Cervical sympathetic trunk: topography, nodes, branches, area of ​​innervation. Thoracic sympathetic trunk Cervical sympathetic trunk

The sympathetic trunk (truncus sympathicus) is paired, formed by nodes interconnected by sympathetic fibers. The sympathetic trunk is located on the lateral surface of the spine throughout its entire length. Each node of the sympathetic trunk represents a cluster of autonomic neurons, with the help of which most of the preganglionic fibers that exit the spinal cord and form white connecting branches (rr. communicantes albi) switch. Preganglionic fibers contact vegetative cells in the corresponding node or are sent as part of internodal branches to higher or lower nodes of the sympathetic trunk. White connecting branches are located in the thoracic and upper lumbar regions. There are no such connecting branches in the cervical, sacral, and lower lumbar nodes. The nodes of the sympathetic trunk are also connected with special fibers to the spinal nerves - gray connecting branches (rr. communicantes grisei), consisting mainly of postganglionic sympathetic fibers. Gray connecting branches depart from each node of the sympathetic trunk to each spinal nerve, in which they are sent to the periphery, reaching the innervated organs - striated muscles, smooth muscles and glands.

The sympathetic trunk is conditionally divided into the cervical, thoracic, lumbar and sacral regions.

The cervical region of the sympathetic trunk includes three nodes: upper, middle and lower.

The upper knot (gangl. cervicale superius) has a spindle shape 5 * 20 mm in size. Located on the transverse processes of II - III cervical vertebrae, covered with prevertebral fascia. Seven main branches depart from the node, containing postganglionic fibers for the innervation of the organs of the head and neck.
1. Gray connecting branches to I, II, III cervical spinal nerves.

2. The jugular nerve (n. jugularis) is divided into two branches, the fibers of which join the vagus and glossopharyngeal nerves in the region of their lower nodes, and into a branch, the fibers of which join the hypoglossal nerve.

3. The internal carotid nerve (n. caroticus internus) penetrates into the adventitia of the internal carotid artery, where its fibers form the plexus of the same name. From the plexus of this artery at the site of its entry into the carotid canal of the temporal bone, sympathetic fibers are separated, forming a deep stony nerve (n. petrosus profundus), passing into the pterygoid canal (canalis pterygoideus) of the sphenoid bone. After leaving the canal, they pass through the pterygopalatine fossa, connecting to the postganglionic parasympathetic nerves of the pterygopalatine ganglion and sensory nerves n. maxillaris, and diverge to the organs of the face. Branches extend from the internal carotid plexus in the carotid canal, penetrating into the tympanic cavity, participating in the formation of the tympanic plexus (plexus tympanicus). In the cranial cavity, the continuation of the internal carotid plexus is the cavernous, the fibers of which are distributed along the branches of the vessels of the brain, forming the plexus of the anterior, middle cerebral arteries (plexus arteriae cerebri anterior et medius), as well as the plexus of the ophthalmic artery (plexus ophthalmicus). Branches depart from the cavernous plexus, passing into the ciliary parasympathetic node (gangl. ciliare), connecting to its parasympathetic fibers to innervate the muscle that dilates the pupil (m. dilatator pupillae).

4. The external carotid nerve (n. caroticus externus) is thicker than the previous one. Around the artery of the same name, it forms the external plexus (plexus caroticus externus), from which the fibers are distributed to all its arterial branches, supplying blood to the facial section of the head, dura mater and neck organs.

5. Laryngeal-pharyngeal branches (rr. laryngopharyngei) are distributed along the vessels of the pharyngeal wall, forming the pharyngeal plexus (plexus pharyngeus).

6. The upper cardiac nerve (n. cardiacus superior) is sometimes absent on the right, descends next to the cervical sympathetic trunk. In the chest cavity, it participates in the formation of a superficial cardiac plexus located under the aortic arch.

7. The branches that make up the phrenic nerve terminate in the pericardium, pleura, diaphragm, parietal peritoneum of the diaphragm, ligaments and liver capsule.

