A comprehensive study of the abdominal ganglia part 3: An overview of the most commonly observed ganglion patterns.

Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology, and interconnections of the abdominal ganglia. The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections, and microscopic structure were studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology. A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed. The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved.

A comprehensive study of the abdominal ganglia part 2: Aorticorenal ganglia.

Investigation into reports of pain treatment for abdominal cancer and abdominal pain syndromes revealed the lack of human studies on some of the abdominal sympathetic ganglia. Recent studies on renal artery denervation therapy as treatment for resistant hypertension has made the aorticorenal ganglia of particular importance. The aim of this study was to investigate the location, morphology, interconnections, and histological nature of aorticorenal ganglia. We dissected nine abdominal cavities and harvested 37 aorticorenal ganglia. Hematoxylin and Eosin, and Masson's staining techniques were used to study the histological structure. Additionally, ganglia harvested from five individuals were stained with immunohistochemical techniques to test for tyrosine hydroxylase activity. All aorticorenal ganglia were located in proximity to the renal artery, and the majority were close to the vessel origin. Identification of multiple aorticorenal ganglia was the norm, and ranged from 2 to 4 on the left and 1 to 3 on the right. While the pattern of aorticorenal ganglia seemed to be unique in each individual case, the interconnections between these and other ganglia were vast. The aorticorenal ganglia shared direct connections with the celiac, gonadal, inferior mesenteric, and first lumbar sympathetic trunk ganglion. Contributions from the greater, lesser, and least thoracic splanchnic nerves were also observed. While the results of our study may not have direct clinical implications in isolation, the vast number of interconnections with the other abdominal ganglia may cause complications in procedures such as celiac ganglion block. In addition, aorticorenal innervation interruption may lead to hypotension.

A comprehensive study of the abdominal ganglia part 1: Celiac, phrenic and superior mesenteric ganglia.

INTRODUCTION: Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. MATERIALS AND METHODS: The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. RESULTS: The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. CONCLUSION: The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.

Anatomical variations of the upper thoracic sympathetic chain: a review.

ABSTRACT OBJECTIVES: The objective of this study is to provide a thorough overview of the anatomical variations of the upper thoracic sympathetic trunk to improve clinical results of upper thoracic sympathectomy. In addition, this study strives for standardization of future studies regarding the anatomy of the upper thoracic sympathetic chain. METHODS: The Web of Science, PubMed and Google Scholar databases were searched using keywords, alone or combined, regarding the anatomy of the thoracic sympathetic chain. The search was limited to studies performed in humans. RESULTS: Fifteen studies were finally included. Cervicothoracic ganglion and nerve of Kuntz were present in 77% and 53%, respectively. The upper thoracic ganglia were predominantly located in their corresponding intercostal space with a relatively downwards shift at the lower thoracic levels. The right sympathetic trunk is prone to have more communicating rami then the left. The lower levels of ganglia tend to have more normal rami. No clear pattern was found concerning the presence of the ascending rami and there was a decrease in the number of descending rami as the chain runs caudally. The intercostal rami remain a rare anatomical variation. CONCLUSIONS: This study presents an overview of the anatomy of the upper thoracic sympathetic chain. Its results may guide upper thoracic sympathectomy to improve clinical results. This review also provides a baseline for future studies on anatomical variations of the thoracic sympathetic trunk. More uniform reporting is necessary to compare different anatomical studies.

The macro and micro-structure of the celiac and cranial mesenteric ganglia in a long-lived rodent - paca (Cuniculus paca, Linnaeus 1766) / La macro y micro estructura de los ganglios mesentéricos celíacos y craneales en un roedor longevo - paca (Cuniculus paca, Linnaeus 1766)

SUMMARY: The celiac, cranial mesenteric and celiacomesenteric ganglia of the paca (Cuniculus paca) were found between the celiac and cranial mesenteric arteries. Two predominant patterns were found: isolated celiac and cranial mesenteric ganglion and the celiacomesenteric ganglion. At the microscopic level, the ganglia are constituted by an agglomeration of neurons surrounded by capsule of connective tissue. Most of these neurons had a single eccentric nucleus. Satellite cells and mast cells were found around the soma. The mast cells were also found ar ound blood vessels and in the capsule of the ganglia.

