Superior cervical sympathetic ganglion. Sympathetic trunk
SYMPATHETIC PART OF THE AUTONOMIC NERVOUS SYSTEM
TO sympathetic part,pars sympathica (sympathetica), include: 1) lateral intermediate (gray) matter (vegetative nucleus) in the lateral (intermediate) columns from VIII cervical segment of the spinal cord to the second lumbar; 2) nerve-
nal fibers and nerves going 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 the autonomic plexuses located anterior to the spine in the abdominal and pelvic cavity and nerves lying near large vessels (perivascular plexuses); 6) nerves leading from these plexuses to the organs; 7) sympathetic fibers that travel as part of the somatic nerves to organs and tissues.
Sympathetic preganglionic nerve fibers are usually shorter than postganglionic fibers.
Sympathetic trunk, truncus sympathicus-
paired formation located on the sides of the spine. It consists of 20-25 nodes connected internodal branches,rr. interganglionares.
Sympathetic trunk nodesganglia trunci sympathici (sym-pathetici), fusiform, ovoid and irregular (polygonal) shape. The sympathetic trunk is located on the anterolateral surface of the spine. Only one type of branches approaches the sympathetic trunk - the so-called white connecting branches, and gray connecting branches emerge, as well as nerves to the internal organs, blood vessels and large prevertebral plexuses of the abdominal cavity and pelvis. White connecting branch, r . communicant albus, called a bundle of preganglionic nerve fibers that branches off from the spinal nerve and enters the nearby node of the sympathetic trunk.
The white connecting branches contain preganglionic nerve fibers, which are processes of neurons in the lateral columns of the spinal cord. These fibers pass through the anterior columns (horns) of the spinal cord and exit it as part of the anterior roots, and then go in the spinal nerve, from which they branch as 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 the cervicothoracic) and two upper lumbar nodes of the sympathetic trunk. The white connecting branches do not approach the cervical, lower lumbar, sacral and coccygeal nodes of the sympathetic trunk. Preganglionic fibers enter these 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, which are directed to the nearest spinal nerve
Rice. 196. Cervical and thoracic sections of the sympathetic trunk; front view. 1 - gangl. cervicale sup-perius; 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. The 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 directed to the skin, muscles, all organs and tissues, blood and lymphatic vessels, sweat and sebaceous glands, to the muscles that lift the hair, and carry out their sympathetic innervation. From the sympathetic trunk, in addition to the gray connecting branches, nerves containing postganglionic fibers depart to the internal organs and vessels, as well as nerves that go to the nodes of the autonomic plexuses and contain preganglionic fibers that transit through the nodes of the sympathetic trunk. Topographically, the sympathetic trunk is divided into 4 sections: cervical, thoracic, lumbar, sacral. The cervical section 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 arrive 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 cervical 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 the II - III cervical vertebrae. In front of the node are the carotid artery, laterally the vagus nerve, and behind the longus capitis muscle. Branches containing postganglionic fibers depart from the superior cervical ganglion:
1) gray connecting branches, rr. communicdntes grisei, with
connect the upper cervical node with the first three (sometimes IV)
cervical spinal nerves;
2) internal carotid nerve, n. caroticus internus, directing
extends from the upper pole of the node to the artery of the same name and along it
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. In a sleepy
the canal from the plexus extends the carotid-tympanic nerves to the mucus
that lining of the middle ear. After the release of the internal carotid ar
teria from the canal is separated from the internal carotid plexus
deep petrosal nerve, n. petrosus profundus. He
passes through the fibrous cartilage of the lacerated foramen and enters
pterygoid canal of the sphenoid bone, where it connects with pain
by the petrosal nerve, forming nerve of the pterygoid canal,
n. canalis pterygoidei. The latter, having entered the pterygopalatine fossa,
joins the pterygopalatine ganglion. Having transited through
pterygopalatine ganglion, sympathetic fibers along the pterygopalatine nerves
you enter the maxillary nerve and spreads as part of
its branches, carrying out sympathetic innervation of blood vessels,
tissues, glands, mucous membrane of the oral cavity and nasal cavity,
conjunctiva of the lower eyelid and facial skin. Part of the inner dream
plexus, located in the cavernous sinus, often
called the cavernous plexus plexus cavernosus. In the eye
sympathetic fibers enter in the form of periarterial
plexus of the ophthalmic artery - branches of the internal carotid artery
rii. Branches from the ocular plexus sympathetic cortex
shock, radix sympathicus, to the ciliary node. The fibers of this
tails pass in transit through the ciliary node and as part of the
The mouth ciliary nerves reach the eyeball. Cuter
Chinese fibers innervate the vessels of the eye and muscle, dilating
pupil. In the cranial cavity, the internal carotid plexus
should be in the perivascular plexus of the branches of the internal sleep
no artery;
3) external carotid nerves, pp. carotici externi,- this is 2-3
stem, they are directed to the external carotid artery and
the external carotid plexus moves along its course, plexus caroticus
externus. This plexus spreads along the branches of the same name
artery, providing sympathetic innervation of blood vessels,
glands, smooth muscle elements and tissues of the head organs.
