ANATOMY - THORAX & ANTERIOR ABDOMINAL WALL

10- Thoracic Wall & Lung

1. Thoracic a. Superior thoracic aperture (Inlet): site of entrance of viscera and vessels from head,
neck, upper limbs into the thorax; Bounded by 1st rib, vertebral column, manubrium

b. Inferior thoracic aperture (Outlet): closed by diaphragm, pierced by inferior vena cava (T8), aorta (T12), esophagus (T10); innervated by phrenic n. (C3, 4, 5) 2. Sternum: a. Manubrium: articulates at sternoclavicular joint, rib 1, & half rib 2 i. Jugular (suprasternal) notch b. Body: articulates with half of rib 2 head & heads of ribs 3-7; pec major attach c. Sternal angle (angle of Louis): 2nd rib attachment (T4/5 level) i. Junction of manubrium with body ii. Where trachea divides into right & left main stem bronchi iii. 2nd intercostal space: listening to aortic (R) and pulmonary (L) valves d. Xiphoid process: level of 6th thoracic dermatome 3. Ribs: a. Costochondral junction: between cartilages & ribs b. Head (crest): articulates with sides of 2 vertebraes bodies at the same superior (superior facet) & inferior (inferior facet) levels
(except for rib 1, 11, 12);

attached to IV disc by intraarticular ligament

c. Costovertebral ligaments: stability & flexibility of the joints

i. Costovertebral articulation: joint of head + joint of rib tubercle

Sternocostal ligaments: attach costal cartilages to the sternum Body: Angle of the rib: frequent place of rib fracture Articulating Tubercle: attached to vertebra transverse process at same level (rib 6 is attached to T6) via costotransverse joint h. Costal groove: i. Pectus excavatum: sunken-in chest; costal cartilages lengthen, pushing sternum in crowding out mediastinum structures j. Pectus carinatum: overly prominent, pigeon chest k. Kyphoscoliosis: hump & lateral spine bending; adds to thoracic wall stiffness 4. 12 pairs of ribs: a. 1-7: vertebrosternal (true ribs): costal cartilages articulate directly with sternum b. 8-10: vertebrochondral (false ribs): cartilage articulates with cartilage above it c. 11 & 12: vertebral (floating): don't have costal cartilages, necks, or tubercles; ends in musculature of posterior abdominal wall d. Cervical rib: extra rib which usually arises from C7 (0.2% of people) i. Can become entrapped between cervical rib and scalenus muscle Thoracic Outlet Syndrome due to compression of the: 1. Brachial plexus lower trunk hand muscle weakness, pain/numbness in medial side of forearm & hand 2. Subclavian artery loss of pulse when arm is abducted

d. e. f. g.

e. Flail chest: multiple rib fractures i. Inspiration: intrapleural pressure becomes more negative, flail segment & underlying lung tissue sucked inward, collapsing lung on affected side, shifting mediastinum toward UNaffected side ii. Expiration: as intrapleural pressure becomes less negative, flail segment & tissue pushed outward, mediastinum shifts to affected side 5. Thoracic Wall Intercostal muscles: (phrenic nerve C3, 4, 5) a. External intercostal: inspiration; project inferiorly in a posterior to anterior direction; replaced in front by external intercostal membrane i. Inspiration: external I.M. contract to raise ribs diaphragm flattens as it contracts increases thoracic cavity height & circumference; decreases intrathoracic pressure & pulls air into lungs 1. Bucket handle: thoracic cavity increased 2.
by 7-10th ribs moving laterally Pump handle: sternum pushed forward by true ribs (1-6) increasing anteroposterior dimension

ii. Accessory muscles: pectoralis major &

minor, sternocleidomastoid, scalenes (1st & 2nd rib)

b. Internal intercostal: expiration; project superiorly in a posterior to anterior direction (perpendicular to external intercostals); replaced in the back by internal intercostal membrane i. Expiration: quiet expiration chiefly passive
1. Inspiratory muscles relax; Rib cage drops under force of gravity; Relaxing diaphragm moves superiorly; Elastic fibers in lung recoil

