Lesions of the cervicothoracic ganglion (CTG) result in interruption of sympathetic fibers to the head, neck, upper limb, and thoracic viscera. The accurate understanding of the anatomy of the CTG is relevant to sympathectomy procedures that may be prescribed in cases where conventional intervention has failed. This study documents the incidence and distribution of the CTG to avoid potential complications such as Horner's syndrome and cardiac arrhythmias. This study utilized 48 cadavers, in which a total of 89 sympathetic chains were dissected. The inferior cervical ganglion (ICG) and the first thoracic ganglion was fused in 75 cases (84.3%) to form the CTG. It was present bilaterally in 48 of these specimens (65.3%). Three different shapes of CTG were differentiated, viz. spindle, dumbbell, and an inverted "L" shape. The dumbbell and inverted "L" shapes demonstrated a definite "waist" (i.e., a macroscopically visible union of the ICG and T1 components of the CTG). Rami from the CTG was distributed to the brachial plexus, the subclavian and vertebral arteries, the brachiocephalic trunk, and the cardiac plexus. This study demonstrates a high incidence of a double cardiac sympathetic nerve arising from CTG. It is therefore imperative that in the technique of sympathectomy, for intractable anginal pain, the surgeon excises both these rami but does not destroy the ganglion itself. The ever-improving technology in endoscopic surgery has made investigations into the nuances of the anatomy of the sympathetic chain essential.

An understanding of the origin of the sympathetic innervation of the upper limb is important in surgical sympathectomy procedures. An inconstant intrathoracic ramus which joined the 2nd intercostal nerve to the ventral ramus of the 1st thoracic nerve, proximal to the point where the latter gave a large branch to the brachial plexus, has become known as the ' nerve of Kuntz ' (Kuntz, 1927). Subsequently a variety of sympathetic interneuronal connections down to the 5th intercostal space were reported and also described as the nerve of Kuntz. The aim of this study was to determine : (1) the incidence, location and course of the nerve of Kuntz ; (2) the relationship of the nerve of Kuntz to the 2nd thoracic ganglion ; (3) the variations of the nerve of Kuntz in the absence of a stellate ganglion ; (4) to compare the original intrathoracic ramus with sympathetic variations at other intercostal levels ; and (5) to devise an appropriate anatomical classification of the nerves of Kuntz.Bilateral microdissection of the sympathetic chain and somatic nerves of the upper 5 intercostal spaces was undertaken in 32 fetuses (gestational age, 18 wk to full term) and 18 adult cadavers. The total sample size comprised 99 sides.Sympathetic contributions to the first thoracic nerve were found in 60 of 99 sides (left 32, right 28). Of these, 46 were confined to the 1st intercostal space only. The nerve of Kuntz (the original intrathoracic ramus) of the 1st intercostal space had a demonstrable sympathetic connection in 34 cases, and an absence of macroscopic sympathetic connections in 12. In the remaining intercostal spaces, intrathoracic rami uniting intercostal nerves were not observed. Additional sympathetic contributions (exclusive of rami communicantes) were noted between ganglia, interganglionic segments and intercostal nerves as additional rami communicantes. The eponym nerve of Kuntz should be restricted to descriptions of the intrathoracic ramus of the 1st intercostal space. Any of these variant sympathetic pathways may be responsible for the recurrence of symptoms after sympathectomy surgery.

Cardiac sympathetic denervation for intractable angina pectoris in patients unsuitable for conventional revascularization is currently gaining popularity since this procedure may be performed via minimally invasive surgery. A thorough understanding of cardiac innervation and its variations is crucial to successfully effect cardiac denervation. This study aimed to demonstrate the cervical and thoracic sympathetic contributions to the cardiac plexus. The cervical and thoracic sympathetic trunks in 21 fetuses and eight adults were micro-dissected bilaterally and documented ( n=58 sides). The superior cervical cardiac ramus originated from the superior cervical ganglion (present in all specimens) in 53% of cases. The middle cervical ganglion (incidence 81%) gave rise to the middle cervical cardiac ramus in 88% of cases. The cervico-thoracic ganglion (incidence 85%) gave the cervico-thoracic cardiac ramus in 84%. In the thoracic region, four cardiac rami arose from the T2-T6 segment of the thoracic sympathetic trunk. All cervical and thoracic cardiac rami were traced consistently to the deep cardiac plexus. Khogali et al.'s (1999) success of limited T2-T4 sympathectomy in relieving pain at rest of patients with intractable angina pectoris appears to indicate that a significant afferent pain pathway from the heart is selectively interrupted. The variability in pattern of the cervical ganglia, cardiac rami and cervical contributions to the cardiac plexus does not appear to affect the outcome of limited sympathectomy. The complexity of cardiac pain pathways is not fully understood. The study is continuing and attempts to contribute to defining these cardiac neuronal pathways.

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 l 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. The 3 splanchnic nerves of the thoracic sympathetic trunk, arise from the lower 8 ganglia. The greater splanchnic nerve (GSN) is formed by branches of the T5-9 sympathetic ganglia, the lesser splanchnic nerve (LSN) from T10-11 ganglia and the least splanchnic nerve (lSN) from the T12 ganglion. These splanchnic nerves contain, predominantly, visceral efferent fibres, as well as pain conducting visceral afferent fibres (McMinn, 1994).The highest cephalad contribution of the sympathetic chain to the GSN is documented as the T4 or

In recent years the second thoracic ganglion has gained anatomical significance as an important conduit for sympathetic innervation of the upper extremity. Thoracoscopic excision of the second thoracic ganglion is now widely recognized as affording the most effective treatment option for palmar hyperhidrosis. This study recorded the incidence, location and associated additional neural connections of the second thoracic ganglion. Bilateral dissection of 20 adult cadavers was undertaken, and all neural connections of the second thoracic ganglion were recorded. Nineteen cadavers (95%) demonstrated additional neural connections between the first thoracic ventral ramus and second intercostal nerve. These were classified as either type A (47.5%) or type B (45%) using the intrathoracic ramus (nerve of Kuntz) between the second intercostal nerve and the ventral ramus of the first thoracic nerve as a basis on both right and left sides. The second thoracic ganglion was commonly located (92.5%) in the second intercostal space at the level of the intervertebral disc between the second and third thoracic vertebrae. Fused ganglia between the second thoracic and first thoracic (5%) and stellate (5%) ganglia were noted. These findings should assist the operating surgeon with a clear knowledge of the anatomy of the second thoracic ganglion during thoracoscopic sympathectomy with a view to improving the success rate for upper limb sympathectomy.