RESUMEN: Los ganglios celíacos, mesentérico-craneales y celíaco mesentéricos de la paca (Cuniculus paca) se encontraron entre las arterias celíaca y mesentérica craneal. Se visalizaron dos patrones predominantes: celiaca aislada y ganglio mesentérico craneal y ganglio celiaco mesentérico. A nivel microscópico, los ganglios están constituidos por una aglomeración de neuronas rodeadas por una cápsula de tejido conectivo. La mayoría de estas neuronas tenían un solo núcleo excéntrico. Se encontraron células satélites y mastocitos alrededor del soma. Los mastocitos también se encontraron alrededor de los vasos sanguíneos y en la cápsula de los ganglios.

The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia.

The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.

The "question-mark" MR anatomy of the cervico-thoracic ganglia complex: can it help to avoid mistaking it for a malignant lesion on 68Ga-PSMA-11 PET/MR?

Background Detectable uptake of 68Ga-PSMA-ligands in sympathetic ganglia may potentially lead to mistaking them for malignant lesions. Our aim was to investigate the anatomy of cervico-thoracic-ganglia-complex (CTG-C) in the MR part of multimodal 68Ga-PSMA-11 PET/MR imaging, in view of PET factors hindering its proper identification. Patients and methods In 106 patients, 212 sites of the CTG-C were retrospectively reviewed to assess the radiotracer uptake (SUVmax), size, shape, position, symmetry of location and visual uptake intensity. Asymmetry of PSMA-ligand uptake and increased uptake were regarded as risk factors of malignancy. Results In 66.0% left (L) and 53.8% right (R) CTG-C we noticed configurations, resembling the shape of an exclamation-mark, a question-mark, or its part (called "typical"). Tumor-like CTG-C shapes (oval, binodular or longitudinal) were detected in 28.3% L-CTG-C and in 40.6% R-CTG-C. When visual assessment of PET suggested malignancy, the recognition of "typical" shape of underlying CTG-C on MR generated a rise in the accuracy of their proper identification (from 34.4% to 75%, χ2(1) = 70.4; p < 0.001). Recognizing the shape of the CTG-C as "typical" in MR allowed us to classify as "not-suspicious" 61.9% of all CTG-C which were treated as "suspicious" after sole PET assessment. Conclusions The characteristic shape of cervico-thoracic-ganglia-complex (resembling a question-mark, or its part) helps in proper recognition of CTG-C on multimodal whole-body 68Ga-PSMA-ligand PET/MR imaging, when detectable uptake might lead to considering pathology.

Topographical study of the connections of the rami communicantes from the first to the fifth thoracic sympathetic ganglia.

This study investigated the morphological variations and histological patterns of the rami communicantes (RCs) arising from the first to the fifth thoracic sympathetic ganglia, and considered the clinical significance of these variations. Fifty upper thoracic portions from 26 adult Korean cadavers were used in this study. There were 731 RCs arising from the first to the fifth thoracic sympathetic ganglia. They were classified into three types depending on the connection between the sympathetic ganglion and the intercostal nerves: in type I, the RCs connected the ganglion to the corresponding intercostal nerve, and in types II and III, respectively, they connected it to the nerve one level above or below the corresponding intercostal nerve. Some RCs of types I and II could not be observed without additional preliminary surgical procedures. Diverse combinations of RC types arose from the first to the fifth thoracic sympathetic ganglia, combinations of types I and III being the most common (70%) in the first sympathetic ganglion and those comprising only type I being most frequent in the other ganglia. The RCs could not be identified by the naked eye in either fresh or fixed cadavers, so they were confirmed on the basis of their histological appearance. These results are expected to improve knowledge of morphological variations of the RCs in the upper five thoracic sympathetic ganglia, and to provide helpful information for clinical management in this region. Clin. Anat. 31:1151-1157, 2018. © 2018 Wiley Periodicals, Inc.

Characteristics of the Middle Cervical Sympathetic Ganglion: A Systematic Review and Meta-Analysis.

