Neuro-Science 1 (Autonomic Plexuses in the Body) By Ehab Abdel-Aziz Mohamed Bakry Medhat Morsy Professors of Anatomy & Embryology Hosam Yahia Ahmed Galal Lecturers of Anatomy & Embryology Department of Anatomy and Embryology Faculty of Medicine Cairo UniversityStaff Members: Ehab Abdel-Aziz Hassan Heider Helana Labib Hafiz Waly Soheir El-Sharouny, Saber Shona Mohamed Bakry Emad Naguib ‘Wafik Halim Nabila Yousef Abdel-Halim Ibrahim Labib Mohamed Emad Sherif Galal Mamdouh Mahmoud Fayza Abdel-Raouf Abdel-Wakeel Essawy Safwat Wadie Al-Moatasem Bellah Al-Sherif Maha Ashmawy Hoda Alaasar Tarek Abdel-Salam Mohamed Wahdan Medhat Morsy Sherif Zaki Naglaa Ali Ayman Abou El-Enein Abeer Oueida Inas Ahmed Walaa Mohamed Sayed Hanan Nabeh Mogeda Mahdy Sherif Fahmy Ahmed Galal Magdy Fouad Ahmed Al-Zainy Tamer Shawky Rasha Abd El Khalek Hosam Yehya Bahaa Khaled Doaa Mahmoud Shereen Abdelfattah Tarek AbdelgalilPreface This book is intended to be a comprehensive guide to the HUMAN ANATOMY in the most reliable, attractive, illustrated manner for undergraduate medical students. In preparing this text, the primary objective of our panel was to supply the reader with a concise source reflecting the progress in our knowledge in the field of Anatomy. We would like to express our thanks to professor Dr. Al Moatasem Bellah Al Sherif, Anatomy Department, Faculty of Medicine, Cairo University, for his effort in the preparation of illustrations of this work. The AuthorsCONTENTS Page Nervous System 1 Lumbar Part of Sympathetic Chain 13 Pelvic Part of Sympathetic Chain 17 Parasympathetic Ganglia of the Head and Neck 20Nervous System (GN) Nervous system is divided into: I. Central nervous system: A- Brain. B- Spinal cord. II. Peripheral nervous system: A- Nerves: 1. Spinal nerves (31 pairs). 2. Cranial nerves (12 pairs). B- Autonomic nervous system: 1. Sympathetic. 2. Parasympathetic.Nervous System [NGS A- Brain Itis present inside the skull. Parts: A- Fore brain: consists of two cerebral hemispheres and diencephalon: B- Mid brain. C- Hind brain: consists of pons, medulla oblongata and cerebellum. Diencephalons: Consists of five parts, the most important of them is the thalamus & hypothalamus. Brain stem: consists of 3 parts: 1+ Midbrain. 2- Pons. 3- Medulla oblongata. B- Spinal Cord It is the continuation of the medulla oblongata, 45 cm in length lies inside the vertebral column and it consists of 31 segments (8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal). Each segment gives origin to a pair of spinal nerves. Peripheral nervous system (PNS): It consists of the: A- Cranial nerves: 12 pairs of nerves, connected to the cerebrum and brain stem. B- Spinal nerves: 31 pairs arise from spinal cord and are divided into; 8 cervical, 12 thoracic, 5 lumber, 5 sacral and one coccygeal.Nervous System [RI C- Autonomic nervous system (ANS): The system which concerned with the Involuntary activities. It supplies the heart, the sooth muscles of the G.l.T., respiratory and urinary system and it stimulates the secretion of the glands. It is divided into: 1. Parasympathetic nervous system (craniosacral) dit Cranial part: related to cranial nerves III, VII, IX and X. Sacral part: related to sacral spinal nerves 2, 3 and 4. 2. Sympathetic nervous system (thoracolumbar) division: arises from the spinal cord [first thoracic segment to second or third lumbar segment (T1-L2 or L3)], its fibers relay in the ganglia of the sympathetic chain.Nervous System [ES Cervical Part of Sympathetic Trunk Ganglionated nerve trunk embedded in the posterior wall of the carotid sheath and carries 3 ganglia. It lies behind CCA and ICA and in front of inferior thyroid artery, prevertebral muscles, fascia and transverse processes of cervical vertebrae. Superior ganglion Middle ganglion Inferior ganglion Position | Lies in front of the Lies in front of the Lies