The internal and external carotid plexuses are connected at a common
Carotid artery, where it is located common carotid plexus,plexus caroticus communis;
4) jugular nerve, n. jugularis, climbs up the wall
anterior jugular vein to the jugular foramen, where it divides into
branches going to the superior and inferior nodes of the vagus nerve,
to the inferior ganglion of the glossopharyngeal nerve and to the hypoglossal nerve.
Due to this, sympathetic fibers spread into
the composition of the branches of the IX, X and XII pairs of cranial nerves;
5) laryngopharyngeal branches, rr. laryngopharyngei /laryngo-
pharyngeales], participate in the formation of the laryngopharyngeal
plexuses, innervate (sympathetic innervation) vessels,
mucous membrane of the pharynx and larynx, muscles and other tissues.
Thus, postganglionic nerve fibers extending
from the upper cervical ganglion, carry out sympathetic inner
vation of organs, skin and blood 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 passes 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 and descends into the superficial part of the cardiac plexus, located between the aortic arch and the bifurcation of the pulmonary trunk (Fig. 197).
Middle cervical nodeganglion cervical medium, 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, rarely 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 ganglion: 1) gray connecting branches to the V and VI cervical spinal nerves, sometimes to the VII;
2) middle cervical cardiac nerve, n. cardiacus cervicalis
medius. It runs parallel and lateral to the upper cervical
cardiac nerve. Right middle cervical cardiac nerve
lies 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 ganglion
occur 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 ganglion, all
the 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.
Cervicothoracic (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 - gg. cardiaci cervicales superiores; 8 - gangl. cervical medium; 9 - n. vagus
lies at the level of the neck of the first rib behind the subclavian artery, at the point where the vertebral artery departs 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 diameter on average is 8 mm. The following branches depart from the node:
1) gray connecting branches, rr. communlicantes grisei, on
go to VI, VII, VIII cervical spinal nerves;
2) several branches, including from the subclavian loop,
form subclavian plexus,plexus subclavius,
continuing to the vessels of the upper limb. Along with the branch
mi subclavian artery sympathetic fibers of this plexus
they 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, fits the vertebral
arteries and participates in the formation of sympathetic vertebral
nogo plexus,plexus vertebralis. Almost always at the entrance
yes vertebral artery into the opening of the transverse process VI
of the 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 section of the sympathetic trunk includes 10-12 chest nodes,ganglia thordcica, flattened, spindle-shaped or triangular in shape. 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, the posterior intercostal vessels pass in the transverse direction. White connecting branches containing preganglionic fibers approach the thoracic nodes of the sympathetic trunk from all thoracic spinal nerves. Several types of branches extend from the thoracic nodes of the sympathetic trunk:
1) gray connecting branches, rr. comunicantes grisei, containing postganglionic fibers, they join adjacent spinal nerves;
2) thoracic cardiac branches, pp. (rr.) cardiaci thoracici, from
run from the second, third, fourth, fifth thoracic nodes,
are directed forward and medially and participate in the formation
cardiac plexus;
3) thin ones extending from the thoracic nodes of the sympathetic trunk
sympathetic nerves (pulmonary, esophageal, aortic) including
ste with the branches of the vagus nerve form the right and left
pulmonary plexus,plexus pulmonalis,esophageal plexus,
plexus esophagedlis/oesophagedlis], And thoracic aortic plenum
shading,plexus aorticus thordicus. Branches of the thoracic aortic
plexuses continue to intercostal vessels and other branches
thoracic aorta, forming periarterial plexuses along their course.
Sympathetic nerves also approach the walls of the azygos and
hemizygos veins, thoracic duct and participate in their innerva
tions.
