A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet‐Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)‐guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful. Clin. Anat. 23:512–522, 2010. © 2010 Wiley‐Liss, Inc.     

Anatomy of thoracic splanchnic nerves for surgical resection

Thoracic splanchnic nerves conduct pain sensation from the abdominal organs around the celiac ganglion. Splanchnicectomy is the procedure used mainly for the control of intractable visceral pain. Forty-six human posterior thoracic walls were dissected. The formation pattern, course, and incidence of communication of the thoracic splanchnic nerves were investigated. The greater splanchnic nerves (GSNs) were formed by nerve branches from the T4-T11 thoracic sympathetic ganglia and the most common type was formed by T5-T9 (21.7%). The uppermost branches originated from T4-T9 while the lowermost branches emanated from the T7-T11. Two to seven ganglia contributed to the GSNs. In 54.3% of the specimens, at least one ganglion in the GSN-tributary ganglionic array did not branch to the GSN. The lesser splanchnic nerves (LSNs) were formed by the nerve branches of the T8-T12 thoracic sympathetic ganglia and the most common type was formed by T10 and T11 (32.6%). One to five ganglia were involved in the LSNs. The least splanchnic nerves (lSNs) were composed of branches from the T10-L1 thoracic sympathetic ganglia and the most common type was composed of nerve branches from T11 and T12 or from T12 only (each 30.4%). One to three ganglia were involved in the lSNs. In 54.3% of the specimens, interconnection between the GSNs and the LSNs existed, bringing the possible bypass around the transection of the GSNs. The splanchnic nerves that appear in textbooks occurred in a minority of our specimens. We provided expanded anatomical data for splanchnicectomy in this report.     

Thoracic splanchnic nerves: implications for splanchnic denervation

Splanchnic neurectomy is of value in the management of chronic abdominal pain. It is postulated that the inconsistent results of splanchnicectomies may be due to anatomical variations in the pattern of splanchnic nerves. The advent of minimally invasive and video-assisted surgery has rekindled interest in the frequency of variations of the splanchnic nerves. The aims of this study were to investigate the incidence, origin and pattern of the splanchnic nerves in order to establish a predictable pattern of splanchnic neural anatomy that may be of surgical relevance. Six adult and 14 fetal cadavers were dissected (n = 38). The origin of the splanchnic nerve was bilaterally asymmetrical in all cases. The greater splanchnic nerve (GSN) was always present, whereas the lesser splanchnic nerve (LSN) and least splanchnic nerve (lSN) were inconsistent (LSN, 35 of 38 sides (92%); LSN, 21 of 38 sides (55%). The splanchnic nerves were observed most frequently over the following ranges: GSN, T6–9: 28 of 38 sides (73%); LSN, when present, T10–11: (10 of 35 sides (29%); and lSN, T11–12: 3 of 21 sides (14%). The number of ganglionic roots of the GSN varied between 3 and 10 (widest T4–11; narrowest, T5–7). Intermediate splanchnic ganglia, when present, were observed only on the GSN main trunk with an incidence of 6 of 10 sides (60%) in the adult and 11 of 28 sides (39%) in the fetus. The higher incidence of the origin of GSN above T5 has clinical implications, given the widely discussed technique of undertaking splanchnicectomy from the T5 ganglion distally. This approach overlooks important nerve contributions and thereby may compromise clinical outcome. In the light of these variations, a reappraisal of current surgical techniques used in thoracoscopic splanchnicectomy is warranted.     

Anatomical variations of the upper thoracic sympathetic chain

The aim is to clearly delineate the upper thoracic sympathetic chains and neural connections between the chains and ventral rami of the thoracic nerves, and to provide an anatomical foundation for successful upper thoracic sympathicotomy for treating upper essential hyperhidrosis. The upper thoracic sympathetic chains, upper five intercostal nerves, and neural connections between them in 50 halves of 25 adult cadavers have been dissected, measured, and mapped. The stellate ganglion had an incidence of 80%. The second to the fourth thoracic sympathetic ganglia were commonly located in the corresponding intercostal spaces with the presence of 92%, 68%, and 50%, respectively. The incidence of the first and second intercostal rami was 40% and 6%, and that of the ascending or descending rami from the second, third and fourth ganglia was 54%, 24%, and 14%, respectively. Additional rami communicantes joined the ventral ramus of the 1st thoracic nerve proximal to the point where the latter gave a branch to the brachial plexus. The farthest horizontal distance from the sympathetic chain to the junction between the additional rami communicantes and the second to the fourth intercostal nerves was 29.1 mm. Only 16% of cadavers had similar anatomy bilaterally. Anatomical variations of the upper thoracic sympathetic trunk in relation to intercostal nerves, which may be one of the causes resulting in surgical failures and recurrences, were striking. Attention should be given to such anatomical variations when planning thoracic sympathicotomy. Clin. Anat. 22:595–600, 2009. © 2009 Wiley‐Liss, Inc.     