BACKGROUND: Understanding the characteristics of the middle cervical sympathetic ganglion (MCSG) may minimize procedure-related complications and maximize efficacy during surgery or ultrasound (US)-guided procedures. The location and detection rate of the MCSG were variable in small population studies. Therefore, a large population study or meta-analysis could give more information about the MCSG. OBJECTIVES: We aim to review the published literature and evaluate the anatomical features of the MCSG, including the detection rate, location, size, and a normal variation, and to review the clinical relevance of MCSG for procedures including, US-guided ganglion block, ethanol ablation (EA), or radiofrequency ablation (RFA). STUDY DESIGN: A systematic review and meta-analysis. The Ovid-MEDLINE and EMBASE databases were searched to find the detection rate, location, and other characteristics of the MCSG. SETTING: The pooled proportions for the detection rate of the MCSG were assessed using the DerSimonian-Laird random-effects model. METHODS: Heterogeneity among the studies was determined using a chi-square analysis for the pooled estimates and inconsistency index (I²). In order to reduce the heterogeneity, sensitivity analyses were performed. RESULTS: A review of 542 studies identified 8 eligible studies, with 273 MCSGs included in the meta-analysis. The pooled proportion for the detection rate of the MCSG was 50.4% (95% confidence interval [CI], 34.5 - 66.4%). Considerable heterogeneity among the studies was observed (I² = 94.9%). In the sensitivity analysis, when excluding one study, heterogeneity was reduced with a recalculated pooled proportion of 44.2% (95% CI, 32.1 - 56.2%; I² = 86.0%). The location of the MCSG is usually posterior to the carotid sheath and anterior to the longus colli muscle at the level of the C3 - C7 vertebrae. There was a variant where the cervical sympathetic trunk was located at the posterior wall of the carotid sheath and was adherent to the sheath. The size of the MCSG is as follows: the width, length, and height ranges were 3.8 - 6.3 mm, 6.3 - 10.5 mm, and 1.7 - 2.1 mm, respectively. A specific type of MCSG, referred to as the "double middle cervical ganglion", consisting of 2 ganglia, was demonstrated in 3 studies with a detection rate of 2.9 - 10%. LIMITATIONS: This meta-analysis included a relatively small number of studies. Significant heterogeneity was also present in the detection rate of MCSG in these studies. There was a lack of concentrated information about the MCSG, because the majority of the included studies focused on the entire cervical sympathetic chain, not only MCSG primarily. Improving complication rates might be limited due to the approximate 50% detection rate. CONCLUSION: Understanding the characteristics and variations of the MCSG could minimize complications and maximize efficacy during surgery and US-guided procedures. KEY WORDS: Middle cervical sympathetic ganglion, cervical sympathetic trunk, cervical sympathetic chain, ultrasound, nerve block, ethanol ablation, radiofrequency ablation, thyroid, Horner syndrome, meta-analysis.

Morphological and neurochemical characterization of the ovarian sympathetic chain ganglia perikarya in testosterone-treated sexually matured pigs.

We studied the effect of testosterone overdose on the number, distribution and chemical coding of ovarian neurons in the sympathetic chain ganglia (SChGs) in pigs. On day 3 of the estrous cycle the ovaries of both the control and experimental gilts were injected with retrograde neuronal tracer Fast Blue to identify the neurons innervating gonads. From the following day to the expected day 20 of the second studied cycle the experimental pigs were injected with testosterone, while the control pigs received oil, and subsequently the SChG Th16-S2 were collected. Testosterone injections increased testosterone (∼3.5 fold) and estradiol-17ß (∼1.6 fold) levels in the peripheral blood, and reduced the following in the SChGs: the total number of Fast Blue-positive neurons, the numbers of perikarya in the L3-L5 ganglia, the numbers of perikarya in the ventral, dorsal and central regions of the SChGs, and the numbers of DßH(+)/NPY(+), DßH(+)/GAL(+), DßH(+)/NPY(-), DßH(+)/SOM(-) and DßH(+)/GAL(-) perikarya. In the testosterone-affected SChGs, the perikarya DßH(-)/SOM(+), DßH(-)/GAL(+) and DßH(-)/NPY(-) were absent. In these ganglia, the population of androgen receptor-positive perikarya was increased, while the population of estrogen receptor-expressing perikarya was lowered. Our data indicate that in the pig SChGs elevated androgen levels occurring during pathological states may affect the morphology and chemical coding of ovarian neurons.

Gross anatomical study of the nerve supply of genitourinary structures in female mongrel hound dogs.

Anatomical variations in lumbosacral plexus or nerves to genitourinary structures in dogs are under described, despite their importance during surgery and potential contributions to neuromuscular syndromes. Gross dissection of 16 female mongrel hound dogs showed frequent variations in lumbosacral plexus classification, sympathetic ganglia, ventral rami input to nerves innervating genitourinary structures and pudendal nerve (PdN) branching. Lumbosacral plexus classification types were mixed, rather than pure, in 13 (82%) of dogs. The genitofemoral nerve (GFN) originated from ventral ramus of L4 in 67% of nerves, differing from the expected L3. Considerable variability was seen in ventral rami origins of pelvic (PN) and Pd nerves, with new findings of L7 contributions to PN, joining S1 and S2 input (23% of sides in 11 dogs) or S1-S3 input (5%), and to PdN, joining S1-S2, unilaterally, in one dog. L7 input was confirmed using retrograde dye tracing methods. The PN also received CG1 contributions, bilaterally, in one dog. The PdN branched unusually in two dogs. Lumbosacral sympathetic ganglia had variant intra-, inter- and multisegmental connectivity in 6 (38%). Thus, the anatomy of mongrel dogs had higher variability than previously described for purebred dogs. Knowledge of this variant innervation during surgery could aid in the preservation of nerves and reduce risk of urinary and sexual dysfunctions.