The largest branches of the sympathetic trunk in the thoracic region are the greater and lesser splanchnic nerves;
4) great splanchnic nerve, n. splanchnicus major, is formed from several branches extending from the 5-9th thoracic ganglion of the sympathetic trunk and consisting mainly of preganglionic fibers. On the lateral surface of the thoracic vertebral bodies, these branches unite into a common trunk of the nerve, which goes down and medially, penetrates into the abdominal cavity between the muscle bundles of the lumbar part of the diaphragm near the azygos vein on the right and the semi-gypsy vein on the left and ends in the nodes of the celiac plexus. At the level of the XII thoracic vertebra along the course of the great internal nerve it meets
expected to be small in size [thoracic] splanchnic node,
ganglion spldnchnicum;
5) small splanchnic nerve, n. splanchnicus minor, start
comes from the 10th and 11th thoracic nodes of the sympathetic trunk and
also contains predominantly preganglionic
ny fibers. This nerve descends lateral to the great
splanchnic nerve, passes between muscle bundles
lumbar part of the diaphragm (together with the sympathetic trunk)
and enters the nodes of the celiac plexus. From small visceral
the nerve goes away renal branch, r. renalis, ending in
aortorenal node of the celiac plexus;
6) inferior splanchnic nerve, n. splanchnicus imus, nepo
standing, goes next to the small splanchnic nerve. Start
comes from the 12th (sometimes 11th) thoracic sympathetic node
trunk and ends in 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, fusiform, their dimensions do not exceed 6 mm. The nodes are located on the anterolateral surface of the lumbar vertebral bodies medial to the psoas major muscle and are covered by the retroperitoneal fascia. The inferior vena cava is adjacent to 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 communicating 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 directed to the lumbar spinal nerves; 2) lumbar splanchnic nerves, nervi splanchnici lumbales, which are directed 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 ganglia. Sacral nodes,ganglia sacralia, fusiform, about 5 mm in size each, connected by internodal branches. These nodes lie on the pelvic surface of the sacrum medial to the pelvic sacral foramina. Below, the right and left sympathetic trunks come together 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 nodeganglion impar, which lies on the anterior surface of the first 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 arise from the sacral nodes:
1) gray connecting branches go to the sacral spinal nerves, which include postnodal sympathetic
Chinese fibers are sent to innervate 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) autonomic plexuses.
Sympathetic trunk(truncus sympathicus), paired, located on the sides of the spine, consists of 20-25 nodes connected internodal branches(rr. interganglionares), . The sympathetic trunk is approached by connecting branches that arise from all the thoracic and upper two lumbar spinal nerves. From the sympathetic trunk emerge gray connecting branches to all spinal nerves, as well as nerves to 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 section 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 arrive from the autonomic 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 extend from the superior cervical ganglion to the upper spinal and nearby cranial nerves (glossopharyngeal, vagus, accessory, sublingual), as well as to the external and internal carotid arteries and other blood vessels passing nearby.
Internal carotid nerve(p. caroticus internus), goes to the artery of the same name and along its course forms 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-tympanic nerves(nn. caroticotympanic!) to the mucous membrane of the middle ear, then - deep petrosal nerve(n. petrosus profundus). This nerve goes into the pterygoid canal of the sphenoid bone, where it connects with the greater petrosal nerve, forming pterygoid nerve(n. canalis pterygoidei), which approaches the pterygopalatine node. Having passed in transit through the pterygopalatine ganglion, sympathetic fibers enter the maxillary nerve and spread as part of its branches, carrying out sympathetic innervation of vessels, tissues, glands of the oral mucosa and walls of the nasal cavity, the conjunctiva of the lower eyelid and the skin of the face. 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 ocular plexus sympathetic spine(radix sympathicus) to the ciliary node. The fibers of this root pass in transit through the ciliary ganglion and, as part of the 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 will continue into the perivascular plexuses of the branches of the internal carotid artery.
External carotid nerves(nn. carotid externi), 2-3 stems, directed to the external carotid artery and formed along its course external carotid plexus(plexus caroticus externus), which continues along the branches of this artery, providing sympathetic innervation to vessels, glands, smooth muscle elements, organs and tissues of the head.
Jugular nerve(p. jugularis) rises along the wall of the internal jugular vein to the jugular foramen, where it divides into branches going to the gonopharyngeal, vagus and hypoglossal nerves. Laryngopharyngeal 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 cervical node(ganglion cervicale medium), unstable, located anterior to the transverse process of the VI cervical vertebra. From the middle cervical ganglion there are connecting branches to the 5th and 6th cervical spinal nerves, as well as middle cervical cardiac nerve(p. cardiacus cervicalis medius). 2-3 thin nerves depart from the middle cervical ganglion, which participate in the formation of the common carotid plexus and innervate the thyroid and parathyroid glands.
