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.

[Neurogenic autonomic dysfunction in adults].

Neurogenic autonomic dysfunction (NAD) is underdiagnosed, and it is likely in patients, who have orthostatic hypotension and symptoms from multiple organ systems as well as abnormal results from a neurological examination. A clinical and neurophysiological examination of the autonomic nervous system combined with a standardised paraclinical evaluation should be performed. NAD may be present in neurodegenerative disorders, vitamin deficiency, toxicity, infection, and in paraneoplastic, metabolic, hereditary and immune-mediated conditions.

Striated Perineal Muscles: Location of Somatic and Autonomic Neurons Projecting to the Male Pig Ischiocavernous Muscle. Neurochemical Features of the Sympathetic Subset.

The location, number and size of the central and peripheral neurons innervating the ischiocavernous muscle (ICM) were studied in male pigs by means of Fast Blue (FB) retrograde neuronal tracing. Moreover the immunohistochemical properties of the sympathetic ganglia were investigated combining the double immunolabeling method. After injection of FB into the left ICM, a mean number of 245.3 ± 134.9 labeled neurons were found in the ipsilateral ventral horn of the S1-S3 segments of the spinal cord (SC), 129.7 ± 45.5 in the L6-S3 ipsilateral and S2-S3 contralateral spinal ganglia (SGs), 2279.3 ± 622.1 in the ipsilateral L2-S2 and contralateral L5-S2 sympathetic trunk ganglia (STGs), 541.7 ± 158 in the bilateral caudal mesenteric ganglia (CMGs), and 78.3 ± 35.8 in the microganglia of the pelvic plexus (PGs). The mean area of the ICM projecting neurons was 1217 ± 69.7 µm2 in the SC, 2737.5 ± 176.5 µm2 in the SGs, 982.8 ± 36.8 µm2 in the STGs, 865.9 ± 39.14 µm2 in the CMGs and 426.2 ± 24.72 µm2 in the PGs. The FB positive neurons of autonomic ganglia contained Dopamine ß hydroxylase, vesicular acetylcholine transporter, neuronal nitric oxyde sinthase, calcitonine gene related peptide, leu-enkephaline, neuropeptide Y, substance P, vasoactive intestinal polypeptide, and somatostatine often colocalized with tyrosine hydroxylase. The particular localization of the motor somatic nucleus, the abundant autonomic innervation and the qualitatively different content of ICM projecting sympathetic neurons suggest a complex regulation of this striated muscle involved in involuntary functions, such as the erection, ejaculation, micturition and defecation. Anat Rec, 301:837-848, 2018. © 2017 Wiley Periodicals, Inc.

Targeting the Sympathetic Chain for Primary Hyperhidrosis: An Evidence-Based Review.

Large case series and randomized trials over the past 25 years have consistently demonstrated thoracoscopic interruption of the sympathetic chain to be a safe and effective treatment of focal primary hyperhidrosis. The surgical technique has evolved toward less-invasive and less-extensive procedures in an effort to minimize perioperative morbidity and effectively balance postoperative compensatory sweating with symptomatic relief. This review summarizes available evidence regarding the surgical approach and the optimal level of interruption of the sympathetic chain based on a patient's presenting distribution of pathologic sweating.

The History of Sympathetic Surgery.

At present, primary hyperhidrosis is the main indication for sympathectomy. For upper thoracic sympathetic ablation, excision of the second thoracic ganglion alone or with the first and/or third ganglia was the standard during the open surgery era. With the advent of thoracoscopy, modifications related to the level, extent, and type of ablation were proposed to attenuate compensatory hyperhidrosis. The ideal operation for sympathetic denervation of the face and upper limbs remain to be defined. Controlled double-blind studies with quantitave measurements of sweat production are required.