in front of the transverse processes of C2 jf transverse process of C6 |] transverse process of C7 and C3 vertebrae and vertebra, and inferior J vertebra behind vertebral behind ICA (2-3 cm long) _ | thyroid artery (the artery (single or fused with smallest ganglion) 1* thoracic ganglion) |_—_—_—___f_ Branches| 1.Cardiac branch to the 1, Cardiac branch to the || 1. cardiac branch to the heart heart heart 2. Vascular branches 2. Vascular branches —_}}2. Vascular branches forming forming plexus around forming plexus around J plexus around vertebral ECA and ICA inferior thyroid artery |) and subclavian arteries 3. Communicating 3. Communicating branches 3. Communicating branches J branches to C5 and to C7 and C8 nerves to upper 4 cervical and || C6 nerves lower 4 cranial nerves ! 4, Visceral branches: 4. Visceral branches to. 4, Branch forming ansa pharyngeal branch to trachea and subclavia with a branch pharyngeal plexus oesophagus coming from the middle ganglionNervous System [EGER Sympathetic Trunk Branches Superior ganglion C3, 5 ce See Cervical nerves es Middle : LCA ganglion Inferior ganglion vase Relations Prevertebral muscle & fa Inferior thyroid A Sympathetic trunk Vertebral A Subclavian A C: Cardiac branch Ph: Pharyngeal branch ‘Trachea OS: OesophagusNervous system [6 the Sympathetic Chain (Trunk) The sympathetic chain is a trunk of nerve fibers and ganglia which runs, one on each side, along the vertebral column. The thoracic sympathetic chain contains 11 (or 12) ganglia. The 1* thoracic ganglion is usually fused with the inferior cervical sympathetic ganglion to form the stellate ganglion which lies in front of the neck of the 1* rib. Beginning, course, relations and termination: It begins as a continuation of the cervical sympathetic chain, in front of the neck of the 1* rib. In the upper part of the thorax, the sympathetic chain lies in front of the necks of the ribs. In the lower part of the thorax, it runs on the sides of the bodies of the thoracic vertebrae. The thoracic sympathetic chain ends by passing behind the medial arcuate ligament of the diaphragm to enter the abdomen where it becomes continuous with the lumbar sympathetic chain. Branches: 1+ Communicating branches: (Rami communicants) Each thoracic sympathetic ganglion is connected with the corresponding spinal nerve by 2 rami communicants: a- White ramus communicants (myelinated): brings preganglionic fibers from the spinal nerve to the ganglion. b- Grey ramus communicants (non-myelinated): carries postganglionic fibers from the ganglion to the spinal nerve. 2- Vascular and visceral branches from the upper ganglia: These are postganglionic fibers which supply the aorta as well as the oesophagus, heart, trachea and lungs through their corresponding plexuses: a- From the upper 5 ganglia to the aortic and oesophageal plexuses. b- From the 2™, 3 and 4" ganglia to the cardiac and pulmonary plexuses.Nervous system [SS ‘Spmpathesic chain Thoracic part of the sympathetic chain (trunk)Nervous system 3+ Splanchnic nerves from the lower ganglia: These carry preganglionic efferent fibers to the abdominal viscera as weil as visceral sensory afferent fibers from these viscera. They include the greater, lesser and lowest (or least) splanchnic nerves: a- Greater splanchnic nerve: It arises from the 5" to 9” ganglia and descends obliquely downwards and medially on the bodies of the vertebrae, medial to the sympathetic chain. It leaves the thorax by piercing the crus of the diaphragm to enter the abdomen were it ends in the coeliac ganglion. b- Lesser splanchnic nerve: Arises from the 9" and 10" ganglia and runs the same course as the greater splanchnic nerve to end in aorticorenal ganglion. c- Lowest (least) splanchnic nerve: Arises from the last ganglion (11™ or 12") and ends in the aorticorenal ganglion or in the renal plexus.Nervous system [ON These are combined plexuses of both sympathetic and parasympathetic fibers, situated close to the viscera which they supply. They include cardiac, pulmonary and oesophageal plexuses. I. Cardiac Plexuses: ‘A- Superficial cardiac plexus: * Site: it lies in the concavity of the arch of the aorta, on the right anterior surface of the ligamentum arteriosum. Formation: it is formed of 2 branches: 1. Superior cervical cardiac branch of the left sympathetic chain. 