardiac cervical superior, middle and inferior nerves (pp. cardiaci cervicales superior, medius et inferior) originate from the corresponding cervical nodes and are part of the cervicothoracic nerve plexus.
6. External carotid nerves(pp. carotid externi) depart from the upper and middle cervical nodes to the external carotid artery, where they participate in the formation external carotid plexus, which extends to the branches of the artery.
7. Laryngo-pharyngeal branches(rr. laryngopharyngei) go from the upper cervical node to the pharyngeal plexus and as a connecting branch to the superior laryngeal nerve.
8. Subclavian branches(rr. subclavii) depart from subclavian loop (ansa subclavia), which is formed by the division of the internodal branch between the middle cervical and cervicothoracic nodes.
Cranial division of the parasympathetic nervous system
Centers cranial department The parasympathetic part of the autonomic nervous system is represented by nuclei in the brainstem (mesencephalic and bulbar nuclei).
Mesencephalic parasympathetic nucleus accessory nucleus of the oculomotor nerve(nucleus accessories n. oculomotorii)- located at the bottom of the aqueduct of the midbrain, medial to the motor nucleus of the oculomotor nerve. Preganglionic parasympathetic fibers run from this nucleus as part of the oculomotor nerve to the ciliary ganglion.
The following parasympathetic nuclei lie in the medulla oblongata and pons:
1) superior salivary nucleus(nucleus salivatorius superior) associated with the facial nerve - in the bridge;
2) inferior salivary nucleus(nucleus salivatorius inferior) associated with the glossopharyngeal nerve - in the medulla oblongata;
3) dorsal nucleus of the vagus nerve(nucleus dorsalis nervi vagi), - in the medulla oblongata.
Preganglionic parasympathetic fibers pass from the cells of the salivary nuclei as part of the facial and glossopharyngeal nerves to the submandibular, sublingual, pterygopalatine and ear nodes.
Peripheral department The parasympathetic nervous system is formed by preganglionic nerve fibers originating from the indicated cranial nuclei (they pass as part of the corresponding nerves: III, VII, IX, X pairs), the nodes listed above and their branches containing postganglionic nerve fibers.
1. Preganglionic nerve fibers, which are part of the oculomotor nerve, follow to the ciliary node and end on its cells with synapses. Depart from the node short ciliary nerves(n. ciliares breves), in which, along with sensory fibers, there are parasympathetic: they innervate the sphincter of the pupil and the ciliary muscle.
2. Preganglionic fibers from the cells of the superior salivary nucleus spread as part of the intermediate nerve, from it through the large stony nerve they go to the pterygopalatine ganglion, and through the tympanic string to the submandibular and hypoglossal ganglions, where they end in synapses. Postganglionic fibers follow from these nodes along their branches to the working organs (submandibular and sublingual salivary glands, glands of the palate, nose and tongue).
3. Preganglionic fibers from the cells of the lower salivary nucleus go as part of the glossopharyngeal nerve and further along the small stony nerve to the ear node, on the cells of which they end in synapses. Postganglionic fibers from the cells of the ear node exit as part of the ear-temporal nerve and innervate the parotid gland.
Preganglionic parasympathetic fibers, starting from the cells of the dorsal node of the vagus nerve, pass as part of the vagus nerve, which is the main conductor of parasympathetic fibers. Switching to postganglionic fibers occurs mainly in the small ganglia of the intramural nerve plexuses of most internal organs, so postganglionic parasympathetic fibers appear to be very short compared to preganglionic ones.
Human Anatomy S.S. Mikhailov, A.V. Chukbar, A.G. Tsybulkin