Morphological investigations of the cervicothoracic sympathetic system in the horse (Equus ferrus caballus) in Egypt / Investigaciones morfológicas del sistema simpático cervicotorácico en el caballo (Equus ferrus caballus) en Egipto

The current study was performed on twelve healthy adult horses (E. ferrus caballus) collected from Egypt were dissected to provide anatomical descriptions of bilaterally cervicothoracic sympathetic system macroscopically. On the left side, cervicothoracic sympathetic system is represented only by the caudal cervical ganglion, which presents on lateral surface of esophagus, cranial to the level of first rib. On right side, cervicothoracic sympathetic system is represented by the caudal and middle cervical ganglion. Caudal cervical ganglion was consisted of the fusion of eighth cervical and first three thoracic nerve ganglia. Caudal directed continuation branch of left ansa subclavia gave off a pericardial branch and then gave branch for ligamentum arteriosum. There are special sympathetic­parasympathetic communicating branches; on left side, there is only one branch that was present on lateral surface of esophagus, while on right side, there were four branches; two from caudal cervical ganglion and two from middle cervical ganglion. The most suitable site of ganglion blocks from both sides; needle was placed medioventrally between the articulation of first and second rib.

Doce caballos (E. ferrus caballus) adultos sanos, procedentes de Egipto, fueron disecados para realizar descripciones anatómicas macroscópicas del sistema simpático cervicotorácico bilateralmente. En el lado izquierdo, el sistema simpático cervicotorácico estuvo representado sólo por el ganglio cervical caudal, en la superficie lateral del esófago, craneal en relación a la primera costilla. En el lado derecho, el sistema simpático cervicotorácico estuvo representado por los ganglios caudal y cervical medio. El ganglio cervical caudal consistió en la fusión del octavo ganglio cervical y el primero de los tres ganglios torácicos. Se observaron ramos comunicantes entre los sistemas simpático y parasimpático; en el lado izquierdo, sólo hubo una rama presente en la superficie lateral del esófago, mientras que en el lado derecho, se observaron cuatro ramos: dos del ganglio cervical caudal y dos del ganglio cervical medio. El sitio más adecuado para la ejecución de los bloqueos ganglionares de ambos lados es a nivel medioventral, entre la articulación de la primera con la segunda costilla.

Topography and morphology of the bovine cranial cervical ganglion and its branches / Topografía y morfología del ganglio cervical craneal bovino y sus ramos

A detailed submacroscopic anatomical study of the cranial cervical ganglion (CCG) and its branches with its adjoining structures was carried out by examining 14 halves of seven heads of Holstein cattle under a magnifying lens to provide comprehensive descriptions with color photographs of the location, relation to neighboring structures, morphometry, and morphology of CCG and its branches. Our results were compared with previously nerves including jugular nerve; internal and external carotid nerves extremely, obtained morphological data on CCG in other ungulates to clarify the detailed comparative anatomy of CCG among them. The morphology of CCG and its branches in bovine was significantly and tangibly different from that of in other reported ungulates, especially in the direction of the ventral and dorsal poles of CCG being caudodorsal and rostroventral respectively, being larger and slightly more rostral, covered laterally by the dorsal part of the stylohyoid bone and caudal stylopharyngeus muscle, close relation of CCG to the medial retropharyngeal lymph node, wider distributions of external carotid nerve and its plexus to the adjacent arteries and visceral structures, lacking a communicating branch with the cervical spinal nerve, although all typical branches including the jugular nerve, carotid sinus branch, internal and external carotid nerves, communicating branches to vagus, glossopharyngeal, hypoglossal, cranial laryngeal, pharyngeal branch of vagus nerves, and close relationship between CCG and the longus capitis muscle, vagus nerve, and internal carotid artery were almost consistently present among the ungulates. The site of origin and the number of the major nerves including jugular nerve, internal and external carotid nerves extremely differed among the ungulates.