The middle node (gangl. cervicale medium), 2x2 mm in size, is located at the level of the VI cervical vertebra at the intersection of the inferior thyroid and common carotid arteries; often missing. Four types of branches depart from this node:

1. Gray connecting branches to the V and VI cervical spinal nerves.

2. Middle cardiac nerve (n. cardiacus medius), located behind the common carotid artery. In the chest cavity, it takes part in the formation of a deep cardiac plexus located between the aortic arch and the trachea.

3. Branches involved in the formation of the nerve plexus of the common carotid and subclavian arteries, as well as the plexus of the inferior thyroid artery. Vegetative plexuses are formed in these organs.

4. Internodal branch to the superior cervical sympathetic ganglion.

The lower node (gangl. cervicale inferius) is located above the subclavian artery and behind the vertebral artery. Sometimes it connects to the I thoracic sympathetic node and is called the cervicothoracic (stellate) node (gangl. cervicothoracicum s. stellatum). 6 branches depart from the lower node.
1. Gray connecting branches to the VII and VIII cervical spinal nerves.

2. Branch to the plexus of the vertebral artery (plexus vertebralis), which extends into the skull, where it forms the basilar plexus and the plexus of the posterior cerebral artery.

3. Lower cardiac nerve (n. cardiacus inferior), located on the left behind the aorta, on the right - behind the brachiocephalic artery; takes part in the formation of the deep plexus of the heart.

4. Branches to the phrenic nerve do not form a plexus. They reach the pleura, pericardium and diaphragm.

5. Branches to the plexus of the common carotid artery (plexus caroticus communis).

6. Branches to the subclavian artery (plexus subclavius).

Thoracic nodes (ganglia thoracica) are located on the sides of the thoracic vertebrae on the necks of the ribs, covered with parietal pleura and intrathoracic fascia (f. endothoracalis). The thoracic sympathetic nodes have mainly six groups of branches:

1. White connecting branches enter the nodes from the anterior roots of the intercostal nerves ().

2. Gray connecting branches depart from the nodes to the intercostal nerves.

3. Mediastinal branches (rr. mediastinales) start from the V upper sympathetic nodes and enter the region of the posterior mediastinum. They take part in the formation of the esophageal and bronchial plexuses.

4. Thoracic cardiac nerves (nn. cardiaci thoracici) start from IV - V upper sympathetic nodes, are part of the deep cardiac plexus and thoracic aortic plexus.

5. The large splanchnic nerve (n. splanchnicus major) is formed from the branches of the V-IX thoracic sympathetic nodes. The nerve is located under the intrathoracic fascia. Through the opening between the medial and intermediate crura of the diaphragm, the large splanchnic nerve enters the abdominal cavity, ending at the nodes of the celiac plexus. The nerve contains a large number of preganglionic fibers that switch in the nodes of the celiac plexus to postganglionic fibers, and fewer postganglionic fibers that have already switched in the thoracic nodes of the sympathetic trunk.

6. Small splanchnic nerve (n. splanchnicus minor) is formed from the branches of nodes X-XII. Through the diaphragm, it descends lateral to the large splanchnic nerve and reaches the celiac plexus. Preganglionic fibers switch to postganglionic ones at the sympathetic nodes, and another group of preganglionic fibers switched at the thoracic nodes goes to the organs.

The lumbar nodes (ganglia, lumbalia) of the sympathetic trunk are a continuation of the chain of nodes of the thoracic part, located between the lateral and intermediate legs of the diaphragm. They include 3-4 nodes located on the sides of the spine on the medial edge of m. psoas major. On the right, the nodes are visible lateral to the inferior vena cava, and on the left, lateral to the aorta. Branches of the lumbar sympathetic nodes:

1. White connecting branches are suitable only for nodes I, II from I and II lumbar spinal nerves.

2. Gray connecting branches connect the lumbar nodes with all lumbar spinal nerves.

3. Lumbar splanchnic nerves (nn. splanchnici lumbales) from all nodes are connected to the celiac (plexus celiacus), renal (plexus renalis), superior mesenteric (plexus mesentericus superior), abdominal aortic (plexus aorticus) and superior hypogastric (plexus hypogastricus superior) , plexus.