Double labelling immunohistochemistry on the sympathetic trunk ganglia neurons projecting to the extrinsic penile smooth musculature of the pig: an experimental study on the retractor penis muscle.

Retrograde neuronal tracing and double labelling immunofluorescence methods were used to define the neurochemical content of sympathetic trunk ganglia neurons projecting to the pig retractor penis muscle, which was taken as an experimental model of the male genital smooth musculature. After the injection of Fast Blue into the bulbo-penile portion of the retractor penis muscle, the eventual co-existence of the catecholaminergic marker tyrosine hydroxylase with calcitonine gene related peptide, leu-enkephalin, neuropeptide Y, neuronal nitric oxide synthase, substance P, vasoactive intestinal polypeptide or vesicular acetylcholine transporter was studied in the ipsilateral S1 sympathetic trunk ganglia, which resulted to contain the greatest number of autonomic retractor penis muscle projecting cells. The observation of Fast Blue positive neurons under the fluorescent microscope allowed the identification of different subpopulations of catecholaminergic and non-catecholaminergic retractor penis muscle-projecting neurons. The majority of catecholaminergic cells contained tyrosine hydroxylase alone, while the remaining part showed co-localization of tyrosine hydroxylase with all the other tested markers. These last neurons were immunoreactive, in decreasing percentages, for neuropeptide Y, leu-enkephalin, neuronal nitric oxide synthase, substance P, calcitonine gene related peptide, vasoactive intestinal polypeptide and vesicular acetylcholine transporter. The majority of non-catecholaminergic neurons were immunonegative for all the tested markers. The remaining non-catecholaminergic cells contained, in decreasing percentages, neuropeptide Y, neuronal nitric oxide synthase, leu-enkephalin, vasoactive intestinal polypeptide, vesicular acetylcholine transporter, substance P and calcitonine gene related peptide. Our findings documented the complexity of the neurochemical interactions that regulate both the motor functions of RPM and the blood flow through the muscle.

The Sympathetic and Parasympathetic Contributions to the Cardiac Plexus: a Fetal Study / Contribuciones Simpáticas y Parasimpáticas al Plexo Cardíaco: Estudio Fetal

The cardiac plexus is formed by sympathetic nerves originating from the superior, middle, inferior cervical or cervicothoracic ganglia as well as from the first to the fifth thoracic ganglia. Furthermore, the vagus nerve and its counterpart, the recurrent laryngeal nerve supply the cardiac plexus with parasympathetic cardiac nerves. This investigation aimed to review and record the medial contributions of the cervical ganglia, first to fifth thoracic ganglia and medial contributions of the vagus and recurrent laryngeal nerves to the cardiac plexus. The study involved bilateral micro-dissection of forty cadaveric fetal specimens (n=80). The origins of sympathetic contributions to the cardiac plexus were described as either ganglionic, inter-ganglionic or from both the ganglion and the inter-ganglionic sympathetic chain. The number of cervical sympathetic ganglia varied from two to five in this study; the superior cervical ganglion was constant while the middle cervical, vertebral, inferior cervical or cervicothoracic ganglia were variable. The prevalence of cardiac nerves were as follows: superior cervical cardiac nerve (95%); middle cervical cardiac nerve (73%); vertebral cardiac nerve (41%); inferior cervical cardiac nerve (21%) and cervicothoracic cardiac nerve (24%). This investigation records the thoracic caudal limit of the thoracic sympathetic contributions to the cardiac plexus as the T5 ganglion. The findings of this study highlight the importance of understanding the medial sympathetic contributions and their variations to the cardiac plexus as this may assist surgeons during minimal access surgical procedures, sympathectomies, pericardiectomies and in the management of diseases like Raynaud's Phenomenon and angina pectoris.