Se realizó un estudio anatómico submi-croscópico detallado del ganglio cervical craneal (GCC) y sus ramos, con las estructuras adyacentes, mediante el examen de 14 hemicabezas, correspondientes a siete cabezas de ganado Holstein, bajo aumento, para proporcionar descripciones completas; además se tomaron fotografías a color de la ubicación, su relación con estructuras vecinas y la morfometría y morfología del GCC y sus ramos. Se compararon los resultados obtenidos relacionados con los nervios, incluyendo las arterias carótidas interna y externa; los datos morfológicos obtenidos del GCC de otros ungulados tal vez aclaren la anatomía comparativa detallada del GCC entre los ungulados. Encontramos diferencia significativas en la morfología del GCC y sus ramos en comparación con otros ungulados reportados en la literatura, particularmente en la dirección de los polos ventral y dorsal del GCC, siendo estos caudodorsal y rostroventral respectivamente, presentándose más grande y ligeramente más rostral, cubierto lateralmente por la parte dorsal del hueso estilohioídeo y el músculo estilofaríngeo caudal. Se evidenció una estrecha relación del GCC con los nodos linfáticos retrofaríngeos mediales, con distribuciones más amplias del nervio carotídeo interno y el plexo adyacente a las arterias y estructuras viscerales, careciendo de un ramo comunicante con el nervio espinal cervical. En todos los ungulados se encontraron consistentemente todos los ramos nerviosos típicos, incluyendo el nervio yugular, el ramo del seno carotídeo, los nervios carotídeos interno y externos, los ramos comunicantes para el nervio vago, glosofaríngeo, hipogloso, laringeo craneal, ramo faríngea del nervio vago, y la estrecha relación entre el GCC y el músculo largo de la cabeza, el nervio vago y la arteria carótida interna. Se determinaron diferencias importantes en el sitio y origen de la mayoría de los nervios, incluyendo el nervio yugular y los nervios carotídeos interno y externos.

Microsurgical anatomy of the human carotid body (glomus caroticum): Features of its detailed topography, syntopy and morphology.

The human glomus caroticum (GC) is not readily accessible during ordinary anatomical teaching courses because of insufficient time and difficulties encountered in the preparation. Accordingly, most anatomical descriptions of its location, relationship to neighboring structures, size and shape are supported only by drawings, but not by photographs. The aim of this study is to present the GC with all associated roots and branches. Following microscope-assisted dissection and precise photo-documentation, a detailed analysis of location, syntopy and morphology was performed. We carried out this study on 46 bifurcations of the common carotid artery (CCA) into the external (ECA) and internal (ICA) carotid arteries and identified the GC in 40 (91%) of them. We found significant variations regarding the location of the GC and its syntopy: GC was associated with CCA (42%), ECA (28%) and ICA (30%) lying on the medial or lateral surface (82% or 13%, respectively) or exactly in the middle (5%) of the bifurcation. The short and long diameter of its oval form varied from 1.0 × 2.0 to 5.0 × 5.0mm. Connections with the sympathetic trunk (100%), glossopharyngeal (93%), vagus (79%) and hypoglossal nerve (90%) could be established in 29 cadavers. We conclude that precise knowledge of this enormous variety might be very helpful not only to students in medicine and dentistry during anatomical dissection courses, but also to surgeons working in this field.

New insights in the neuroanatomy of the human adult superior hypogastric plexus and hypogastric nerves.

BACKGROUND: The superior hypogastric plexus (SHP) is an autonomic plexus, located ventrally to the abdominal aorta and its bifurcation, innervating pelvic viscera. It is classically described as being composed of merely sympathetic fibres. However, post-operative complications after surgery damaging the peri-aortic retroperitoneal compartment suggest the existence of parasympathetic fibres. This immunohistochemical study describes the neuroanatomical composition of the human mature SHP. MATERIAL AND METHODS: Eight pre-determined retroperitoneal localizations including the lumbar splanchnic nerves, the SHP and the HN were studied in four human cadavers. Control tissues (white rami, grey rami, vagus nerve, splanchnic nerves, sympathetic ganglia, sympathetic chain and spinal nerve) were collected to verify the results. All tissues were stained with haematoxylin and eosin and antibodies S100, tyrosine hydroxylase (TH), vasoactive intestinal peptide (VIP) and myelin basic protein (MBP) to identify pre- and postganglionic parasympathetic and sympathetic nerve fibres. RESULTS: All tissues comprising the SHP and hypogastric nerves (HN) showed isolated expression of TH, VIP and MBP, revealing the presence of three types of fibres: postganglionic adrenergic sympathetic fibres marked by TH, unmyelinated VIP-positive fibres and myelinated preganglionic fibres marked by MBP. Analysis of control tissues confirmed that TH, VIP and MBP were well usable to interpret the neurochemical composition of the SHP and HN. CONCLUSION: The human SHP and HN contain sympathetic and most likely postganglionic parasympathetic fibres. The origin of these fibres is still to be elucidated, however surgical damage in the peri-aortic retroperitoneal compartment may cause pelvic organ dysfunction related to both parasympathetic and sympathetic denervation.