2. Inferior cervical cardiac branch of the left vagus (parasympathetic). + Branches: it gives branches to: a- The deep cardiac plexus. b- The right coronary plexus. c The left anterior pulmonary plexus. B- Deep cardiac plexus: * Site: it lies in front of bifurcation of trachea, deep to the aortic arch. * Formation: it is formed by all cardiac branches of 2 sympathetic chains and the 2 vagi in the neck and thorax except those sharing in the superficial cardiac plexus. + Branches: it gives branches to: a- Right and left atria (direct branches). b- Right and left coronary plexuses. > Right and left anterior pulmonary plexuses.Nervous system 10 II. Pulmonary Plexuses: There are 2 pulmonary plexuses, posterior and anterior, which lie on the back and front of the root of each lung, respectively. They are mainly parasympathetic, derived from the vagus nerve or its branches. The few sympathetic fibers come from the 2™, 3 and 4 sympathetic ganglia. The posterior pulmonary plexus is the larger; it derives its parasympathetic fibers from the break up of the vagus nerve itself. The anterior pulmonary plexus is formed by few filaments from the posterior pulmonary plexus; it receives additional filaments from the cardiac plexuses. Fibers form the pulmonary plexuses reach the lung via 3 routes: a- along the bronchial tree. b- along the pulmonary arteries. c- along the stroma as far as the visceral pleura.Nervous system NGI ‘Trachea ine c Left vagus (X) ner ‘Arch of aorta Fight primary bronchus Fight sympathetic trunk gangion. “Thoracic aorta Greater splanchnic nerve Lesser splenchnic nerve Inferior vena cava (out) Colac truck Diaphragm (artery) AORTICORENAL CELIAC GANGLION AND PLEXUS att SUPERIOR MESENTERIC Sipetor mesernisatey GANGUON AND PLEXUS RENAL GANGLION Fight kidney ‘AND RENAL P_EXUS INFERIOR MESENTERIC ‘GANGLION AND PLEXUS Inferior mesenteric anery Fight sympathetic trunk ganglion HYPOGASTRIC PLEXUSNervous system [AGAR III, Oesophageal Plexuses: These are anterior and posterior plexuses which lie on the front and back of the oesophagus, respectively, below the root of the lung. They are mainly parasympathetic derived from the vagi. They receive few sympathetic fibers form the upper 5 thoracic ganglia. The right vagus nerve forms most of the posterior oesophageal plexus which gives the posterior gastric nerve. The left vagus nerve forms most of the anterior oesophageal plexus which gives the anterior gastric nerve. The anterior and posterior gastric nerves reach the abdomen through the oesophageal opening of the diaphragm to form the parasympathetic fibers of the celiac plexus. MCQs: Regarding the thoracic part of the sympathetic chain, one of the following statements is incorrect: a- The 1* thoracic ganglion usually fuse with the inferior cervical ganglion to from the stellate ganglion. b- The grey ramus communicants carriers postganglionic fibers. c= The oesophageal plexus receives sympathetic fibers from the upper 5 ganglia. d- The pulmonary plexus recelves sympathetic fibers from the 3", 4° and 5” ganglia.Lumbar Part of Sympathetic Chain [G30 = The sympathetic chain enters the abdomen behind the medial arcuate ligaments of the diaphragm, one on each side. It each chain has four lumbar sympathetic ganglia. It passes downwards in a groove between the vertebral column and the medial border of the psoas major muscle. Then it enters the pelvis behind the common iliac vessels. Branches: ‘A- Rami communicants: 1. The four ganglia give off postganglionic fibers to all lumbar nerves. 