Cervicothoracic (stellate) node(ganglion cervicothoracicum) is formed as a result of the fusion of the lower cervical node with the first thoracic node. The connecting branches of the cervical spinal nerves extend from the node to the subclavian artery, where they form subclavian plexus(plexux subclavius), continuing to the vessels of the shoulder girdle and the free part of the upper limb. Vertebral nerve(p. 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 approach from all thoracic spinal nerves. From the thoracic nodes of the sympathetic trunk, gray connecting branches containing postganglionic fibers depart to the adjacent spinal nerves.
Thoracic cardiac nerves(nn. cardiaci thoracici) extend from the second to fifth thoracic nodes and participate in the formation of the cardiac plexus. Thin sympathetic nerves (pulmonary, esophageal, aortic) depart from the thoracic nodes, 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), the branches of which continue to the intercostal vessels and other branches of the thoracic aorta, forming the periarterial plexuses, and also approach the walls of the azygos and semi-gyzygos veins, the thoracic lymphatic duct. The large branches of the sympathetic trunk in the thoracic region are the greater and lesser 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 rib heads. Consists of the 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 that take part in the formation of reflexogenic zones - vegetative plexuses on the vessels and organs of the thoracic and abdominal cavities.
Greater splanchnic nerve (p. splan-chnicus major) begins with five roots from V to IX thoracic nodes. Having united into one trunk, the nerve goes to the diaphragm, penetrates the abdominal cavity between the legs of the diaphragm and takes part in the formation of the celiac plexus (plexus coeliacus).
Lesser splanchnic nerve (n. splanchnicus
minor) starts from the tenth-eleventh thoracic sympathetic nodes and penetrates together with the greater splanchnic nerve into the abdominal cavity, where it is partially 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 to fifth thoracic sympathetic nodes, pass forward and medially, take part in the formation of the aortic plexus (plexus aorticus). The branches of the thoracic aortic plexus on the arteries arising 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 <■ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY « Chapter 9
Rice. 9-67. Sympathetic trunk. 1 - celiac plexus, 2 - small splanchnic nerve, 3 - greater splanchnic nerve, 4 - thoracic nodes of the sympathetic trunk, 5 - azygos 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 ganglion of the sympathetic trunk, 14 - hypoglossal nerve, 15 - vagus nerve, 16 - middle cervical ganglion of the sympathetic trunk, 17 - general 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 breast
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 communicating branch, 4 - somatic sensory nerve fibers of the cells of the spinal ganglion, 5 - trunk of the spinal nerve, 6 - white communicating branch, 7 - spinal ganglion , 8 - dorsal root, 9 - dorsal 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 cord 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,
rotating into the phrenic-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 layer of intrathoracic fascia lining the transverse thoracic muscle
736 ♦ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY ♦ Chapter 9
(i.e. transversus thoracis). Posteriorly, this space is limited by the fascial sheaths of the thymus and vessels located anterior to the trachea, and the pericardium. From below, the prepericardial space is limited by the phrenic-pleural fascia, communicating through the sternocostal triangle with the preperitoneal tissue. 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 azygos vein. Anteriorly, this space is limited by the fascial sheath of the thymus and the posterior wall of the pericardium, A behind - the trachea and the fascial sheet stretched between the main bronchi.
The peri-esophageal space in the upper mediastinum is separated from the sides and back by the leaves 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 paraesophageal space is located between the posterior wall of the pericardium and the layer of intrathoracic fascia lining the aorta. The lower part of the paraesophageal space is divided into anterior and posterior sections by fascial spurs connecting the lateral walls of the fascial sheath of the esophagus with the mediastinal pleura below the roots of the lungs. The paraesophageal 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.
Purulent inflammation of the mediastinal tissue - mediastinitis - can occur in the chest cavity. There are anterior and posterior media astinitis.
With anterior purulent mediastinitis, purulent melting of tissue along the intercostal spaces, destruction of the pericardium is observed - purulent pericarditis or empyema of the pleural cavity.
With posterior mediastinitis, pus penetrates the subpleural tissue and can descend down into the retroperitoneal tissue through the openings of the diaphragm - the lumbocostal triangle, 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 different parts of the mediastinum are not delimited from each other.