Eye on children: acute work-up for pediatric Horner's syndrome. case presentation and review of the literature.

BACKGROUND: Ptosis and anisocoria in a child may be subtle indications of occult pathology, and making the observation acutely in the emergency department (ED) is important in guiding patient management and treatment. Emergency physicians must evaluate patients to exclude serious or life-threatening emergencies and ensure correct disposition of patients. Horner syndrome in children may be considered congenital or acquired and may be from benign or malignant causes. When an isolated, acquired Horner syndrome is suspected in a pediatric patient, physical examination of the neck and abdomen for masses, as well as spot urine catecholamines, vanillylmandelic acid and homovanillic acid, and varying degrees of imaging are recommended as part of the initial evaluation. These evaluations may be performed in the ED or may require hospitalization, depending on the suspected anatomical localization and diagnostic considerations. CASE REPORT: A 21-month-old, normally developed girl presented to the University Hospital ED with a 2-h history of right-sided eyelid drooping in the setting of a febrile illness. An eventual diagnosis of Horner syndrome from cervical lymph node compression was made on the basis of history, examination, and imaging findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ED evaluations of pediatric patients differ from adults. Evaluation and work-up of Horner syndrome in children can be challenging and can require varying degrees of assessment and evaluation, depending on the diagnostic considerations. This article will address the common pathologies responsible for isolated pediatric Horner syndrome and the recommended ED evaluation.

Revisitando a fisiologia do sistema nervoso simpático: o que há de novo? / Facing sympathetic nervous system physiology: what's new?

o sistema nervoso autônomo (SNA), descrito no inicio do século passado, é definido como sendo o sistema de neurônios motores que inervam as glândulas e a musculatura lisa e cardíaca, sendo fundamental para a manutenção do equilibrio organismo, definindo esta situação com o termo "homeostasia", Atualmente, entretanto, reconhece-se que este sistema também apresenta neurônios sensoriais (neurônios aferentes), que transmitem as informações recebidas de receptores sensoriais autonômicos, principalmente viscerais, para o sistema nervoso central. O termo autônomo, hoje consagrado, vem da ideia de que este sistema atuava somente de forma autônoma; no entanto, hoje se admite que a atividade deste sistema é gerada, ou pelo menos supervisionada, pelo sistema nervoso central. A ativação e a desativação tônicas e reflexas de seus dois componentes, simpático e do parassimpático, determinam em condições fisiológicas ajustes do débito cardíaco e da resistência vascular periférica, contribuindo para a estabilização e manutenção da pressão arterial sistêmica durante diferentes situações fisiológicas, ampliando a capacidade de adaptação e sobrevivência do organismo. Neste contexto, o termo disautonomia se refere àquelas condições em que a função autonômica se modificou de maneira a contribuir negativamente para a saúde. Estas mudanças têm sido quantificadas e têm permitido estimar a contribuição da hiperatividade simpática na instalação e na manutenção da doença cardiovascular. Neste artigo, são revisados aspectos anatômicos e funcionais do sistema nervoso simpático e parassimpático, destacando os principais métodos de avaliação do SNA, bem como o papel da hiperatividade simpática como mecanismo desencadeador e de agravamento de disfunções cardiovasculares.