2. Volume of thorax and lungs decrease simultaneously, increases intrathoracic pressure air forced out c. Innermost (incomplete) intercostal: i. Transversus thoracis: from back of sternum and xiphoid process, onto
costochondral junctions ribs 3-6; travels superior & laterally to 2nd 6th ribs

ii. Subcostalis: can bridge more than one intercostal space 6. Vessels and nerve of thoracic wall: a. Axillary: i. Supreme thoracic: supplies first two intercostal spaces from inside ii. Lateral thoracic: supplies first few intercostal spaces from outside b. Subclavian: i. Internal thoracic artery: deep to intercostal cartilages to anterior abdominal wall to give rise to anterior epigastric arteries 1. Musculophrenic: 2. Superior epigastric: 3. Anterior intercostal artery: supply sternum skin; anastomose
with posterior vessels in intercostal spaces around midclavicular line

c. Thoracic Aorta: i. Posterior intercostal artery: travel with intercostal nerves, giving branches to intercostal muscles d. Aortic coarctation: lower BP in lower limb than in arm; intercostal arteries can be used to supply blood past the constriction below the diaphragm i. In an infant, post-ductal coarctation is better adapted to than pre-ductal ii. Rib notching: due to intercostal a. carrying more blood than normal (from coarctation) e. Anterior intercostal veins drain into internal thoracic vein drains into brachiocephalic vein f. Posterior intercostal veins drain into right azygos & left hemiazygos vein drains into superior vena cava g. Intercostal nerves (Ventral primary rami of thoracic T1-12 spinal nerves): mixed nerves containing both motor & sensory fibers i. Damage to spinal cord between C8 & T1 would affect all intercostal nerves affects muscles of respiration 1. Diaphragm unaffected (still functions) ii. Anterior (ventral) rami: innervate intercostal muscles (run between innermost & internal intercostals), rib periostum, & skin of the thorax (dermatome) iii. Herpes zoster (shingles): painful rash of blisters in a dermatonal pattern (limited area on one side of body); virus affects dorsal root ganglia and travels down nerve axons to cause viral infection of the skin in the region of the nerve iv. Posterior (dorsal) rami: innervate back muscles between angle of the ribs
& vertebrae spinous processes; cutaneous branches innervate overlying skin

v. T7, 8, 9, 10, 11: innervate abdominal wall vi. T12 (subcostal nerve) & L1: innervate region above pubis vii. Neurovascular bundle: intercostal vein (below rib above), artery, nerve (above rib below) (VAN) travel between innermost & internal intercostal muscles
1. 2. 3. Main NV bundle travels just below the rib above the intercostal space Collateral nerve & vessels travel just above rib below Important for thoracocentesis don't want to insert needle just below the rib above so as to avoid the main NV bundle want to insert in the middle

7. Two pulmonary cavities a. Pleurae: fluid allowing lung to expand & contract during respiration (lubricant); provides for surface adhesion between parietal & visceral pleurae i. Visceral pleura: on lung tissue; sensitive to visceral pain (stretching, inflammation, noxious stimuli) - Generally insensitive to pain 1. Blood supply from bronchial arteries

ii. Parietal pleura: not in direct contact with lung tissue; sensitive to somatic pain (temperature, tough, pressure) 1. Costal pleura: deep to ribs; innervated by intercostal nerve 2. Innervated by phrenic nerve (C3, 4, 5) referred pain to shoulder; blood supply from intercostal, musculophrenic arteries a. Diaphragmatic pleura: above diaphragm b. Mediastinal pleurae: lateral to mediastinum 3. Cervical pleurae: extends above 1st rib iii. Pleurisy: inflammation of visceral & parietal pleura rub against each other
causing sharp pain during breathing; coughing, sneezing, rough, scratchy sound 1. Infections (pneumonia, TB), pneumothorax, pulmonary embolism, lung cancer

2. May cause Pleural effusion: build-up of fluid in pleural space, particularly in the costodiaphragmatic recess iv. Four types of fluids can accumulate in the pleural space 1. Serous fluid (hydrothorax); Blood (hemothorax) 2. Lymph (chylothorax); Pus (pyothorax or empyema) 3. Air (Pneumothorax collapsed lung) air in pleural space causes loss of adhesion & surface tension between visceral & parietal pleuras; pressure in pleural cavity slightly below atmospheric pressure (negative-pressure) a. Pulmonary blebs: cause of spontaneous pneumothorax b. Tension pneumothorax: wound allows air into pleural space, but tissue flap does not allow air during expiration (one-way valve); pressure continues to build causing mediastinal shift to UNaffected side b. Costodiaphragmatic recesses: wedge space where costal pleura meets diaphragmatic pleura i. Potential space where 1. Lung can move into during full inspirations 2. Excess pleural fluid can accumulate (pleural effusion) c. Bare area of pericardium: lateral to left edge of sternum; area where needle can be inserted during Pericardiocentesis without piercing the parietal pleura d. Lung root: sheath of parietal pleura that conjoins the pericardium and encloses pulmonary arteries, veins, main bronchus, lymph nodes, and autonomic nerves e. Pulmonary ligament: inferior to lung root; segment of reflected pleura forming a sleeve 8. Lungs: a. Cupola Hilus (root): point of entry of vessels, nerves, bronchi i. Secondary bronchi: Most posterior structure in hillus (Bronchus Behind) ii. Pulmonary arteries: bring deoxygenated blood for alveoli oxygenation 1. Uppermost structure in the hillus (Artery Above) 4

