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Somatic: Provides Sensory and Motor Innervation ○ a Part of the Somatic Nervous System Innervates the Dermatomes of Thorax, Abdomen and Pelvis

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Somatic: Provides Sensory and Motor Innervation ○ a Part of the Somatic Nervous System Innervates the Dermatomes of Thorax, Abdomen and Pelvis Lecture 1: Autonomic Nervous System Organisation of the Autonomic Nervous System - Somatic: Provides sensory and motor innervation ○ A part of the somatic nervous system innervates the dermatomes of thorax, abdomen and pelvis. - Autonomic: Provides innervation to the viscera ○ Sympathetic ○ Parasympathetic Somatic Neurons - Sensory fibres ○ Bring information about touch, pressure and pain from the periphery to the CNS. ○ Originate from body wall ➔ Spinal nerve ➔ Dorsal root ganglion (cell body) ➔ Dorsal horn ➔ Ascend up to CNS - Motor fibres ○ Carry information from the CNS to skeletal muscles for movement. ○ Originates in ventral horn ➔ Ventral root ➔ Spinal nerve ➔ To muscle - Spinal nerves run laterally. - In the context of the thorax, abdomen and pelvis, spinal nerves provides segmental innervation to the body wall. ○ Forms basis of dermatomes. Autonomic neurons - Sympathetic: Some of the sympathetic neurons will ascend or descend through the chain to access the top and bottom. - Parasympathetic: Most of the parasympathetic innervation are from the vagus nerve. SYMPATHETIC PARASYMPATHETIC Short preganglionic neurons Long preganglionic neurons - Some lumbar neurons bypass the sympathetic chain and run in splanchnic - Run in vagus nerve for thorax and abdomen. nerves which leads to the prevertebral ganglia ➔ Pelvic viscera - Run in pelvic splanchnic nerves for pelvis. Synapse with postganglionic neurons Synapse with postganglionic neurons near viscera. - In sympathetic trunk ➔ Thorax or head - In prevertebral ganglia, which is in front of the abdominal aorta, and not in the sympathetic trunk ➔ Abdomen Sympathetic neurons - Originate from the intermediolateral nucleus/horn ➔ Ventral root ➔ Spinal nerve ➔ Communicating rami ➔ Sympathetic chain ganglion - Rami communicantes ○ Connects spinal nerves with sympathetic chain ○ White communicating rami = More distal ● White because the preganglionic sympathetic neurons are myelinated. ○ Grey communicating rami = More proximal - Postganglionic neurons can also go through the grey communicating rami and into the spinal nerve, which will go out of the body wall to blood vessels, sweat glands etc. Visceral afferent neurons Visceral afferent neurons: Sensory neurons that innervate viscera. - Follows sympathetic pathway back to CNS from the viscera. - Can also follow parasympathetic pathways via the vagus nerve back to CNS. - Take information about the state of the viscera back to the CNS ➔ Visceral state contributes to all sorts of reflexes. ○ Sensory to viscera ○ Distension of viscera ○ Visceral pain Referred pain - Pain associated with viscera is usually referred to body wall/skin. - Referred pain is the perception of pain in areas other than the site of stimulation, usually due to a common spinal segmental origin of the nerves to the site of stimulation and the site to which the pain is referred. - Probably due to the convergence of the two inputs, one somatic and one visceral sensory neuron, to the same population of neurons or one neuron at a given spinal segmental level. - Visceral pain is referred to somatic regions. - Somatic pain can be referred to other somatic regions. - Pain is often referred to the body walls and limbs. ○ Heart attack ➔ Refer pain to T1-T4 - The brain can't tell that information is coming from the viscera because the body doesn't have a good map of the organs, but it has a good map of the body wall due to frequent stimulation. ○ Since it can't distinguish between these two groups of inputs, it will refer pain out to the dermatome associated with that spinal cord segment because it has a familiarity with that map. Referred pain from paired viscera Unpaired viscera - GIT and associated glands and ducts: Develop in midline, but migrate away from it. ➔ Associated orifices: mouth, anal canal remains in midline. - Nerve supply from both sides of spinal cord. - Visceral pain referred to midline skin over origin of viscera, because dual sensory nerve reaches both sides of spinal cord simultaneously. - Pain only referred to local overlying skin when somatic nerves involved. Lecture 2: Thoracic Walls and Breast Thoracic wall - Function: To protect the viscera within ➔ Heart, lungs - Forms mechanical basis of breathing. - Includes: ○ Thoracic cage: Ribs, sternum, vertebrae ○ Covering: Skin, muscle Thoracic cage - Ribs ○ 12 ribs ○ Each rib, except for floating ribs, associates with a costal cartilage anteriorly and these costal cartilages attach to the sternum. ○ Costal cartilage ➔ Contributes to mobility of thorax which is important for breathing. ➔ Allows thoracic cage to expand in