Branches of the thoracic sympathetic trunk in the human fetus

Summary The segmental organization of the thoracic sympathetic trunk and all its ramifications was studied in 6 human fetuses (16–22 weeks) by means of the acetylcholinesterase in toto staining method. Each trunk was divided into 12 sympathetic segments. A segment is defined as that part of the sympathetic trunk which is connected via its rami communicates with one spinal nerve, without discriminating between grey and white rami. The diameter of the rami communicantes and their direction towards the spinal nerves are variable. The number of peripheral segmental ramifications of the trunk is much larger than assumed previously. Each thoracic sympathetic segment gives off at least 4–5 nerves. Three categories of nerves are discerned: (1) large splanchnic rootlets confined to the greater, lesser and least thoracic splanchnic nerves, (2) medium-sized splanchnic nerves directed towards thoracic viscera, some of which give off branches towards costovertebral joint plexuses and, described for the first time in man, (3) small nerves which ramify extensively and form nerve plexuses in the capsule of the costovertebral joints. The majority of the ramifications is formed by the nerves of the third category. The existence of Kuntz's nerve, connecting the 2nd intercostal nerve and 1st thoracic spinal nerve, is confirmed in four specimens. The nerve plexuses of the costovertebral joints receive a segmentally organized innervation: they receive their input from the neighbouring sympathetic segment and the one cranial to it.It is concluded that the thoracic sympathetic branches in man show a complex, segmentally organized pattern and may have a considerable component of somatosensory nerve fibers. The complex relationships must be taken into account in surgical sympathectomies.     

Nervous control of pancreatic endocrine secretion in pigs. V. Influence of the sympathetic nervous system on the pancreatic secretion of insulin and glucagon, and on the insulin and glucagon response to vagal stimulation

Electrical stimulation of the splanchnic nerves in anesthetized pigs was found to stimulate markedly the pancreatic secretion of glucagon. The response pattern was glucose dependent, the glucagon responses at blood glucose concentrations below 4.5 mmol x l-1 being significantly greater than those noted during stimulation at higher concentrations. Insulin secretion was stimulated weakly and variably and only at higher glucose levels. The magnitude of the glucagon response was comparable to that obtained by electrical stimulation of the thoracic vagus nerves with the same frequency. The glucagon response to combined vagal and splanchnic stimulation was nearly identical to the sum of the responses to the two types of stimulation, whereas splanchnic stimulation abolished or reduced the increase in insulin secretion elicited by vagal stimulation. Combined alpha- and beta-adrenergic blockade markedly reduced the glucagon responses to splanchnic stimulation.     

Nervous control of pancreatic endocrine secretion in pigs V. Influence of the sympathetic nervous system on the pancreatic secretion of insulin and glucagon,and on the insulin and glucagon response to vagal stimulation

Electrical stimulation of the splanchnic nerves in anesthetized pigs was found to stimulate markedly the pancreatic secretion of glucagon. The response pattern was glucose dependent, the glucagon responses at blood glucose concentrations below 4.5 mmol×l^–1being significantly greater than those noted during stimulation at higher concentrations. Insulin secretion was stimulated weakly and variably and only at higher glucose levels. The magnitude of the glucagon response was comparable to that obtained by electrical stimulation of the thoracic vagus nerves with the same frequency. The glucagon response to combined vagal and splanchnic stimulation was nearly identical to the sum of the responses to the two types of stimulation, whereas splanchnic stimulation abolished or reduced the increase in insulin secretion elicited by vagal stimulation. Combined α- and β-adrenergic blockade markedly reduced the glucagon responses to splanchnic stimulation.     