The sacral nodes (ganglia sacralia) of the sympathetic trunk include 3-4 paired sacral and 1 unpaired coccygeal nodes, which are located medially to the anterior sacral foramen.
1. Gray connecting branches go to the spinal and sacral nerves.

2. Internal nerves (nn. splanchnici sacrales) are involved in the formation of the autonomic plexus of the small pelvis. Visceral branches form the lower hypogastric plexus (plexus hypogastricus inferior), located on the branches of the internal iliac artery; along its branches, sympathetic nerves reach the pelvic organs.

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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. one.

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(p. 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 (p. jugularis) starts from the upper cervical node, 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(p. 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

In the cervical part of the sympathetic trunk, there are three nodes - the upper, posterior and lower cervical nodes.
From the superior cervical sympathetic ganglion, postganglionic sympathetic fibers go to the choroid plexuses of the internal carotid, vertebral, and basilar arteries in various regions of the head. These include the jugular nerve and the internal carotid nerve, which forms a wide-loop network around the internal carotid artery - the internal carotid plexus, which later passes to branches of the internal carotid artery, forms a number of plexuses and gives off the following nerve branches: carotid-tympanic nerves, deep stony nerve (has a sympathetic root in the pterygopalatine node) and the cavernous plexus. The latter surrounds the trunk of the internal carotid artery at its location in the cavernous sinus and sends branches to the nerves and other formations lying in this area and in the cavity of the orbit:

• to the pituitary
• to the trigeminal node;
• to the middle portion of the muscle that lifts the upper eyelid (Muller's muscle);
• to the orbital (circular) muscle of the eye and to the lacrimal gland;
• to blood vessels, sweat glands of the skin of the face and neck;
• to the ophthalmic artery, forming a plexus on its walls, which sends a stem that accompanies the central retinal artery to the retina itself;
• to the anterior artery and middle artery of the brain, to the anterior artery of the choroid plexus;
• to the ciliary ganglion, from which the sympathetic branch as part of the short ciliary nerves goes to the muscle.

Superior cervical sympathetic ganglion syndrome
The clinical picture can develop according to one of the types - a variant of loss or irritation is possible.
In the variant of prolapse on the homolateral half of the face, vasomotor disorders occur.
With a variant of irritation, attacks of burning pain appear, which last from several hours to several days. The pain appears in the occipital region and radiates to the neck, shoulder and forearm. The development of an attack is provoked by hypothermia, sinusitis, frontal sinusitis.
eye symptoms. A characteristic manifestation of loss of function is the appearance of signs of the Bernard-Horner syndrome. The manifestations of the syndrome are caused by a violation of the sympathetic innervation of the eyeball, which includes the following symptoms:

• narrowing of the palpebral fissure - associated with partial ptosis resulting from dysfunction of the middle portion of the muscle that lifts the upper eyelid (Muller muscle). As a rule, there is a drooping of the upper eyelid by 1-2 mm in combination with a rise of the lower eyelid by 1 mm;
• enophthalmos occurs due to a decrease in the tension of the orbital muscle;
• miosis is due to the absence of contraction of the pupil dilator;
• heterochromia is observed, which is manifested by a lighter color of the iris on the affected side. Basically, heterochromia occurs with a congenital syndrome, although cases of heterochromia have also been described in patients with an acquired disorder;
• lack of sweating is associated with damage to preganglionic neurons. The process of sweating on the ipsilateral side of the face is disturbed, there are flushes of blood to the face, conjunctival injection and difficulty in nasal breathing.

In the variant of irritation, Petit's syndrome develops, which includes the following symptoms: mydriasis, expansion of the palpebral fissure, exophthalmos. As a rule, one-sided irritation of the cervical sympathetic nodes is observed. In the case of bilateral irritation, signs of Petit's syndrome are observed on both sides, as a result of which external signs of excitation appear (wide-open shiny eyes).

Syndrome of the cervicothoracic (stellate) node
Clinical signs and symptoms. There are pains in the neck, chest to the level of the V-VI ribs, and pain in the arm also occurs. It should be noted that there are no pain sensations on the inner surface. There is a decrease in pain sensitivity, impaired sweating and piloarrection in these areas.
eye symptoms.

