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THE ANATOMY of the SYMPATHETHIC TRUNKS in MAN by MARTIN WRETE Histological Department, the University of Uppsala, Sweden

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THE ANATOMY of the SYMPATHETHIC TRUNKS in MAN by MARTIN WRETE Histological Department, the University of Uppsala, Sweden [ 448 ] THE ANATOMY OF THE SYMPATHETHIC TRUNKS IN MAN BY MARTIN WRETE Histological Department, The University of Uppsala, Sweden INTRODUCTION Even a cursory study of the anatomical descriptions of the cervical parts of the sympathetic trunks given in modern text-books or articles discloses that, now as earlier, great confusion exists with respect to terminology. This applies even to monographs and more specialized presentations. The primary cause of this confusion is the very marked variability of the trunks in the neck region, which gives wide scope for arbitrary interpretations of the arrangement; some uncertainty about the terminology and notation of other parts of the trunks also persists. It is true that the terms to be used for the sympathetic nervous system were fixed by the International Anatomical Nomenclature Committee (Nomina Anatomica, Paris, 1955). This does not, however, prevent some of the individual terms being used to denote different anatomical units, and for practical reasons (such as limiting printing costs) comprehensive explanations could not always be given in the annota- tions to the Parisian Nomina Anatomica. As one of the three members of the Sub- Committee responsible for the nomenclature of the peripheral nervous system, I wish to define more exactly my views on the terminology adopted for the sympathetic trunks. I also take this opportunity of revising a few terms I used in certain papers published some twenty years ago. In Nomina Anatomica the term truncus sympathicus is followed by the names of its ganglia, ganglia trunci sympathici, as well as of its connecting rami interganglio- nares. But, also under the heading ganglia trunci sympathici, the term ganglia intermedia is used to denote ganglia on the rami communicantes and certain ganglia on the trunks in the rami interganglionares between the other ganglia-namely the ganglion cervicale superius, ganglion cervicale medium, ganglion cervicothoracicum (s. stellatum), ganglia thoracica, ganglia lumbalia, ganglia sacralia, and ganglion impar. The term ganglion vertebrate is listed under the heading ganglion cervicale medium, without further commentary. The main object of the present paper is to define those anatomical units to which the above terms should be applied. CERVICAL REGION The cervical parts of the sympathetic trunks differ essentially from the other parts, because their segmentation has become so obliterated, owing to fusion and division of the segmental ganglia, that it has been necessary to give each ganglion a special name. In many text-books it is stated that the individual cervical ganglia corre- spond to certain fixed segments, as evidenced by their macroscopically demonstrable connexions with certain spinal nerves through the communicating rami. In the The anatomy of the sympathetic trunks in man 449 cervical region it is not possible to analyse the connexions between the spinal nerves and the trunk solely by macroscopic dissection (Wrete, 1934 a) because the con- nexions consist partly of spinal-nerve branches to the prevertebral muscles, which are joined to the grey communicating rami in a highly complicated way (Fig. 1). However, by microscopic studies of embryos and foetuses (Wrete, 1934b) it was possible to make a segmental analysis of the cervical sympathetic trunks (Fig. 2). Va 6 t b d a V Va * -~~~~~~~~Stg Fig. 1. Human foetus, 39*6 mm. Profile reconstruction from the left half of the body, seen from the median plane. C5, C6, etc., parts of cervical spinal nerves; Va, vertebral artery; Vg, vertebral ganglion; Str, sympathetic trunk; Sig, stellate ganglion; a, grey communicating ramus; b, spinal-nerve branch to prevertebral muscles (the arrows mark the terminal branches of the spinal-nerve branches running towards the muscles); c and d, junction of a and b (the broken line denotes part of a muscle branch which follows a grey communicating ramus); Img, intermediate ganglion on this communicating ramus. This was done by investigating the embryonic segmental parietal arteries, and par- ticularly the grey communicating rami accompanying them, but unfortunately little attention has been paid to these observations. These communicating rami, which are present only in the lower part of the cervical region and the uppermost part of the thoracic region, are characterized by their division into two branches, one to the segmental artery corresponding to the spinal nerve, and one to the cranial artery in immediate succession; I therefore introduced the term 'rami communi- cantes grisei bipartiti' for these rami. From a linguistic point of view, the term is 29 Anat. 93 450 M. Wrete not particularly appropriate, and it does not seem to have become generally accepted. (I have, in fact, seen it only in two text-books.) Consequently, in view of the fork-like mode of branching of the nerves in question, I now suggest that they be named 'rami communicantes grisei