2. Pulmonary Embolism: blockage of p.a. or branches that has traveled from elsewhere in the body through the bloodstream a. Difficulty breathing, chest pain upon inspiration b. Low blood O2 levels, cyanosis, rapid breathing & HR c. Tx: anticoagulants & thrombolytics iii. Pulmonary veins: oxygenated blood to left atrium from alveoli iv. Bronchial arteries: branches of descending aorta or intercostal branch; carry oxygenated blood to airways & lung tissue v. Lymph nodes: 1. Pulmonary bronchopulmonary (hilar) inferior (carinal) & superior tracheobronchial nodes 2. Right lung drains into venous angle 3. Left lung drains into thoracic duct a. Left lower lobe may cross over to right side and effect the right lung if there is a tumor in the left lower lobe b. Bronchopulmonary plexus: i. Parasympathetic: Vagus nerve (CN X) 1. Bronchoconstrictor a. Asthma: dyspnea with wheezing due to spasmodic contraction & airway narrowing; possibly by vagal stimulation i. Tx: inhalation of sympathomimetics (mimic
sympathetic effects relaxes muscle; prevents mucous)

2. Promotes secretion of mucous glands 3. R-e-l-a-x-e-s blood vessels ii. Sympathetic: postganglionic fibers & vasomotor to arterial system 1. Bronchodilator; Inhibits mucous secretion; Constricts vessels 9. Right Lung: 3 lobes; shorter (diaphragm dome higher on right side) a. Superior, middle and inferior lobes: b. Oblique fissure: creates superior & inferior lobes c. Horizontal fissures: creates middle lobe d. Azygous impression: from azygous vein e. 10 bronchopulmonary segments: i. Right main stem bronchus wider, shorter, & more vertically oriented than left *more likely to be obstructed when standing 10. Left Lung: 2 lobes a. Superior and inferior lobes: divided by oblique fissure b. Lingual: anterior projection of the superior lobe overlying anterior aspect of the heart c. Cardiac notch: indentation formed by the heart d. Aortic impression: e. 10 bronchopulmonary segments: 5

11- Heart and Pericardium

1. Fibrous pericardium: outermost tough fibrous single layer 2. Pericardial effusion: hemopericardium (blood in pericardial sac); water-bottle silhouette a. If acute: Cardiac tamponade: pressure causes reduced cardiac output b. Becks triad: i. Muffled heart sounds due to blood insulation, weakened beat ii. JVD (Jugular venous distension) due to reduced venous return iii. Low arterial pressure due to decreased stroke volume c. Tx: Pericardiocentesis: pericardial tap Larreys pt (left xiphosternal angle) or 5th/6th intercostal space 3. Serous pericardium (epicardium): thin double wall inner layer 4. Transverse pericardial sinus: posterior to aorta & pulmonary trunk a. Permits expansion of great vessels during systole 5. Oblique pericardial sinus: inferior, surrounded by veins & pul. arteries a. Permits expansion of left atrium during exhalation 6. Sulci: reduce friction against pericardial sac; facilitate coronary artery perfusion a. Anterior Interventricular sulcus: i. Anterior: separates the R & L ventricles ii. Posterior: separates RV from LV b. Coronary sulcus: i. Anterior: separates RA from RV ii. Posterior: separates L & R atria from L & R ventricles 7. Right, left auricles: (ear-like) small structures of the atria that are truly anterior Coronary = arterial vessels; Cardiac = venous vessels
8. Coronary arteries: from corresponding L & R coronary sinuses of aortic valve; flow during diastole
a.

Right coronary artery: supplies RV wall, posterior LV wall, SA & AV nodes; runs in the coronary sulcus between the RA & RV i. SA nodal (atrial) branch: posterior aspect of RA ii. Right marginal branch: supplies the RV iii. AV nodal branch: dominance depends on supply 1. Right dominant heat: formed by posterior IV artery 2. Left dominant heart: formed by left circumflex artery iv. Posterior (descending) interventricular artery: posterior IV
sulcus; supplies posterior R & L ventricles and posterior of IV septum

b. Left coronary artery: supplies LV, anterior 2/3 of septum (bundle branches) i. Anterior interventricular (LAD): ant R&L V & anterior IV septum ii. Left Circumflex branch: between LA&LV; anastomoses w/ posterior IV sulcus a. 1. Left marginal branch: supplies lateral margin of the LV c. Coronary artery bypass graft (CABG): hook new vessel upstream
& connect to vessels distal to the damage, bypassing diseased tissue

i. CA occlusion: LAD: 50%; RCA: 40%; Circumflex branch: 20%; Graft options: 1. Great saphenous vein: (medial leg) *must reverse direction due to valves
2. Internal thoracic (mammary) a.: quick fix (location & high collateral flow)