The autonomic nervous system (ANS) described at the beginning of the last century is defined as the system of motor neurons that innervate glands as well as smooth and cardiac musc/es essential for maintaining the body's balance, defining this situation with the term "homeostasis". Current1y, however it is recognized that this system also provides sensory neurons (afferent neurons) that transmit information received from sensory autonomic receptors mainly visceral to the central nervous system. The use of the term autonomic comes from the idea that this system acts only in autonomic way; however, nowadays it is accepted that the activity of this system is generated or at least supervised by the central nervous system. The tonic and reflex acti vation and deacti vation of both of its components, the sympathetic and the parasympathetic system, can determine adjustments in cardiac output and peripheral vascular resistance contributing to the stabilization and maintenance of systemic blood pressure during different physiological situations, expanding the capacity of adaptation and survival of the organismo ln this context, the terrn dysautonomia refers to those conditions in which autonomic function was changed in a way that negatively contribute to health. These changes have been quantified and have alJowed to estimate the contribution of sympathetic hyperactivity in the installation and maintenance of cardiovascular disease. In this manuscript anatomical and functional, sympathetic and parasympathetic nervous system aspects are reviewed, highJighting key evaluation methods of ANS and the role of sympathetic overacti vity as a trigger and as a worsening mechanism that can contribute to cardiovascular dysfunctions.

Nerve supply to the internal anal sphincter differs from that to the distal rectum: an immunohistochemical study of cadavers.

PURPOSE: Fecal incontinence is a common problem after anal sphincter-preserving operations. The intersphincteric autonomic nerves supplying the internal anal sphincter (IAS) are formed by the union of: (1) nerve fibers from Auerbach's nerve plexus of the most distal part of the rectum and (2) the inferior rectal branches of the pelvic plexus (IRB-PX) running along the conjoint longitudinal muscle coat. The aim of the present study is to identify the detailed morphology of nerves to the IAS. METHODS: The study comprised histological and immunohistochemical evaluations of paraffin-embedded sections from a large block of anal canal from the preserved 10 cadavers. RESULTS: The IRB-PX came from the superior aspect of the levator ani and ran into the anal canal on the anterolateral side. These nerves contained both sympathetic and parasympathetic fibers, but the sympathetic content was much higher than in nerves from the distal rectum. All intramural ganglion cells in the distal rectum were neuronal nitric oxide synthase-positive and tyrosine hydroxylase-negative and were restricted to above the squamous-columnar epithelial junction. Parasympathetic nerves formed a lattice-like plexus in the circular smooth muscles of the distal rectum, whereas the IAS contained short, longitudinally running sympathetic and parasympathetic nerves, although sympathetic nerves were dominant. CONCLUSIONS: The major autonomic nerve input to the IAS seemed not to originate from the distal rectum but from the IRB-PX. Injury to the IRB-PX during surgery seemed to result in loss of innervation to the major part of the IAS.

Localization of peripheral autonomic neurons innervating the boar urinary bladder trigone and neurochemical features of the sympathetic component.