The functional morphology of the afferent systems of the splanchnic nerves

Summary The morphology, the sources of formation and the functional characteristics of the afferent sympathetic fibers of the splanchnic nerves were studied.The removal of the gall bladder and of the small intestine, as well as of the semilunar ganglia of the solar plexus was associated with a secondary degeneration of the amyelinated and thin myelinated conductors contained in the splanchnic nerves. This fact shows that they pertain to the neurites of the receptor neurons (II type Dogiel's cells) located in the plexuses within the walls of the corresponding organs.The electrophysiological and the histochemical study of these neurites was studied after the exclusion of all the spinal afferent fibers of the splanchnic nerves. The preservation of their morphology, function and the enzymatic activity in the peripheral portion of the splanchnic nerve in 21–27 days after its section was demonstrated. Their physiological characteristics are determined by the functional, state of the corresponding organ.Presented by Active Member AMN SSSR V.N. ChernigovskiiA paper presented to the First Belorussian Conference of Anatomists, Histologists, Embryologists and Topographical Anatomists on June 14, 1957, in Minsk.     

Myelinated nerve fiber analysis of the human greater splanchnic nerve.

The purpose of the present study is to analyze the human greater splanchnic nerve in relation to aging. We adopted a new staining method which makes it possible to discriminate various structures of the nervous tissue. We examined 25 human greater splanchnic nerves from cadavers for anatomy dissection. We measured the number, area and perimeter of axons. The results reveal that: (1) there is no correlation between age and the number of axons; (2) the mean area and perimeter of axons increase with age, but not the total area and perimeter. We compared these results with those for the lesser splanchnic nerve. These morphological changes in the greater splanchnic nerve may indicate a kind of compensation through axon hypertrophy for hypofunctions in abdominal organ control.     

Pathways of anesthetic from the thoracic paravertebral region to the celiac ganglion

Communication between the lower thoracic paravertebral region and the celiac ganglion through the retrocrural space was investigated. After dye was injected into the endothoracic fascia in the lower thoracic paravertebral region at the T11 level, its spread to the celiac ganglion was examined in fifteen cadavers. The dye reached the celiac ganglion in nine cadavers (60%) by passing through the retrocrural space, along the greater and lesser splanchnic nerves and through the split in the crus of the diaphragm through which the splanchnic nerves traveled. In the remaining six cadavers, dye spread toward the ganglion along the crus of the diaphragm. In three living subjects the spread of a radio-opaque dye injected in the same manner was studied using 3D-computed tomography. This study confirmed that the radio-opaque dye traveled toward the celiac ganglion along the crus of the diaphragm. From our results we suggest that a fluid communication may exist between the lower thoracic paravertebral region and the celiac ganglion in cadavers and in living humans and that clinicians should be aware of this possible route of spread when administering lower thoracic paravertebral anesthesia.     

Anatomical study of the articular branches innervated the hip and knee joint with reference to mechanism of referral pain in hip joint disease patients

Introduction : Referred pain in the anterior knee joint is the most common symptom in hip disease patients. The development of referred pain is considered to be related to dichotomizing peripheral sensory fibers. However, no gross anatomical findings identify any dichotomizing fibers innervating both the hip and knee joints. We dissected the femoral and obturator nerves in human cadavers to investigate the distribution of the articular branches in the hip and knee joints. Fourteen embalmed left lower limbs from 14 Japanese adult cadavers (five from females, nine from males, average age 73.8 ± 14.1 years) were observed macroscopically. The articular branches of the femoral and obturator nerves were dissected at the anterior margin of the groin toward the thigh region. After dissections of the articular nerves of the hip joints, the femoral and obturator nerves were exposed from proximally to distally to identify the articular nerves of the knee joints. The branching pattern of the articular branches in the hip and knee joints was recorded. In six of 14 limbs (42.9%), the femoral nerve supplied articular branches to the anteromedial aspect of both the hip and knee joints. These articular branches were derived from the same bundle of femoral nerve. These gross anatomical findings suggested that dichotomizing peripheral sensory fibers innervate the hip and knee joints and these could relate to the referred pain confirmed in the anterior knee joints of patients with hip disease. Clin. Anat. 31:705–709, 2018. © 2018 Wiley Periodicals, Inc.     

On the gastrocecal inhibitory reflex in the rat

In rats anesthetized with urethane, the effects of distention of the stomach upon cecal motility and neural mechanisms which generate this effect were studied. Cecal motility was inhibited which generate this effect were studied. Cecal motility was inhibited when the pars glandularis of the stomach was distended by pressure ranging from 25 to 30 cm H2O. This inhibitory reflex was not affected by bilateral cervical vagotomy, but completely abolished following bilateral severance of the greater splanchnic nerves or after intravenous administration of guanethidine. After transection of the spinal cord at the level of the 5th thoracic segment the inhibitory reflex remained intact, but was abolished following pithing of the 6th thoracic segment and below. It may be concluded that the afferent and efferent path of the gastrocecal inhibitory reflex mainly pass through the greater splanchnic nerves and the reflex center is located in thoracic segments caudal to the 6th thoracic segment.     