3. Radial artery: greater longevity (patency) than vein grafts

9. Coronary sinus (thebesian valve): derived from sinus venosus; drains cardiac veins drains into RA via opening to the left of IVC entrance a. Great cardiac vein: forms in anterior IV sulcus; travels with anterior IV (left anterior descending) artery; joins coronary sinus near L heart margin b. Middle cardiac vein: occupies posterior IV sulcus; travels with posterior IV artery; enters coronary sinus near RA c. Small cardiac vein: follows RCA marginal branch; joins coronary sinus near middle cardiac vein junction

10. Atrioventricular valves: prevents blood rushing back into atria upon contraction; a. Free edges protrude into ventricles; big & floppy, requiring firm attachment to ventricular wall through chordae tendinear & papillary muscles 11. Semilunar valves: smaller valves in arterial outflow vessels prevent arterial blood from rushing back into the ventricles when they relax a. Small; forced close against each other by blood filling the sinuses

12. Right atrium: larger than left atrium, but thinner wall a. Crista terminalis: ventricle muscular ridge running anteriorly along RA wall from SVC opening to IVC opening i. Juncture of sinus venarum (smooth part of RA composed of former veins) & more muscular atrium proper (pectinate muscles) b. Musculi pectinati: prominent ridges of atrial myocardium in auricles and RA c. Fossa ovalis: site of former communication between atria i. Can be open in some congenital heart defects, allowing mixing of oxygenated & unoxygenated blood in atria ii. Limbus fossa ovalis: closes at birth; opening in inter-atrial wall between RA & LA, allowing blood to cross right into LA d. Opening for coronary sinus: draining of cardiac veins e. Tricuspid valve: right AV valve with 3 cusps and 3 corresponding papillary muscles

13. Right ventricle: works against low pulmonary circulation systolic pressure (25 mmHg); 1/3 as thick as LV; located right under sternum, most likely to be injured by blunt trauma a. Trabeculae carnae: small muscular ridges of myocardium b. Papillary muscles (anterior, posterior, septal): attaches tricuspid v. to chordae tendinae c. Moderator band (septomarginal trabecula): tissue band from septum to
anterior papillary muscle

d. e. f. g.

i. Contains purkinje fibers: allows papillary muscles to fire slightly before rest of myocardium Chordae tendinae: attach to papillary muscles; taught to allow proper valve function Infundibulum: Pulmonic semilunar valve: right SL valve; 3 cusps Anterior cardiac veins: drain anterior surface of RV; open directly into RA 7

14. Left Atrium: smaller than RA with thicker walls; most posterior of the 4 chambers a. Openings for pulmonary veins: oxygenated blood into LA b. Mitral valve: left AV valve with two cusps (anterior, posterior) i. Stenosis: valve narrowing due to scarring & adhesion of diseases at the
commissures pressure in chamber from which blood is being pumped 1. Mitral valve stenosis: pressure & dilation in LA & pul. veins

ii. Incomplete valves: lead to regurgitation- increases pressure & dilation in chamber from which blood was originally pumped 1. Tricuspid valve regurgitation: blood in RA, SVC, IVC 15. Left Ventricle: works against systemic circulation high systolic pressure (120mmHg)
a. Chorda tendinae & 2 papillary muscles: prevents blood reflux from ventricle to atria

b. Aortic semilunar valve: left SL valve; three cusps 16. Systole: ventricular contraction AV valves open systemic flow out aorta & pul. trunk a. Myocardial arteries are compressed during systole b. S1 (lub: AV valves close) i. Mitral: L 5th intercostal space in midclavicular line ii. Tricuspid: L 5th intercostal space over sternal xiphoid process 17. Diastole: Aorta elastic recoil blood backflow AV valves close myocardium relaxed, coronary artery filling & perfusion a. S2 (dub: semilunar valves close) i. Pulmonary semilunar: L 2nd intercostal space ii. Aortic semilunar: R 2nd intercostal space 18. Conduction System of the Heart: a. Sino-atrial node (100 bpm): junction of SVC & RA; spontaneous & rhythmical depolarizations (60-80/min) spread & cause atrial contraction b. Atrioventricular node (50 bpm): in interarterial septum by coronary sinus; delays SA impulse i. Sympathetic stimulation: conduction speed (stress; exercise) ii. Parasympathetic: conduction (Normal heart control predominately PNS) c. Atrioventricular bundle (Bundle of His): sole electrical A-to-V connection i. Left and right bundle branches: descend along septum surfaces to V d. Purkinje fibers: widespread reticulum delivers impulses to V causing contraction i. Coronary artery disease: inner
(endocardial) surface dies first, including purkinje fibers (last perfused, first to die)