Posterior cervical sympathetic syndrome (syn. Barre-Lie syndrome, "cervical migraine")
The defeat of the sympathetic plexus of the vertebral artery can occur due to transient circulatory disorders, mechanical compression, intoxication and infectious processes. The most common causes of the development of the syndrome are osteochondrosis of the cervical spine, arachnoiditis, lymphadenitis, stenosing processes in the basin of the vertebral and main arteries, tumors located in the neck, injuries with displacement of the intervertebral cartilage.

There are three variants of the syndrome:

1. manifested by damage to the spinal nerves;
2. accompanied by a violation of the diencephalon;
3. involving peripheral nerves.

Clinical signs and symptoms. There is a constant long (up to 1 day or more) excruciating headache. Less commonly, the pain may be paroxysmal in nature. The pain is usually unilateral. Initially, it appears in the back of the neck and occipital region and spreads to the parietal, frontal regions, as well as to the orbit and the region of the nose; may be aggravated by turning the head, at night and after sleep. At the peak of a headache attack, debilitating vomiting may occur. Along with a headache, vestibular dizziness, loss of stability when standing and walking, hearing disorders, tinnitus, sweating, a feeling of heat, redness of the face, sometimes pain in the face, and discomfort in the pharynx appear. Neurotic phenomena often occur (fixed position of the head in the direction of the lesion, palpitations, pain in the hands, paresthesia and numbness of the hands).
eye symptoms. Against the background of a headache, blurred vision, photopsias, atrial scotomas, photophobia, accommodative asthenopia, pain behind the eyeball, a feeling of pressure in the eyes, blepharospasm occur, and a decrease in the sensitivity of the cornea is observed. In some cases - deterioration of blood circulation in the arterial vessels of the retina, signs of retrobulbar neuritis, superficial keratitis, miosis, Fuchs heterochromia; increase in IOP is possible.
Differential diagnosis is carried out with hypertensive cerebral crises, occipital neuralgia, atypical trigeminal neuralgia, with Meniere's, Barani's syndromes, etc.

Jugular foramen syndrome (syn. Berne-Sicard-Colle syndrome)
Occurs when the glossopharyngeal, vagus and accessory nerves are damaged. It is observed with the localization of pathological processes in the region of the jugular foramen. The cause of the development of the syndrome can be fractures of the base of the skull, sarcoma, etc.
eye symptoms. There are signs of the Bernard-Horner syndrome.

Riley-Day syndrome (syn. autonomic dysfunction, familial dysautonomy)
Occurs mainly in Jewish children.
The disease occurs due to the disintegration of the functions of the autonomic nervous system, one of the causes of which, perhaps, is a congenital defect in the conversion of catecholamine precursors to norepinephrine and epinephrine.
Clinical signs and symptoms. Characterized by vasomotor lability, decreased pain sensitivity and perception of smells and tastes, episodic rises in body temperature, attacks of respiratory and cardiac disorders, transient arterial hypertension. There is difficulty in swallowing, increased salivation and sweating, impaired urination. Most patients develop coordination disorders, epileptiform convulsions, vomiting, aspiration of vomit, diarrhea. There is a delay in physical development. At the age of 8-10 years, scoliosis develops in half of the cases. Approximately half of patients have mental retardation.
In the blood plasma, the concentration of epinephrine and norepinephrine is increased, in the urine there is a high level of O-tyrosine and homovaleric acid.
The prognosis for life is unfavorable. Patients often die in adolescence from renal hypertension, bronchopneumonia and other diseases.
Eye symptoms. There is a decrease or absence of tear production, dry eyes, decreased sensitivity and ulceration of the corneas, sometimes without signs of inflammation and without pain, corneal perforation may occur. With ophthalmoscopy, attention is drawn to the tortuosity of the retinal vessels. In most cases myopia develops.
Differential diagnosis is carried out with Sjögren's syndrome, congenital analgia syndrome.

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 reflex 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 st ox, 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). Behind 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. Paresthesia, hypoesthesia or hyperesthesia, 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 injected 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 cholinolytic 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. On the area of ​​the affected areas of the sympathetic trunk, electrophoresis of novocaine, amidopyrine, ganglerone, potassium iodide is used. 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.