The urinary bladder trigone (UBT) is a limited area through which the majority of vessels and nerve fibers penetrate into the urinary bladder and where nerve fibers and intramural neurons are more concentrated. We localized the extramural post-ganglionic autonomic neurons supplying the porcine UBT by means of retrograde tracing (Fast Blue, FB). Moreover, we investigated the phenotype of sympathetic trunk ganglion (STG) and caudal mesenteric ganglion (CMG) neurons positive to FB (FB+) by coupling retrograde tracing and double-labeling immunofluorescence methods. A mean number of 1845.1±259.3 FB+ neurons were localized bilaterally in the L1-S3 STG, which appeared as small pericarya (465.6±82.7 µm2) mainly localized along an edge of the ganglion. A large number (4287.5±1450.6) of small (476.1±103.9 µm2) FB+ neurons were localized mainly along a border of both CMG. The largest number (4793.3±1990.8) of FB+ neurons was observed in the pelvic plexus (PP), where labeled neurons were often clustered within different microganglia and had smaller soma cross-sectional area (374.9±85.4 µm2). STG and CMG FB+ neurons were immunoreactive (IR) for tyrosine hydroxylase (TH) (66±10.1% and 52.7±8.2%, respectively), dopamine beta-hydroxylase (DßH) (62±6.2% and 52±6.2%, respectively), neuropeptide Y (NPY) (59±8.2% and 65.8±7.3%, respectively), calcitonin-gene-related peptide (CGRP) (24.1±3.3% and 22.1±3.3%, respectively), substance P (SP) (21.6±2.4% and 37.7±7.5%, respectively), vasoactive intestinal polypeptide (VIP) (18.9±2.3% and 35.4±4.4%, respectively), neuronal nitric oxide synthase (nNOS) (15.3±2% and 32.9±7.7%, respectively), vesicular acetylcholine transporter (VAChT) (15±2% and 34.7±4.5%, respectively), leu-enkephalin (LENK) (14.3±7.1% and 25.9±8.9%, respectively), and somatostatin (SOM) (12.4±3% and 31.8±7.3%, respectively). UBT-projecting neurons were also surrounded by VAChT-, CGRP-, LENK-, and nNOS-IR fibers. The possible role of these neurons and fibers in the neural pathways of the UBT is discussed.

Nerves in the intersphincteric space of the human anal canal with special reference to their continuation to the enteric nerve plexus of the rectum.

In the intersphincteric space of the anal canal, nerves are thought to "change" from autonomic to somatic at the level of the squamous-columnar epithelial junction of the anal canal. To compare the nerve configuration in the intersphincteric space with the configuration in adjacent areas of the human rectum, we immunohistochemically assessed tissue samples from 12 donated cadavers, using antibodies to S100, neuronal nitric oxide synthase (nNOS), and tyrosine hydroxylase (TH). Antibody to S100 revealed a clear difference in intramuscular nerve distribution patterns between the circular and longitudinal muscle layers of the most inferior part of the rectum, with the former having a plexus-like configuration, while the latter contained short, longitudinally running nerves. Most of the intramural ganglion cells in the anal canal were restricted to above the epithelial junction, but some were located just below that level. Near or at the level of the epithelial junction, the nerves along the rectal adventitia and Auerbach's nerve plexus joined to form intersphincteric nerves, with all these nerves containing both nNOS-positive parasympathetic and TH-positive sympathetic nerve fibers. Thus, it was histologically difficult to distinguish somatic intersphincteric nerves from the autonomic Auerbach's plexus. In the intersphincteric space, the autonomic nerve elements with intrapelvic courses seemed to "borrow" a nerve pathway in the peripheral branches of the pudendal nerve. Injury to the intersphincteric nerve during surgery may result in loss of innervation in the major part of the internal anal sphincter.

Morphology of sympathetic chain in Saguinus niger.

Saguinus niger popularly known as Sauim, is a Brazilian North primate. Sympathetic chain investigation would support traumatic and/or cancer diagnosis which are little described in wild animals. The aim of this study was to describe the morphology and distribution of sympathetic chain in order to supply knowledge for neurocomparative research. Three female young animals that came death by natural causes were investigated. Animals were fixed in formaldehyde 10% and dissected along the sympathetic chain in neck, thorax and abdomen. Cranial cervical ganglion was located at the level of carotid bifurcation, related to carotid internal artery. In neck basis the vagosympathetic trunk divides into the sympathetic trunk and the parasympathetic vagal nerve. Sympathetic trunk ran in dorsal position and originated the stellate ganglia, formed by the fusion of caudal cervical and first thoracic ganglia. Vagal trunk laid ventrally to heart and formed the cardiac plexus. In abdomen, on the right side, were found the celiac ganglion and cranial mesenteric ganglion; in the left side these ganglia were fusioned into the celiac-mesenteric ganglion displaced closely to the celiac artery. In both sides, the caudal mesenteric ganglion was located near to the caudal mesenteric artery.