19. Heart beat: ~72/min (60)(24) = 103,680/day [~3 billion in 80 year lifespan] a. Sympathetic: fibers from T2-T4, to cardiac plexus, SA node, then cardiac muscle i. @ SA node: HR ii. @ Muscle: ventricular pressure rise, stroke volume b. Parasympathetic: Vagus nerve (CN X) i. @ SA node: decrease HR ii. @ AV node: excitability slower transmission possible AV block iii. vagal innervation immediate acceleration of heart
c. R Vagal & R sympathetic branches end in SA node; L Vagal & L sympathetic in AV node (RAS LAV)

20. Lymphatic drainage a. Right side drains to left, joins thoracic duct joins venous sys at left venous angle b. Left side drains to the right right lymphatic duct

12- Mediastinum

Superior mediastinum: above the T4/5 level to the superior thoracic aperature 1. Brachiocephalic veins: union of subclavian & internal jugular (@ L & R venous angles where thoracic & R lymphatic ducts also drain); joint to form SVC a. Right BCV: (shorter) No valves - assess Jugular Venous Pressure (CVP, RA pressure) b. Left BCV: (longer; posterior to manubrium) drains upper 2-3 intercostal spaces on left; joined by: i. Left superior intercostal v. (crosses anterior
aortic arch); goes between the two nerves

superficial to vagus, deep to phrenic ii. Highest posterior intercostal v. (1st intercostal)
c. Inferior thyroid v.s. at union of L & R brachiocephalic v.s.

2. Superior vena cava: formed by L & R brachiocephalic v.; enters RA a. Superior Vena Cava Syndrome: blockage of SVC
by tumor (lung cancer) causing collateral vein dilation

3. Aorta: from LV @ T4-T5 junction; situated left of vertebral column; approaches median line as it descends a. Ascending: gives rise to R & L coronary arteries arising within the Sinus of Valsalva b. Passes superiorly to the right, forming aortic arch c. Arch: passes posteriorly and to left, descending along left side of esophagus 9

i. Right Brachiocephalic trunk: forms right subclavian (to superior extremity) & right common carotid (to head/neck) ii. Left common carotid artery: to head/neck iii. Left subclavian artery: to superior extremity 1. Aortic Coarctation: if occurs proximal to left subclavian artery origin, adequate collateral circulation does not develop; results in enlarged vessels (internal thoracic, intercostal, epigastric, scapular) a. Radial artery elevated BP b. Femoral artery decreased BP, occurring after radial pulse iv. Aortic Arch Aneurysm: sac formed by arch dilation; compresses left recurrent laryngeal nerve cough, hoarsness, ipsilateral vocal cord paralysis, dysphagia, dyspnea, downward tug on trachea during systole v. Variations:
1. 2. 3. Left common carotid arising from brachiocephalic trunk (27%) L vertebral a. arising from aortic arch (5%) Anomalous (retroesophageal) R subclavian artery (difficulty swallowing)

d. Descending (thoracic) aorta: left side of body @T5, descends left to vertebral column posterior to L lung root, midline @T8, passes through aortic hiatus @T11/12, joins greater splenic nerve as it enters abdomen i. Firmly anchored to posterior body wall by posterior intercostal arteries ii. Parietal (thoracic) branches: Posterior intercostal arteries join posterior intercostal veins & nerves = neurovascular bundle iii. Bronchial branches enter lung root iv. Esophageal branches to pericardium & diaphragm v. Pericardial arteries 4. Pulmonary trunk: starts at RV base a. Left & Right pulmonary arteries: deoxygenated blood from RV to lung b. Carina landmark for: Transverse thoracic plane (sternal angle T4/5), L&R pul. artery bifurcation 5. Ligamentum arteriosum: vestige of fetal ductus arteriosus (connect pul. trunk & aortic arch) where blood was shunted into arterial system when lungs were not functional a. Located at origin of LP artery & aortic arch; point of weakness in trauma b. Aorta is relatively fixed in place; heart & lungs are more mobile
i. In trauma, aorta & visceral organs tend to go separate ways - aortic rupture

ii. Aortic dissection: inner blood vessel lining torn arterial pressure into vessel wall aortic lumen; commonly at ligamentum arteriosum 6. Thoracic duct: on posterior thoracic wall between azygous vein & aorta a. Begins in abdomen as cisterna chili [L1-L3] b. Enters thorax posterior to descending aorta c. Stays on right of vertebral column; posterior to esophagus @T8 d. Ascends to T4, crossing to left aortic side just anterior to anterior longitudinal
L subclavian v. & L internal jugular v. (L venous angle) forms brachiocephalic v.
ligament, entering the neck to empty into union point of

e. Drains all of bodys lymph except upper right quadrant (right thorax, right upper limb, right side of head/neck) and often left lower lung lobe drain into R lymphatic duct joins R internal jugular & R subclavian veins
7. Mediastinal Lymph Nodes enlarged in Hodgkins lymphoma : Virchows (sentinel); Paratracheal; Superior/inferior tracheobronchial; Posterior mediastinal; Superior phrenic