2. The 1* and 2% lumbar nerves send preganglionic fibers (white rami ‘communicantes) to the corresponding ganglia. B- Lumbar splanchnic nerves: 1. There are four nerves, one from each ganglion. 2. They join the abdominal autonomic plexuses (coeliac, aortic and hypogastric). C- Vascular branches: Surround the aorta and iliac arteries.Lumbar Part of Sympathetic Chain [GANS I. Coeliac Plexus: * The largest autonomic plexus in the body, it is present around the coeliac trunk at the level of T12 and L1 vertebra. It is composed of two large coeliac ganglia, one ‘on each side of the coeliac artery. The lower part of the coeliac ganglion is partly detached and is called aorticorenal ganglion. Formation: It is formed by: 1. Sympathetic fibers: from the greater and lesser splanchnic nerves coming from the thoracic sympathetic chain. 2. Parasympathetic fibers: from the vagus nerve. Through its anterior and posterior gastric nerves. The coeliac plexuses give off secondary plexuses around the branches of the coeliac trunk (hepatic, splenic and left gastric artery) as well as the aorta, renal and superior mesenteric arteries. IL. Aortic Plexus: + It covers the aorta between the origins of the two mesenteric arteries. It is formed by: 1, Branches from the coeliac plexus. 2. Branches from the 1 and 2" lumbar sympathetic nerves (sympathetic). * It gives off secondary plexuses around the inferior mesenteric, gonadal and iliac arteries, III. Superior Hypogastric Plexus (Presacral Nerve): +t lies just below the bifurcation of the aorta between the two common ilica arteries in front of 5" lumbar vertebra and promontory of the sacrum. Formation: It is formed by: 1. Filaments descending on each side from the aortic plexus. 2. Branches from the 3% and 4" lumbar splanchnic nerves (sympathetic). 3. Branches from pelvic sphanchnic nerves (parasympathetic).Lumbar Part of Sympathetic Chain Gas a- It divides into right and left divisions which descend into the pelvis to join the inferior hypogastric (pelvic) plexuses that lie one on each side of the rectum and the urinary bladder. b- It also gives branches to inferior mesenteric plexus. Celiac ganglion ‘Superior mesenteric ganglion Aorticorenal ganglion Lumbar splanchnic nerves Aortic plexus ‘Sympathetic trunk and ganglion Inferior mesenteric ganglion Hypogastric nerve Inferior hypogastric plexus Autonomic plexusesLumbar Part of Sympathetic Chain eae) MCQs: Regarding the abdominal part of the sympathetic chain, one of the following statements is incorrect: a) It has 5 lumbar ganglia. b) It enters the abdomen through the crus of diaphragm. c) It gives vascular branches around abdominal aorta and iliac arleries. d) It enters the pelvis in front of the common iliac vessels.Pelvic Part of Sympathetic Chain NG Pelvic part of sympathetic chain: Tt is the direct continuation of the abdominal part. It crosses the ala of the sacrum deep to the common iliac vessels. Site: it lies on the anterior surface of the sacrum anterior or medial to the anterior sacral foramina and just lateral to the median sacral artery. Below, the two chains unite in front of the coccyx to form a single ganglion called the ganglion impar. Each trunk contains four or five sacral ganglia which give: ‘a- Lateral branches: give grey rami communicants to the sacral and coccygeal spinal nerve b- Medial branches: give branches from the first two ganglia to join the inferior hypogastric plexus. Other branches form a plexus on the median sacral artery.Pelvic Part of Sympathetic Chain RUIN Autonot hi I. Superior hypogastric plexus (the presacral nerve) (see P. 14): Plexusé IL. Inferior hypogastric (pelvic) plexuses: right and left ‘Site: medial to the internal iliac vessels. Formation: 1. Right and left hypogastric nerves (mainly sympathetic) from the superior hypogastric plexus. 