"Pes anserinus" of the right phrenic nerve innervating the serous membrane of the liver: a case report (anatomical study)

During the preparations of cadavers for educational purposes we followed the course of the right phrenic nerve. On one of them and especially a female cadaver aged 72-year-old we found a branch arising from the thoracic portion of the right phrenic and passing through the two layers of the falciform ligament distributed to the upper surface of the serous layer of the liver in the form of "pes anserinus". As it is known, pain referred from the diaphragmatic peritoneum is classically felt in the shoulder tip but pain from thoracic surfaces supplied by the phrenic nerve is usually located there albeit vaguely. We believe that the above anatomical finding is the explanation of distinct radiating pain from the hepatic region to the right shoulder in some patients. The stimulations is carried through the phrenic nerve to the fourth cervical neurotome from were arise the supraclavicular nerves which are distributed to the shoulder region.     

Anatomical bases of the transhiatus approach to the greater splanchnic nerve

Summary The level of origin and mode of constitution of the greater splanchnic nerve and its relations in the posterior mediastinum were studied. The aim of this work was to identify the anatomical basis of the transhiatus approach to the right and left greater splanchnic nerves. The azygos venous system was seen to be the main anatomical relation of these nerves. The results of this study should allow the surgeon to perform total bilateral neurotomy.

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Bases anatomiques de l'abord trans-hiatal des nerfs grands splanchniques

Résumé La hauteur et le mode de constitution des nerfs grands splanchniques ainsi que leurs rapports dans le médiastin postérieur ont été étudiés pour préciser les bases anatomiques de l'abord trans-hiatal des nerfs grands splanchniques. Le système veineux azygos constitue le rapport essentiel. Le but de ce travail est de permettre une neurectomie bilatérale complète.

     

Three muscles in the upper costovertebral region: Description and clinical anatomy

The aim of the study was to describe three small muscles in the upper costovertebral region that have close proximity to the ventral rami of the lower cervical and upper two thoracic spinal nerves. The study was performed using both anterior and posterior approaches to the costovertebral region. Twenty‐five human cadavers, 15 males and 10 females with a mean age of 50 years and with normal spines, constituted the material of the study. Dissection revealed the presence of three triangular muscles that extended from the transverse processes of the seventh cervical through second thoracic vertebrae to the upper borders of the necks of the first through third ribs, respectively. The second and third muscles are described and reported for the first time. The ventral rami of the lower cervical and upper two thoracic spinal nerves emerged through narrow gaps between the described muscles and the bodies of seventh cervical and upper two thoracic vertebrae, respectively. The lateral branch of the dorsal ramus of the corresponding spinal nerve issued posteriorly between the muscle and the articular capsule of the zygapophyseal joint. It then curved round the posterior aspect of the muscle and passed through the gap between the muscle and the levator costarum, after supplying them both. We suggest that these three muscles were suggested to share a common embryogenesis with the intertransverse muscles. In addition, this study suggests that the three muscles described herein could be one of the potential causes of thoracic outlet syndrome. Clin. Anat. 22:352–357, 2009. © 2009 Wiley‐Liss, Inc.     

The long thoracic nerve: Its origin,branches, and relationship to the middle scalene muscle

Anatomical knowledge regarding the long thoracic nerve (LTN) is important during surgical procedures considering that dysfunction of this nerve results in clinical problems. The purpose of this study was to explore the anatomy of the LTN, its origin, configuration, branching pattern, and relationship to the middle scalene muscle (MSM). The course of the LTN was investigated in 12 embalmed cadavers (21 sides). We defined four different types for this nerve according to the origins of its roots. The most common formation of the LTN was the contribution of three branches that originated from the fifth, sixth, and seventh cervical ventral roots. C5 and C6 components or upper portion of the LTN roots lay primarily between the middle and posterior scalene muscles, sometimes passed through the MSM, and less frequently coursed over the MSM. C7 contributions to the LTN were always located anterior to the MSM. Contributions from C8 were also found over the MSM. The median number of branches arising directly from the cervical roots and branches arising from the main trunk of the nerve were 3 and 7, respectively. Along its course, the median number of branches to the serratus anterior was 10. Clin. Anat. 22:476–480, 2009. © 2009 Wiley‐Liss, Inc.     