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INFERIOR mediastinum: below T4/5 level

8. ANTERIOR Mediastinum: Thymus; internal thoracic vessels; sternopericardial ligaments; fat, lymph nodes

9. MIDDLE Mediastinum: a. Phrenic nerves: descend from cervical plexuses, lateral to jugular vein & pericardium i. innervate diaphragm muscles (motor); sensory to diaphragmatic & mediastinal pleurae (C3,4,5 keeps the diaphragm alive) 10. POSTERIOR Mediastinum: a. ESOPHAGUS: posterior pharynx C6 level to stomach; pierce diaphragm at rib 7/T10 level i. Constricted in 4 regions, where obstructions may occur: 1. C6 (cricopharyngeus (upper esophageal sphincter) voluntary) a. Inferior esophageal cardiac sphincter under control of: Vagal (opens); sympathetic fibers (closes) 2. T2/3 (crossing of aortic arch) 3. T4/5 (crossing of L primary bronchus) 4. T10 (diaphragm)
ii. Anterior to vertebra C7-T8, thoracic duct, R posterior IC a., azygous & hemiazygous iii. Posterior to the trachea (C7-T4) & heart base (LA)

iv. Transesophageal EKG: pass through esophagus to get clear heart pictures b. Azygous system of veins: drains thoracic wall from 3rd intercostal space to the subcostal
veins; found behind & alongside thoracic duct; begins in abdomen as ascending lumbar veins

i. Provides venous shunts in SVC/IVC pathology (malignancy; DVT) ii. Azygous vein: (right side; larger) begins at junction of ascending lumbar vein & subcostal vein, passes deep to diaphragm, along right side of thoracic vertebrae, receiving posterior intercostal veins along the way 1. At T8 forms arch over R lung root, enters posterior SVC @ rib 3, draining L superior intercostal vein and 2nd/3rd posterior intercostal spaces into SVC 2. Right superior intercostal vein drains 2nd, 3rd, 4th right intercostal spaces & then joins azygous iii. Hemiazygous vein: (left side) really tributaries draining into azygous v.; pass upward, superior & inferior, drain upper & lower intercostal spaces, then join to form one hemiazygous passing behind thoracic duct to empty into azygous vein 1. Posterior intercostal veins drain into hemiazygous; join azygous mid-thorax by passing anterior to vertebral column iv. Accessory hemiazygous vein: passing downward on the left 11

c. Nerves of Cardiac plexus: cervical cardiac branches from Vagus (CN X; PNS), Cardiopulmonary (SNS) & Thoracic sympathetic d. Vagal nerves: (PNS) descend from skull lateral to carotid arteries, posterior to heart; innervate thorax & abdomen viscera esophageal peristalsis; motor to mucous glands i. Right vagus nerve: posterior to esophagus ii. Left vagus nerve: anterior to esophagus (LARP L Ant, R Post)
iii. Branches form A&P Esophageal Plexuses: single nerve pierce diaphragm at hiatus

iv. Recurrent laryngeal nerves: not symmetrical; both sensory & motor; damaged from thyroid surgery, mediastinal pathology (aortic aneurisms, enlarged lymph nodes) presenting with increasingly hoarse voice 1. Left recurrent laryngeal n.:posterior to lig. arteriosum & around A. arch;
between trachea & esophagus; innervate larynx muscles for phonation

2. Right recurrent laryngeal n.: around R subclavian up to larynx v. Below diaphragm: renamed A & P gastric nerves 11. 31 segments of the spinal cord with 31 pairs of spinal nerves: 12. 14 White rami communicantes: arise from spinal cord T1 - L2; preganglionic axons 13. 31 Gray rami communicantes: exit from paravertebral chain ganglia interconnected by sympathetic trunk a. Sympathetic trunks: (T1-L3) begin in intermediolateral cell column i. Pre-ganglionic: myelinated; sits in CNS, motor route out to synapse ganglion ii. Post-ganglionic: unmyelinated b. Greater splanchnic nerves: from sympathetic chains & thoracic ganglion T5-T10;
postganglionic fibers form plexuses on blood vessels, pass to gut organs (L. entrails); branches:

i. Cardiopulmonary: (T1-4) originate at upper thoracic levels

1. Synapse at thoracic ganglia, postganglionic fibers travel a. To the heart, trachea, esophagus, or, b. Upwards: synapse at cervical ganglia, travel back down as superior, middle & inferior cardiac nerves to innervate the heart, trachea, esophagus