2. Branches from the first two ganglia of the pelvic part of sympathetic chain. 3. Parasympathetic fibers: from the pelvic splanchnic nerves (S2, 3, 4). Distribution: It supplies the pelvic viscera either directly or via their blood supply.Pelvic Part of Sympathetic Chain ea Sympathetic unk and gangion MCQs: 1- Preganglionic parasympathetic nerve fibers within the pelvic (inferior hypogastric) plexus arise from S2, 3, 4 and enter the plexus via: A- Hypogastric nerves. B- Pelvic splanchnic nerves. C- Sacral splanchnic nerves. D- White rami communicants.Parasympathetic Ganglia of the Head and Neck (SSU30) jary ganglion: A small parasympathetic ganglion, lies near the apex of the orbit between the optic nerve and the lateral rectus. It is suspended from the nasociliary nerve from ophthalmic nerve. Roots: It has 3 roots: 1- Sensory root: from the nasociliary nerve. 2 Parasympathetic root: from the oculomotor nerve it relays in the ganglion. 3- Sympathetic root: From the sympathetic plexus around the internal carotid artery. Branches: 12-15 short ciliary nerves which pierce the back of eyeball around the entrance of optic nerve. They contain the following fibers: a- Parasympathetic postganglionic fibers which supply the ciliary and the sphincter pupillae muscles. b- Sympathetic fibers supply the dilator pupillae and the blood vessels of the eyeball. > Sensory fibers: carry the sensation from the eyeball.Parasympathetic Ganglia of the Head and Neck juwwaaames Motor Nerves of the Orbit Levator Palpebrae Superioris - Superior Oblique Lateral Recta ‘Medial Rectue Inferior Rectus Taferlor Oblique Ciliary Ganglion Short ciliary nerves _ Nasociliary nerve Eye ball Roots of the ciliary ganglion: ee LIE i Nerve to inferior 1. Sensory root \ Ciliary " oblique 2. Parasymp. root LCA. ganglion 3. Sympath. rootParasympathetic Ganglia of the Head and Neck jmappee) Otic Ganglion Small parasympathetic ganglion lying in the infra-temporal fossa deep to the trunk of mandibular nerve suspended from it by the nerve to medial pterygoid. Roots and branches of the ganglion: a- Parasympathetic root (Lesser superficial petrosal nerve): It is indirect branch of the glossopharyngeal nerve. It passes through foramen ovale to reach and relay in otic ganglion. The postganglionic fibers join the auriculo-temporal nerve to reach and supply the parotid gland. b- Sympathetic root: It arises from sympathetic plexus around middle meningeal artery (it is postganglionic fibers from the superior cervical sympathetic ganglion). ¢- Motor root: Two fibers arise from nerve to medial pterygoid. They traverse the ganglion without relay to supply 2 muscles: tensor palati and tensor tympani. Branche: Parasympathetic and sympathetic fibers: They join the aucirulo-temporal nerve to reach and supply the parotid gland. Motor fibers: They traverse the ganglion without relay to reach and supply 2 muscles, tensor palati and tensor tympani.Parasympathetic Ganglia of the Head and Neck (GNI300 Glossopharyngeal nerve : Tympanic plexus Middle meningeal Foramen artery ovale Tensor palati Nerve to medial pterygoid Tensor. Mandibular nerve Parasympathetic and sympathetic post ganglionic fibers Lateral pterygoidParasympathetic Ganglia of the Head and Neck [ERRG2IR Sphenopalatine Ganglion ‘Small parasympathetic ganglion lies in the pterygopalatine fossa, suspended by 2 roots from maxillary nerve. Roots of the ganglion: A- Parasympathetic root: Greater superficial petrosal nerve. It arises from facial nerve (seventh cranial nerve) in the middle ear. It reaches and relays in the ganglion. B- Sympathetic root: Deep petrosal nerve. It arises from sympathetic plexus around internal carotid artery (originally it is postganglionic fibers from superior cervical