Innervation pattern of the preocular human central retinal artery.

The central retinal artery (CRA) is the main vessel for inner retinal oxygen and nutrition supply. While the intraocular branches lack autonomic innervation, the innervation pattern of the extra-ocular part of this vessel along its course within the optic nerve is poorly investigated. This part however is essential for maintenance of retinal blood supply, in physiological and pathological conditions. Therefore, the aim of this study was the characterization of the autonomic innervation of the preocular CRA in humans with morphological methods. Meeting the Declaration of Helsinki, eyes of body or cornea donors were processed for single or double immunohistochemistry against tyrosine hydroxilase (TH), dopamine-ß-hydroxylase (DBH), choline acetyl-transferase (ChAT), vesicular acetylcholine transporter (VAChT), neuronal nitric oxide synthase (nNOS), calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal polypeptide (VIP), and cytochemistry for NADPH-diaphorase (NADPH-d). For documentation, light-, fluorescence-, and confocal laser-scanning microscopy were used. TH and DBH immunoreactive nerve fibres were detected in the CRA vessel wall, although a distinct perivascular plexus was missing. Further, nerve fibres immunoreactive for ChAT and VAChT were found, while CGRP, SP, and VIP were not detected. NADPH-d staining revealed scattered nerve fibres in the adventitia of the CRA and in close vicinity; however, nNOS-immunostaining could not confirm this finding. The CRA receives adrenergic and cholinergic innervations, indicating sympathetic and parasympathetic components, respectively. Remarkably, a peptidergic primary afferent innervation was missing. Since clinical results suggest an autoregulation of intraretinal vessels, further studies are needed to clarify the impact of CRA innervation for retinal perfusion.

The sympathetic innervation of the human foot.

BACKGROUND: The sympathetic innervation of the hand was demonstrated using formaldehyde staining techniques in the 1990s and provides a basis for both medical (botulinum toxin type A) and surgical (sympathectomy) therapeutic approaches. This research investigates the sympathetic innervation of the human foot using tyrosine hydroxylase immunohistochemistry. METHODS: With institutional review board approval, six freshly amputated lower extremities had arterial, venous, and peripheral nerve biopsies obtained at the distal leg, ankle, and forefoot levels. Tibial, peroneal, sural, and saphenous nerves were processed immediately for immunohistochemical staining using an anti-tyrosine hydroxylase antibody, for light and electron microscopy evaluation. Qualitative assessments noted the presence or absence of tyrosine hydroxylase-positive fibers in artery, vein, and peripheral nerve. Within the nerve, location of the tyrosine hydroxylase staining was noted. RESULTS: The presence of tyrosine hydroxylase-positive material was identified in each artery, vein, and nerve examined at each level of the foot and ankle. For the artery, the staining was in the adventitia, and rarely in the media of the vessel wall. There were clear entry points into the artery from the connective tissue. For the vein, the staining was more evenly distributed but to a lesser intensity than in the artery. Within each nerve at the proximal levels, the staining was diffusely throughout the fascicles, with clear sites of fibers leaving the periphery. CONCLUSIONS: It is concluded that (1) sympathetic innervation of the foot arrives along each peripheral nerve, (2) the vessels already contain sympathetic innervation at the level of the ankle, and (3) the sympathetic innervation of the foot is extensive.

The innervation of the cranial dura mater: neurosurgical case correlates and a review of the literature.

OBJECTIVE: Headache and postcraniotomy pain can be disabling. In addition, generation of pain on manipulation of dural membranes during an awake craniotomy can limit the mapping procedure and create significant discomfort for the patient. There is controversy regarding the distribution of innervation of the cranial dura mater. Our aim was to review the literature regarding the innervation of the cranial dura mater and provide surgical case illustrations to highlight the relevance of such innervation to the neurosurgeon. METHODS: A review of the literature regarding the nerves thought to innervate the cranial dura mater was performed. Case illustrations are provided to highlight such innervation patterns. RESULTS: The cases provided reinforce the finding that the posterior part of the falx cerebri, tentorium cerebelli, and the dura mater along the middle cranial fossa floor are heavily innervated and most likely cause intense pain by their manipulation, which should therefore be avoided, if possible, during surgical procedures. CONCLUSIONS: Knowledge of the nerves that supply the dura mater of the skull and their pathways is important to the clinician who treats headache and to the neurosurgeon who operates in this region.