Mobility of the pleural layers and diaphragm, constant spatial and volumetric changes in the organs and vessels of the mediastinum. /
The disease has different names: when one node is affected - sympathoglionitis, when several nodes are affected - polyganglionitis, or truncitis. Sometimes they talk about ganglioneuritis, since it is very difficult to determine which structures are predominantly affected, 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 most often occurs in acute infectious diseases (influenza, measles, diphtheria, pneumonia, tonsillitis, scarlet fever, dysentery, sepsis, erysipelas) and chronic infections (tuberculosis, syphilis, brucellosis, rheumatism). It is likely that primary viral lesions are also possible. Metabolic disorders, intoxication, and neoplasms (both primary ganglioneuromas and metastatic ones) are important.
Clinical picture
There are sympathoglionitis: cervical, upper and lower thoracic, lumbar, sacral. The main symptom is periodically exacerbating burning pain that has no precise boundaries. Paresthesia, hypoesthesia or hyperesthesia, pronounced disorders of pilomotor, vasomotor, secretory and trophic innervation are detected
Lesions of the four cervical sympathetic nodes have a special clinical picture: superior, middle, accessory and stellate (not all people have the middle and accessory nodes).
Upper cervical ganglion lesion manifested by a violation of the sympathetic innervation of the eye (Bernard-Horner syndrome). Vasomotor disturbances are often observed in the same half of the face. When this node is irritated, dilation of the pupil (mydriasis), widening of the palpebral fissure, and exophthalmos (Pourfur 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 the face and even the entire half of the torso (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, damage to this node can cause the mistaken removal of several teeth. One of the provoking factors is hypothermia, but various inflammatory processes, surgical interventions on the neck, etc. can also play a role. With a long duration of the disease, patients become emotionally labile, explosive, and sleep is disturbed. Changes in the psyche often develop according to the type of astheno-hypochondriacal syndrome.
Prosopalgia with sympathetic truncinitis differs from other forms of facial sympathalgia by significant irradiation: increasing in intensity, pain in the face radiates throughout the entire half of the body.
Damage to the stellate ganglion characterized by pain and sensitivity disorders in the upper limb and upper chest.
At lesions of the upper thoracic nodes pain and skin manifestations are combined with autonomic-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 disruption of the cutaneous-vegetative innervation of the lower torso, legs and vegetative-visceral disorders of the abdominal organs.
Treatment
During an exacerbation, analgesics (paracetamol) and tranquilizers are prescribed. In case of pronounced pain syndrome, novocaine is administered intravenously or a preganglionic novocaine blockade is performed (50-60 ml of a 0.5% novocaine solution is administered paravertebrally at the level of the II and III thoracic vertebrae; for a course of 8-10 blockades every 2-3 days). Tegretol is effective. In acute cases, anti-infective treatment is simultaneously carried out. If damage to the sympathetic trunk is caused by influenza infection, gamma globulin is prescribed. In cases of bacterial infection (tonsillitis, pneumonia, rheumatism), a course of treatment with antibiotics is carried out. When the tone of the sympathetic part of the autonomic nervous system increases, anticholinergic, ganglion-blocking, neuroplegic and antispasmodic drugs are indicated. Some antihistamines have anticholinergic properties, so diphenhydramine, diprazine, etc. are also prescribed. When sympathetic structures are suppressed, cholinomimetic drugs (ephedrine, glutamic acid), as well as calcium gluconate, calcium chloride are prescribed. Electrophoresis of novocaine, amidopyrine, ganglerone, and 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 indicated. Diphenin, multivitamins, phosphorus, iron, lecithin, aloe, and vitreous are prescribed. Rarely, for pain that is not amenable to drug therapy, a 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 connections with each other. The plexus lies lateral to the transverse processes between the vertebral (posterior) and prevertebral (anterior) muscles (Fig. 1). The nerves emerge from under the posterior edge of the sternocleidomastoid muscle, slightly above its middle, and spread in a fan-like manner upward, forward and downward. The following nerves depart from the plexus:
Rice. 1.
1 - hypoglossal nerve; 2 - accessory nerve; 3, 14 - sternocleidomastoid muscle; 4 - great auricular nerve; 5 - lesser occipital nerve; 6 - greater occipital nerve; nerves to the anterior and lateral rectus capitis muscles; 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 omohyoid muscle; 15 - neck loop; 16 - sternohyoid muscle; 17 - sternothyroid muscle; 18 - upper belly of the omohyoid muscle: 19 - transverse nerve of the neck; 20 - lower root of the neck loop; 21 - upper root of the cervical loop; 22 - thyrohyoid muscle; 23 - geniohyoid muscle
1. Lesser occipital nerve(p. occipitalis mino) (from C I - C II) spreads upward to the mastoid process and further to the lateral parts of the back of the head, where it innervates the skin.