sympathetic ganglion). It reaches and traverses the ganglion without relay to reach and supply the blood vessels of orbit, nose, palate and pharynx. C- Sensory root: Two ganglionic branches which connect the ganglion to the maxillary nerve. N.B.: The parasympathetic and sympathetic root join together to form nerve of pterygoid canal. Facial nerve Be Foramen — Prerygopalatine taterior orbits fossa Petrous bone rotundum fissure cervical Greater palatine canal Lesser palatine foramen — (Nose) incisive fossa Soft palate ‘ 1. Orbital 2. Nasal branches: medial (N) and Lateral (L) 3. Palatine branches: a) Greater and b) Lesser 4. Pharyngeal Branches of sphenopalatine colParasympathetic Ganglia of the Head and Neck (NWG50) Spine of sphenoid bone Foramen spinosum Foramen ovale Greater wing of sphenoid ‘Sphenopalatine foramen (Pterygopalatine fossa) Back of maxilla Styloid process Lateral pterygoid plate Prerygoid hamulus Medial pterygoid plateParasympathetic Ganglia of the Head and Neck ummm Branches of Sphenopalatine Ganglion 1- Orbital branches: Reach the orbit through inferior orbital fissure (IOF) to supply the periosteum of orbit. 2+ Nasal branches: They reach the nose through the sphenopalatine foramen (SPF) and divide into 2 groups lateral (L) and medial (M) to supply the mucous membrane and glands of the nasal cavity. 3- Palatine branches: a. Greater palatine nerve: It descends in the greater palatine canal to reach the hard plate and supply its mucosa and glands. b. Lesser palatine nerves: They descend in the greater palatine canal, tien they pass through the lesser palatine foramina to supply the soft palate. 4- Pharyngeal branches: They run posteriorly to supply the nasopharynx.Parasympathetic Ganglia of the Head and Neck Ree Orbit Pterygopalatine Maxillary fossa Foramen nerve rotundum Palatovaginal canal 4 Greater palatine canal Lateral pterygoid plateParasympathetic Ganglia of the Head and Neck esas Submandibular Ganglion ‘A small parasympathetic ganglion suspended from lingual nerve in the upper part of the lateral surface of hyoglossus muscle in the submandibular region. Roots: 1- Parasympathetic root: Chorda tympani: It a branch of facial nerve (seventh cranial nerve) in the middle ear. Tt reaches and relays in the ganglion. 2- Sympathetic root: Sympathetic plexus around facial and lingual arteries (originally they arise as postganglionic fibers from the superior cervical sympathetic ganglion). They traverse the ganglion without relay. 3- Sensory root: Short trunk connecting the lingual nerve to the ganglion. It contains sensory fibers which traverse the ganglion without relay to reach the submandibular and sublingual glands. Branches: Parasympathetic, sympathetic and sensory fibers to the submandibular and sublingual glands and to their blood vessels. 1 Parasympathetic nervi Baranympathetie nerve, Lingual nerve Hyoglossus muscle (chorda tympani) 2 Sympathetic plexus around facial artery Sympathetic plexus lingual artery Submandibular gland Submandibular ganglionParasympathetic Ganglia of the Head and Neck S300 MCO: 1- Regarding the sphenopalatine ganglion, mark one true statement: A. It lies in the infratemporal fossa. B. It gives deep petrosal nerve. C. It gives lesser petrosal nerve. D. It receives its sympathetic root through greater petrosal nerve. E. It is attached to the maxillary nerve by the sensory roots. 2- Sphenopalatine ganglion gives the following branches, except: A. Greater palatine nerve. B. Lesser petrosal nerve. C. Nasopalatine nerve. D. Lesser palatine nerves. E, Orbital branches. 3- Regarding the otic ganglion mark the one true statement: A, It lies in the submandibular region B. It supplies the lacrimal gland C. It supplies the parotid gland D. Its sympathetic root arises from the sympathetic plexus around lingual artery E, Its motor root supplies buccinator muscle