breathing. ○ Classification Attachment: True, false, floating ■ Ribs 1-7 ■ True ribs ■ Attach directly to the sternum via their own costal cartilage. ■ Ribs 8-10 ■ False ribs ■ Have costal cartilage that extends anteriorly from them, but attaches to the costal cartilage of the rib above. ■ No direct attachment to the sternum. ■ Ribs 11-12 ■ Floating ribs ■ No anterior attachment at all. ■ Mobile Features: Typical, atypical ■ Ribs 3-9 ■ Typical ribs ■ Curved and flat ■ Angle ➔ Most of the bend of the rib. ■ Costal groove ➔ At inferior surface of rib. ➔ Shelters and protects neurovascular structures that run through intercostal spaces. ■ Posterior end (Head): Superior and inferior facet ➔ Articulate with the demifacets on the vertebral body. ➔ Superior facet articulates with inferior demifacet of the vertebral body above. ➔ Inferior facet articulates with the superior demifacet of the vertebral body below (same number). ● Neck ➔ Small narrowing ➔ Articular facet: Articulates with the transverse process of the vertebrae. ➔ Tubercle: Attachment for ligaments associated with the costotransverse joint. ■ Ribs 1-2, 10-12 ■ Atypical ribs ■ All have slightly different features. ■ Rib 1 ➔ Flat in the coronal plane unlike other ribs that are flat vertically. ➔ 2 grooves for the subclavian vessels over the top of the rib. ➔ Scalene tubercle for attachment of scalene muscles of the neck. - Sternum ○ Commonly known as breastplate. ○ 3 parts ■ Manubrium ■ Jugular notch: Has defined sensory innervated periosteum which can hurt if pressed ➔ Pressure point ■ Clavicular notch: Articulation of medial clavicle ■ Articulates with rib 1 below clavicular notch. ■ Articulates partly with rib 2. ■ Body of sternum ■ Xiphoid process ■ Largely cartilaginous for most of our life, but become less cartilaginous as it starts to ossify later in life. ■ Forms some attachment to the diaphragm. ○ Manubriosternal joint: Articulation between manubrium and sternum. ● Defined bump ■ Allows palpation of rib 2 ➔ Rib 2 attaches via its costal cartilage at this joint. ● Angle of Louis/Sternal angle: Angle which forms lump at manubriosternal joint. ● Plane of Louis: Horizontal line through the thorax which forms a transverse plane through sternal angle. ■ Significance of Plane of Louis: ✩ Aortic arch ✩ 2nd Rib ✩ T4/5 vertebrae ✩ Bifurcation of trachea - Thoracic vertebrae ○ 2 articular points ● Costovertebral joint: Joint where head of rib articulates with body of the vertebrae. ■ The rib articulates at the top of the body of the vertebrae with the same number. ● Costotransverse joint: Joint where articular facet distal to the neck of rib articulates with transverse process of vertebrae. Intercostal space - Intercostal space: Space between ribs. ○ Intercostal veins, arteries and nerves run between the internal intercostal muscle layer and the innermost intercostal muscle layer. ○ They are sheltered superiorly in the intercostal space under the costal groove of the rib above. ■ Importance: For injections, penetrate above the rib below to avoid damaging neurovascular bundle in intercostal space. - Intercostal muscles ○ 3 Layers ● External intercostal muscles ■ Superficial layer ■ Fibre direction: Anteroinferiorly ■ Breaks down anteriorly at costochondral junction ➔ Continues as external intercostal membrane. ■ Action: Elevate the ribs ● Internal intercostal muscles ■ Intermediate layer ■ Fibre direction: Posteroinferiorly ➔ Perpendicular to external intercostal muscles. ■ Breaks down posteriorly and continues as a membrane. ■ Action ➔ Lateral to costochondral junction: Depress ribs because they have the opposite fibre direction to the external intercostal muscles. ➔ Medial to costochondral junction: Elevate the ribs because of the 3D shape of ribs. ● Innermost intercostal muscles ■ Deep layer ■ Fibre direction: Posteroinferiorly ➔ Same direction as internal intercostal muscles which means it has the same function. ■ Tend to be broken down and patchy particularly around the posterior end. ✩ Importance: Allows us to see neurovascular structures running through the intercostal space in the posterior thoracic wall. - Intercostal nerves ○ Intercostal nerves are extensions of segmental spinal nerves ➔ Ventral rami of spinal nerves coming from each thoracic spinal cord segment. ○ These ventral rami continue in the intercostal space and are now referred to as intercostal nerves. ○ Intercostal nerves give off a muscular and cutaneous branches. ● Supplies all intercostal muscles and overlying skin in their respective space. ● Forms basis of the 12 thoracic dermatomes ➔ Clinical importance: Maps out patterns of referred pain. ■ T4: Strip over nipples ■ T10: Strip over belly button ○ Intercostal nerves terminate anteriorly via some cutaneous branches. ● Cutaneous supply: Skin anteriorly, laterally and posteriorly until the angle to the ribs. ■ The dorsal rami of the spinal nerves supply the hypaxial muscles and the skin medial to angle of
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