Histomorphometric and sympathetic innervation of the human posterior intercostal artery and its clinical importance.

The purpose of this investigation was to study the characteristics of arterial wall and sympathetic innervation of the human posterior intercostal artery (PIA) in order to assess its suitability as an arterial graft for vascular surgeries. Fifty PIA samples were obtained from 25 cadavers (18 males and 7 females). Samples were divided into three age groups: group 1: 19-40 years; group 2: 41-60 years; and group 3 over 61 years. Sections (5 µm-thickness) of each sample were taken and stained with haematoxylin-eosin, Verhoeff's-Van Gieson. Five samples were processed for tyrosine hydroxylase immunostaining. The differences in the thickness of tunica intima were not statistically significant when group 1 was compared with group 2 (p = 0.798), but significant differences were observed in the thickness of the tunica intima when comparing group 2 with group 3 (p = 0.012) and group 3 with group 1 (p = 0.002). The tunica media was not statistically significant when group 1 was compared with group 2 (p = 0.479). However, significant differences were observed in the thickness of the tunica media when comparing group 2 with group 3 (p = 0.001) and group 3 with group 1 (p = 0.011). The mean (SD) number of elastic laminae in group 1, group 2, and group 3 were 7.88 ± 0.69, 6.62 ± 0.51, and 4.56 ± 0.82, respectively. Tunica intima/media ratios in groups 1, 2, and 3 were found to be 0.09 ± 0.01, 0.11 ± 0.02, and 0.27 ± 0.16, respectively. Tyrosine hydroxylase immunostaining revealed that sympathetic fibres are found mainly in the tunica adventitia and at the adventitia-medial border. The sympathetic nerve fibre area and sympathetic index were found to be 0.004 mm2, and 0.151 mm(2), respectively. PIA has relatively thin intima and media, which are favourable features regarding its potential suitability as an alternate coronary bypass conduit.

Does the nerve of Kuntz exist?

A best evidence topic was written according to a structured protocol. The question addressed was, in what proportion of patients is the nerve of Kuntz identifiable? A total of 55 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The nerve of Kuntz was originally described in 1927 as being a connection from the second intercostal nerve to the first thoracic ventral ramus. Controversy exists as to whether it is present universally and thus whether it should be identified during thoracoscopic sympathectomy. The six studies highlighted involved dissection of the upper thoracic sympathetic chain of adult cadavers with descriptions of the anatomical variations. A study by Cho et al. [Cho HM, Lee DY, Sung SW. Anatomical variations of rami communicants in the upper thoracic sympathetic trunk. Eur J Cardiothorac Surg 2005;27:320-324] suggested that anatomical variation was more common at T2 compared to T3 and T4, of which 60% corresponded to the original description of the nerve of Kuntz. A similar prevalence was found by Marhold and colleagues [Marhold F, Izay B, Zacherl J, Tschabitscher M, Neumayer C. Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery. Ann Thorac Surg 2008;86:1653-1658], who also suggested that open dissection led to significantly easier identification of this anatomy than thoracoscopy. The same authors frequently found that the nerve of Kuntz was associated with a superior intercostal vein located parallel to it, meaning that these subpleural veins may act as an anatomical landmark. In four of the papers where cadavers where dissected bilaterally, variations in the anatomy of the sympathetic chain were not always symmetrical. We conclude that most patients will have some form of variation in the anatomy of their T2 ganglion, which often corresponds to the original description of the nerve of Kuntz. The appreciation of this variation may be more difficult during thoracoscopy as compared to open anatomic dissection.