2. Speed up HR ii. Thoracic: first neuron in intermediolateral cell column (T5-T12) 1. Preganglionic (long) passes through sympathetic chain 2. Synapses at prevertebral (preaortic) ganglia 3. 3 Thoracic splanchnic: Greater (T5-9); Lesser (T10-11); Least (T12) iii. Also: Lumbar, Sacral, & Pelvic (PNS) Splanchnic nerves

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13- Anterior Abdominal Wall

1. Abdominal cavity Roof: diaphragm; Floor: none (continuous with pelvic cavity); Surface: surrounded by multilayered abdominal wall 2. Campers Fascia: outer fatty layer; continues from abdomen onto thighs fatty layer a. Passes into scrotum (loosing fat, gaining smooth muscle) becomes Tunica Dartos: wrinkling 3. Scarpas Fascia: inner membranous layer; attach to iliac crest; fascia lata inferior to inguinal ligament, allowing free passage into the uppermost thigh deep to SF a. Fibers to fundiform ligament; Passes into scrotum to become Colles Fascia 4. Transversalis Fascia: lines cavity deep to abd muscles; forms Internal Spermatic Fascia 5. Linea Alba: midline tendinous band formed by aponeurosis of 3 flat abd muscles 6. Three flat muscles: a. External Oblique: most anterior; forms external spermatic fascia; origin from ribs 5-12, interdigitate with i. Serratus anterior (upper fibers) - terminate on aponeurosis in linea alba ii. Latissimus dorsi (lower fibers) - terminate on anterior iliac crest b. Internal Oblique: origin from lateral half of inguinal ligament & anterior iliac crest, inserts ribs 9-12; contributes to rectus sheath i. Conjoint tendon (Falx inguinalis): formed by medial fibers of internal oblique and underlying fibers of transversus abdominis aponeurosis ii. Cremaster muscle: formed by lower internal oblique border at inguinal canal 1. Cremaster reflex: contraction pulls up on the side stroked 2. Afferent (sensory): ilioinguinal nerve (L1) 3. Efferent (motor): genitofemoral nerve (L1/L2) 4. NB cremaster muscles has some smooth muscle fibers which contract under sympathetic stimulation to cold c. Transversus Abdominus: origin from lateral inguinal lig., anterior iliac crest, thoraco-lumbar
fascia, & ribs 5-12; terminates on an aponeurosis which fuses with internal oblique aponeurosis

i. Arcuate Line: formed by splitting of the aponeurosis of transversus d. Contraction action of the 3 flat muscles: Expiration, micturition (urination), defecation, emesis (vomiting), parturition, abdominal content support
i. Contraction of the diaphragm (inspiration) opposes actions of these muscles

7. Two vertical muscles: a. Rectus Abdominus: origin from pubic crest via two tendons; separated along middle by linea alba; inserts in cartilages of ribs 5-7 & side of xiphoid process; flexes vertebral column & tenses abdomen; innervated by intercostal nerves 7-12 i. Tendinous intersections: fibrous bands transversing rectus muscle; firmly
attached to anterior rectus sheath, but dorsal rectus sheath free of attachments

ii. Linea Semilunaris: lateral border of rectus abdominis iii. Rectus sheath: covering for rectus abdominis from the 3 aponeurosis forming 2 layers @ Linea Semilunaris; deficient inferior to Arcuate Line on posterior aspect 1. Anterior (ventral) RS: fusion of ant. internal oblique & external oblique with transversus muscle (below arcuate line) 2. Posterior (dorsal) RS: formed by posterior aponeurosis & internal oblique fusion with transversus muscle (above arcuate line) b. Pyramidalis: small muscle keeps tension on linea alba; innervated by a nerve from T12 13

8. Inguinal Region/Peritoneum: a. Inguinal (pouparts) ligament: anterior superior iliac spine to pubic tubercle; formed by inferior border of aponeurotic external oblique fibers rolling under lower aponeurosis border; medially forms inguinal canal floor i. Gives rise to Lacunar (gimbernats) & Pectineal (coopers) ligaments b. Inguinal canal: tunnel deep to abd. aponeurosis from the deep to the superficial inguinal ring i. Transmits spermatic cord (male) & round ligament (female)
1.
ii. iii. iv. v.