Communications between the palmar digital branches of the median and ulnar nerves: A study in human fetuses and a review of the literature

In this study, median nerves (MNs) and ulnar nerves (UNs) were dissected in 200 palmar sides of hands (left and right) of 100 (50 male, 50 female) spontaneously aborted fetuses with no detectable malformations. The fetuses, whose gestational ages ranged from 13 to 40 weeks, were dissected under an operating microscope. The MN divided first into a lateral ramus and a medial ramus and then formed a common digital nerve. The first common digital nerve trifurcated in all of the studied cases. The branching patterns were classified into two types (Type 1 and Type 2) based on the relationship with the flexor retinaculum (behind/distal of it). A communication branch between the UNs and MNs in the palmar surface of the hand was found in 59 hands (29.5%). The proper palmar digital nerves were numbered from p1 to p10, starting from the radial half of the thumb to the ulnar half of the little finger, and these nerves exhibited six types of variations. The present data obtained from human fetuses will aid in elucidating the developmental anatomy of the nervous system and provide hand surgeons with a more complete anatomical picture to help them to avoid iatrogenic injuries. Clin. Anat. 23:234–241, 2010. © 2009 Wiley‐Liss, Inc.     

A computed tomography and magnetic resonance imaging study of the variations of the sciatic nerve branches of the pediatric knee: Implications for peripheral nerve blockade

In pediatric patients, peripheral anesthetic blockade of the sciatic nerve is useful for postoperative pain relief after orthopedic procedures of the lower limb. The identification of the sciatic and its branches relative to the surrounding anatomical structures of the knee significantly contribute to the successful nerve blockade. However, reports have demonstrated complications arising from the inadequate and inconsistent understanding of the anatomy of the nerves in the knee region. In addition, the paucity of information regarding the location of the nerves of the knee throughout the pediatric development needs to be addressed in order for peripheral nerve blockades to become more readily used among the pediatric population. This clinical imaging study therefore aimed to document and analyze the relative morphometric relationship of the nerves in the knee region throughout the different stages of pediatric development. The locations of the sciatic, tibial, and common fibular nerves were measured in relation to relevant anatomical structures in 142 pediatric magnetic resonance imaging and computed tomography. A strong correlation was found between age and the distance from the common fibular nerve to the semitendinosus muscle, and thus can be used to predict stature. Significant differences were found between males and females, specifically after puberty, suggesting that sexual dimorphism emerges more distinctively at puberty. In order to predict the location of the nerves at the popliteal fossa, a regression formula using the patient's age and bicondylar width was created. These finding may have significant implications for popliteal approach of the sciatic nerve blockade in pediatric patients. Clin. Anat. 32:836–850, 2019. © 2019 Wiley Periodicals, Inc.     

Selective effects of vagal deafferentation and celiac-superior mesenteric ganglionectomy on the reinforcing and satiating action of intestinal nutrients

The role of vagal afferents and splanchnic fibers in nutrient-induced flavor conditioning and feeding suppression was determined. Male rats were fitted with intraduodenal (ID) catheters and given subdiaphragmatic vagal deafferentation (SDA), celiac-superior mesenteric ganglionectomy (CGX), combined (COM) treatments, or sham surgery. In separate conditioning trials, they were trained to drink (30 min/day) flavored saccharin solutions paired with concurrent ID infusions of 8% maltodextrin or water and 3.55% corn oil or water. Experiment 1 revealed that SDA and sham rats showed equal preferences for the nutrient-paired flavors over the water-paired flavors. In contrast, SDA rats, unlike sham rats, failed to suppress their intake of a palatable fluid when infused intraduodenally with maltodextrin or corn oil. Experiment 2 revealed that CGX, COM and sham rats all developed preferences for the maltodextrin-paired flavor, although CGX alone or COM attenuated the conditioned preference. CGX and COM treatments also attenuated or blocked the feeding inhibitory actions of ID nutrient infusions. These findings along with prior data indicate that gut vagal afferents and splanchnic nerves are not essential for flavor-nutrient preference conditioning, whereas both vagal afferents and splanchnic nerves are implicated in carbohydrate- and fat-induced satiation.