Anatomical variations of the upper thoracic sympathetic chain

Abstract

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.

Nerves of the Upper Extremity

“…It has been found that the fibers from the second to eighth thoracic levels may participate in the sympathetic innervation of the upper extremity, although a narrow number of thoracic levels has also been suggested (Cho et al 2005;Zhang et al 2009). A variant communication from the second thoracic level to the brachial plexus, commonly referred to as the nerve of Kuntz (1927), may exist in 12-68% of individuals (12%, Marhold et al 2008;34%, Ramsaroop et al 2001;67%, Marhold et al 2008;68%, Chung et al 2002), which has been found less commonly in intraoperative series (Marhold et al 2008).…”

Thoracoscopic anatomy and approaches of the anterior thoracic spine: cadaver study

“…They carry a major part of the sympathetic and afferent supply for the abdominal viscera. The size, location, shape and number of the sympathetic ganglia are quite variable [33,36]. Lin [20] reported that the second thoracic ganglion lies consistently between the second and third ribs.…”

“…Of significance is the relationship of the second thoracic ganglion to the intrathoracic ramus (between the first and second thoracic nerves) described by Kuntz [17] in 1927. Variations associated with the second thoracic ganglion include a communicating branch from the ganglion or the sympathetic trunk traced directly into the intrathoracic ramus connecting the first and second thoracic nerves [33,36]. This intrathoracic ramus can divide into two branches to join the second intercostal nerve at more than one place.…”

The Sympathetic and Parasympathetic Contributions to the Cardiac Plexus: a Fetal Study

“…Khogali et al (1999), was successful in interrupting the pain pathway in a limited second to fourth thoracic ganglionectomy to relieve pain at rest in patients with intractable angina pectoris. This highlights the importance of medial sympathetic contributions to the cardiac plexus and their relevance to surgical procedures such as sympathectomies, pericardiectomies and in the management of diseases like Raynaud's phenomenon and angina pectoris (Kalsey et al;Zhang et al, 2009).…”