El plexo cardíaco está formado por los nervios simpáticos procedentes de los ganglios cervicales superior, medio e inferior o cervicotorácico, así como los ganglios torácicos desde el primero al quinto. Por otra parte, el nervio vago y su contraparte, el nervio laríngeo recurrente suministra al plexo cardíaco nervios cardíacos parasimpático. Esta investigación tuvo como objetivo revisar y registrar las contribuciones mediales de los ganglios cervicales, ganglios torácicos del primero al quinto ganglios y contribuciones mediales de los nervios laríngeos recurrentes y vagos en el plexo cardíaco. Se realizó la micro-disección bilateral de cuarenta especímenes cadavéricos fetales (n = 80). Los orígenes de las contribuciones simpáticas hacia el plexo cardíaco se describen de forma independiente como ganglionar o inter-ganglionar, o desde ambos ganglios y la cadena simpática interganglionar. El número de ganglios simpáticos cervicales varió de dos a cinco; el ganglio cervical superior fue constante, mientras que los ganglios medio-cervical, vertebral, cervical inferior o cervicotorácico fueron variables. La prevalencia de los nervios cardíacos fueron: nervio cardíaco cervical superior (95%); nervio cardíaco cervical medio (73%); nervio cardiaco vertebral (41%); nervio cardíaco cervical inferior (21%) y nervio cardíaco cervicotorácico (24% ). La investigación registró el límite torácico caudal de las contribuciones torácicas simpáticos al plexo cardíaco como el ganglio T5. Los resultados de este estudio muestran la importancia de comprender las contribuciones simpáticas mediales y sus variaciones en el plexo cardíaco, ya que podrían ayudar a los cirujanos durante los procedimientos quirúrgicos mínimanente invasivos, simpatectomías, pericardiectomías y en el manejo de enfermedades como el fenómeno de Raynaud y la angina de pecho.

Horner syndrome after carotid sheath surgery in a pig: anatomic study of cervical sympathetic chain.

In an experimental model, iatrogenic Horner syndrome developed after a right carotid sheath surgery in an infant pig (Sus scrofa). Horner syndrome is a classic clinical triad consisting of ipsilateral eyelid ptosis, pupil miosis, and facial anhydrosis. This syndrome results from cervical sympathetic chain (CSC) paresis and usually is acquired in humans. To determine whether the development of Horner syndrome in this situation could be attributed to pig anatomy, we compared the anatomy of the CSC in pigs and humans, by using 10 infant (age, 1 to 3 wk) pig cadavers. The CSC and cranial cervical sympathetic ganglion (CCG) were dissected bilaterally under a surgical microscope. These structures were consistently within the carotid sheaths of the pigs. In contrast, the CSC and CCG are outside the carotid sheath in humans. Awareness of the anatomic variation of the CSC and CCG within the carotid sheath in the pig and the possibility of the same variation in humans may help surgeons to identify and preserve important structures while performing cervical surgery in pigs and humans. Furthermore, this knowledge can aid in the diagnosis and prognosis of schwannoma.

Human laryngeal ganglia contain both sympathetic and parasympathetic cell types.

The presence of ganglia associated with the laryngeal nerves is well documented. In man, these ganglia have been less well studied than in other species and, in particular, the cell types within these ganglia are less well characterized. Using a panel of antibodies to a variety of markers found in the paraganglion cells of other species, we were able to show the existence of at least two populations of cells within human laryngeal paraganglia. One population contained chromogranin and tyrosine hydroxylase representing a neurosecretory population possibly secreting dopamine. A second population of choline acetyltransferase positive cells would appear to have a putative parasympathetic function. Further work is needed to characterize these cell populations more fully before it will be possible to assign functions to these cell types but our results are consistent with the postulated functions of these ganglia as chemoreceptors, neurosecretory cells, and regulators of laryngeal mucus secretion.

An anatomical study of the relationship between the sympathetic trunk and intercostal veins of the third and fourth intercostal spaces during thoracoscopy.

The complexity of the anatomy of the sympathetic trunk and intercostal veins in the third and fourth intercostal space may lead to intraoperative or postoperative bleeding. The purpose of this study was to investigate the anatomical variations of the sympathetic trunk and intercostal veins in the third and fourth intercostal spaces. The size and crossing type of veins in the third and fourth intercostal spaces in 44 Korean patients with palmar hyperhidrosis were analyzed. We classified intercostal veins by their size (small, medium, and large) and crossing type (anterior or posterior to sympathetic nerve). Large intercostal veins susceptible to bleeding were found in 36.4 and 68.2% of patients in the right third and fourth intercostal spaces, respectively and in 2.3 and 4.5% of left third and fourth intercostal spaces, respectively. More than 80% of the left third and fourth intercostal veins were small. Anterior crossing intercostal veins, which often cause problems at the third and fourth right intercostal spaces, were found in 27.3% (third) and 15.9% (fourth). However, there were only two cases of anterior crossing veins on the left side. Large anterior crossing veins were found only on the right side. In conclusion, surgical procedures of the right sympathetic ganglia may have increased risks due to a higher frequency of large anterior crossing intercostal veins. Careful dissection is necessary to decrease the incidence of intraoperative or postoperative bleeding.