bifurcati'. Throughout the literature the term superior cervical ganglion is used to denote the most cranial of the ganglia on the cervical part of the sympathetic trunk, i1 Va Fig. 2. Schema showing the course of the rami communicantes grisei bifurcati in man. Left sympathetic trunk seen from the lateral view. The transverse process and ribs are sawn through, and the lateral parts of the cut surface are removed (broken lines indicate the cut surfaces). Pc, costal process of 7th cervical vertebra; PI, lateral process of same vertebra; Co, neck of first rib; Pt, transverse process of first thoracic vertebra; Va, vertebral artery; C1 C4, etc., cervical spinal nerves; Th,, etc., thoracic spinal nerves; Mcg, middle cervical ganglion; Scg, superior cervical ganglion; Stg, stellate ganglion; Vg, vertebral ganglion; Tg2, etc., thoracic ganglia; 1mg, intermediate ganglion; a, b, deep rami communicantes; c, vertebral nerve; d, e, f, g, caudal rami communicantes grisei bifurcati. The anatomy of the sympathetic trunks in man 451 irrespective of variations in shape, size and position. There is no unanimity about these variations. In most text-books the term stellate ganglion is used to denote that ganglion formed by fusion of the lowest ganglion on the cervical trunk and one or more (usually one to four) of the adjacent thoracic ganglia. These most cranial thoracic ganglia can be identified with the help of the rami communicantes grisei bifurcati. The upper part of the stellate ganglion was formerly known as the inferior cervical ganglion. This term has sometimes given rise to confusion, since it has also been used, incorrectly, for a ganglion cranial to the subclavian artery. The fact that the term has been discarded in Nomina Anatomica is justified by the fact that the in- ferior cervical ganglion appears only exceptionally as an independent formation. The part of the stellate ganglion which corresponds to it is characterized by its position directly caudal to the subclavian (and the root of the vertebral) artery, and by the fact that it gives off two rami communicantes grisei bifurcati (Wrete, 1934b); the cranial ramus, which is developed along the 7th cervical segmental artery and is named the vertebral nerve (nervus vertebralis), joins the spinal nerves C7 and C6; the caudal ramus, developed along the 8th cervical artery, joins C8 and C7. It is not unusual to find a constriction on the stellate ganglion, marking the borderline between the parts representing the inferior cervical ganglion and the 1st thoracic ganglion. The suggestion put forward by Lazorthes & Cassan (1939), and adopted by Guerrier (1944), that the term cervicothoracic or stellate ganglion should include the vertebral ganglion cranial to the origin of the vertebral artery is not warranted, as Mitchell (1953) has justifiably stressed. In my opinion this also applies to a similar suggestion put forward by Axford (1927-8) and Woollard & Norrish (1933), i.e. that it should also include this ganglion, although they failed to differentiate the verte- bral from the middle cervical ganglion. The greatest divergences in the nomenclature are encountered with respect to the part of the sympathetic trunk between the superior cervical ganglion and the stellate ganglion. In most descriptions only one ganglion is mentioned, namely the middle cervical ganglion. Some authors state it is situated relatively high up and others place it relatively low down, close to the root of the vertebral artery. Axford (1927-8) refers to high and low middle cervical ganglia. When two ganglia were present, they were described by van den Broek (1908) as a middle cervical ganglion split into two parts. In an earlier publication (Wrete, 1934 b) I also used this less appropriate nomenclature. Mannu (1914) denoted all ganglia between the superior cervical ganglion and the inferior cervical ganglion as intermediate ganglia; he distinguished as particularly characteristic a superior one, the thyroid ganglion, and an inferior one, close to the subclavian artery, the vertebral or subclavian ganglion. In some modern text- books of anatomy an attempt has been made to clarify the terminology by denoting the superior, generally larger ganglion as the middle cervical ganglion, and the inferior one as the intermediate cervical ganglion (e.g. Jonnesco, 1923; Hovelacque, 1927; Kuntz, 1946; Brodal, 1948; White & Srnithwick, 1952). Matsui (1925-6) has used the term intermediate ganglion as a synonym of middle cervical ganglion. On the basis of a study of the cervical sympathetic trunks in 120 foetuses and 29-2 452 M. Wrete newborn infants, Laubmann (1931) set up a schema with five basic types (Fig. 3), some of which are stated to be more and others less common. Since there is reason to presume a postnatal reshaping of the cervical sympathetic trunks (Wrete, 1934 b), the incidence figures given by Laubmann may not be fully applicable to adults, nor does this schema cover all the variants which may occur. Despite these drawbacks, Laubmann's schema is of great value. In all the main types and subtypes the lower of the two interjacent ganglia, lying slightly cranial to the origin of the verte- bral artery from the subclavian artery, is indicated.
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