2. Greater auricular nerve(p. auricularis major) (from C III - C IV) runs along the sternocleidomastoid muscle upward 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 cervical nerve(p. transverses colli) (from C III - C 1 V) goes anteriorly and at the anterior edge of the sternocleidomastoid muscle it 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 downwards in a fan-shaped manner under the subcutaneous muscle of the neck; They branch in the skin of the posterior lower part of the neck (lateral branches), in the region of the clavicle (intermediate branches) and the upper anterior part of the chest to the third 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 root of the lung between the mediastinal pleura and the pericardium. Innervates the diaphragm, gives off sensory 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 ganglia ( ganglii phrenici) and connect to the celiac nerve plexus. The right phrenic nerve especially often has such connections, which explains the phrenicus symptom - irradiation of pain to the neck area due to liver disease.
6. Lower root of the cervical 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 upper 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 scapulohyoid, sternohyoid, thyrohyoid and sternothyroid muscles.
7. Muscular branches (rr. musculares) go to the prevertebral muscles of the neck, to the levator scapula muscle, as well as to the sternocleidomastoid and trapezius muscles.
It lies in front of the transverse processes of the cervical vertebrae on the surface of the deep muscles of the neck (Fig. 2). Each cervical region has 3 cervical nodes: superior, 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 range from 2 to 6. Nerves extend 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 - superior laryngeal nerve; 6 - internal carotid artery and sinus branch of the glossopharyngeal nerve; 7 - carotid glomus; 8 - carotid sinus; 9 - superior cervical cardiac branch of the vagus nerve; 10 - upper cervical cardiac nerve: 11 - middle cervical ganglion 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 - thoracic cardiac sympathetic nerves and branches of the vagus nerve; 20 - subclavian artery; 21 — gray connecting branches; 22 - superior 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(n. 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 extends to its branches. Branches off from the plexus deep petrosal nerve (p. petrosus profundus) to the pterygopalatine ganglion.
3. The jugular nerve (n. jugularis) starts from the upper cervical ganglion, within the jugular foramen it 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) extends from the cervicothoracic node to the vertebral artery, around which it forms vertebral plexus (plexus vertebralis).
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(p. carotid externi) extend from the upper and middle cervical nodes to the external carotid artery, where they participate in the formation external carotid plexus (plexus caroticus externus), which extends to the branches of the artery.
7. Laryngopharyngeal branches(rr. laryngopharyngei) go from the superior cervical ganglion to the pharyngeal nerve 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 region The parasympathetic part of the autonomic nervous system is represented by nuclei in the brain stem (mesencephalic and bulbar nuclei).
Mesencephalic parasympathetic nucleus - accessory nucleus of the oculomotor nerve(nucleus accessories n. oculomotorii)- located at the bottom of the midbrain aqueduct, medial to the motor nucleus of the oculomotor nerve. Preganglionic parasympathetic fibers go 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 auricular nodes.
Peripheral department The parasympathetic nervous system is formed by preganglionic nerve fibers originating from the indicated cranial nuclei (they pass through the corresponding nerves: III, VII, IX, X pairs), the nodes listed above and their branches containing postganglionic nerve fibers.
1. Preganglionic nerve fibers running as part of the oculomotor nerve follow to the ciliary ganglion and end at synapses on its cells. They depart from the node short ciliary nerves(pp. ciliares breves), in which, along with sensory fibers, there are parasympathetic fibers: 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 greater petrosal nerve they go to the pterygopalatine ganglion, and through the chorda tympani - to the submandibular and hypoglossal nodes, where they end in synapses. From these nodes, postganglionic fibers follow 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 inferior salivary nucleus go as part of the glossopharyngeal nerve and further along the lesser petrosal nerve to the ear ganglion, on the cells of which they end in synapses. Postganglionic fibers from the cells of the ear ganglion emerge as part of the auriculotemporal nerve and innervate the parotid gland.
Preganglionic parasympathetic fibers, starting from the cells of the dorsal ganglion 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 small ganglia of the intramural nerve plexuses of most internal organs, therefore postganglionic parasympathetic fibers appear to be very short compared to preganglionic fibers.
Human anatomy S.S. Mikhailov, A.V. Chukbar, A.G. Tsybulkin