Quantitative anatomical study of male pelvic autonomic plexus and its clinical potential in rectal resection.

The pelvic autonomic nerves innervate the pelvic viscera, and carry a high risk of damage during surgery. This high risk has been ascribed to the complex interrelationship of pelvic paravisceral structures and the difficulty in identifying particular structures, despite the fact that the anatomic characteristics of the pelvic autonomic plexus have been well documented. We dissected ten male embalmed adult cadavers with particular attention to the quantitative parameters of the pelvic plexus and its subsidiary plexus. The right inferior hypogastric plexus and its rectal branch were found to be significantly longer and wider than the left one, while the transverse diameter of the vesical and prostatic branches of the left side was significantly larger the right. The inferior mesenteric plexus gave off fibers directly to form the pelvic plexus in four of 20 hemipelves (20%). In the side-by-side comparison, the distance to midpoint of the sacral promontory of the left rectal plexus was significantly longer than that of the right, whereas the maximum length (the length of the longest nerve fiber from origin to corresponding organ) of the left vesical plexus was significantly shorter than that of the right. Additionally, the craniocaudal and dorsoventral diameters of the right pelvic autonomic plexus were significantly shorter those of the left. The quantitative parameters relating to the pelvic autonomic plexuses not only can enhance our understanding of its anatomy and function, but can also be used as references for surgical procedures and robot-assisted surgery.

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.

Radiofrequency cannula with active tip radio-opaque marker: image analysis for facet, gray ramus, and dorsal root ganglion techniques.

BACKGROUND: Radiofrequency neurolysis is a common technique used in the treatment of chronic pain, particularly facet (zygapophyseal joint) arthralgia. A needle-like cannula is insulated except for the exposed active tip, which is positioned as parallel and adjacent as possible to the targeted nerve branch. Via an inserted probe connected to a radiofrequency generator, energy flowing from the tip of the cannula creates a heat lesion in the 80 - 85 degree Celsius range mostly about the length of the exposed active tip and in proportion to the diameter of the probe. The common active tip lengths used for neurolysis are 5mm or 10mm. The cannulae are FDA approved. The manufacturer advises physicians not to bend or otherwise modify a cannula prior to use. The cannulae are available straight or bent, sharp and blunt. The technique is guided under C-arm fluoroscopy. X-rays passing through the patient demonstrate in 2 dimensions the projected relative radio-opaque bony landmarks and the metallic cannula. Most currently available cannulae are uniform in their radio-opacity from tip to hub. The physician must make an educated guess as to the portion of the cannula that will be making the lesion in relationship to the bony landmark. OBJECTIVE: A new radiofrequency cannula with a radio-opaque marker (ROC) delineates the proximal end of the active tip. The cannula was used in a phantom model. Images were reproduced with explanation of the potential advantage of the new device. RESULT: The marker on the new cannula was visible and did help delineate the active tip as well as its orientation. It was also helpful in making sequential lesions at the same nerve using a "tip to tail" repositioning technique. CONCLUSION: The ROC did represent an improvement over standard cannulae to optimize visualization of cannula and thus lesion placement using a phantom model. The applications described were only for conventional or "hot" RF.

Immunohistochemical study of the phrenic ganglion.

Peripheral nerve 'pseudoganglia' are described in the literature with little focus on histology. The phrenic ganglia, which are located on the inferior surface of the diaphragm and are associated with the phrenic nerves, have been described by some authors as potentially sympathetic ganglia although this, to the authors' knowledge, has not been proven. The purpose of the present study was to elucidate further the true autonomic nature of this collection of nerve cell bodies. In eight fresh adult cadavers < 6 h after death, the left and right phrenic ganglia were harvested and subjected to immunochemistry. All phrenic ganglia were vasoactive intestinal polypeptide negative but tyrosine hydroxylase positive. These findings indicate that the phrenic ganglia are sympathetic ganglia with most likely a vasomotor function.