(transversus abdominis muscle does not contribute to cord & testis layers)

Anterior wall: external oblique aponeurosis Posterior wall: transversalis fascia, conjoint tendon Roof: internal oblique transverse abdominal mm. Floor: in-curving external oblique apponeurosis

c. External (SUPERFICIAL) inguinal ring: formed by termination of (opening in)

external oblique at pubic tubercle; bordered by superior & inferior crus of ext. oblique aponeurosis

d. Internal (DEEP) inguinal ring: opening in transv. fascia; lateral to inferior epigastic vessels e. Umbilical folds (5): abd wall ridges within the transversalis fascia i. Median: urachus (old allantoic duct) connected bladder to umbilical cord ii. Medial (2): remnants of umbilical arteries iii. Lateral (2): inferior epigastric vessels; anastomose within rectus sheath
with superior epigastric vessels from internal thoracic/subclavian vessels

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9. Hernia: abd straining forces contents to perforate abd wall (where there is no skeletal muscle);
can damage spermatic cord (compression), or contents can be infarcted (strangulation) resulting in gangrene

a. Direct & indirect pass through superficial IR - superior & medial to pubic tubercle b. Indirect inguinal hernia: (congenital) pass through deep inguinal ring, inguinal canal, and out superficial inguinal ring (same as testes & spermatic cord)

i. Lies above IL & lateral to deep inferior epigastric vessels c. Direct inguinal hernia: (acquired) asymptomatic i. Lies medial to deep epigastric vessels & above IL in Hesselbachs triangle 1. Ignores deep inguinal ring
ii. Hesselbachs triangle: rectus abdominus, inguinal lig., deep inferior epigastric a. d. Femoral hernia: through femoral ring into femoral canal, BELOW IL; protrusion on thigh
anterior to saphenous opening, inferior & lateral to pubic tubercle

e. Lumbar hernia: through lumbar (petits) triangle superior to middle iliac crest f. Spiegelian hernias: umbilicus, linea alba, and/or linea semilunaris; mid-clavicular line g. Also: ventral hernia; incisional hernia 10. Blood supply: a. Superficial vessels: run between Campers & Scarpas fascia
i. Superficial inferior epigastric; circumflex iliac; external pudendal vessels

ii. Superficial arteries: from femoral artery close to inguinal ligament iii. Superficial veins: pass through saphenous opening to empty into femoral v. b. Deep vessels: i. Epigastric: 1. Superior (from internal thoracic a.) 2. Inferior (from external iliac, empties into femoral vein) a. Deep inferior epigastric artery: hernia landmark ii. Deep iliac circumflex vessels: from external iliac artery iii. Testicular vessels: from anterior aorta 11. Lymphatic drainage: a. Above the umbilicus: Axillary nodes b. Inferior to umbilicus: Superficial Inguinal lymph nodes c. Testis: para-aortic nodes cysterna chili (beginning of thoracic duct) 12. Innervation a. Ilio-hypogastric nerve: (branch of lumbar plexus L1 level) pierces transversus & internal oblique (antero-laterally); lies posterior to external oblique b. Ilio-inguinal nerve: (branch of lumbar plexus L1 level) same course as IHG n. but exits through the superficial inguinal ring and proceeds into scrotum c. Genito-femoral nerve: (branch of lumbar plexus) motor + sensory fibers; enters anterior abd wall through deep inguinal ring to supply cremaster muscles

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14- Back
1. Causes of Low Back Pain a. Lumbar strain or sprain (70%); Degenerative changes (10%); Herniated disk (4%); Osteoporosis compression fractures (4%); Spinal stenosis (3%) b. Spondylolisthesis (2%): anterior slippage of vertebrae or column; may cause nerve damage i. Pain (back, thigh, buttocks), tightness (hamstrings); stiffness; tenderness ii. Causes: congenital; isthmic (fracture); degenerative (arthritic); trauma; pathological (osteoporosis, infection, tumor); post-surgical 1. Spondylolysis: fracture or malformation of pars interarticularis (region between inferior & superior articular processes) 2. Ankylosing Spondylitis: chronic inflame. arthritis; eventual spine fusion stiff & inflexible 3. Potts Disease: from hematogenous TB spread to spine; may lead to psoas abscess 4. Scoliosis: Four general causes
i. ii. iii. iv. Congenital: malformation of vertebrae or fused ribs during development Functional: spine normal, abnormal curve develops because of problem elsewhere Neuromuscular: by poor muscle control/weakness, or paralysis due to diseases Idipoathic: unknown cause, appears in a previously straight spine

b. Kyphoscoliosis: combination lateral bending & excessive thoracic curvature 5. Range of vertebral column motion limited by: a. Thickness, elasticity, & compression of IV disks b. Shape of facet joints between adjacent vertebrae c. Resistance of back muscles & ligaments d. Bulk of surrounding tissue 6. Vertebral column: a. Kyphosis: anteriorly concave curvature of thoracic & sacral regions (KATS) b. Lordosis: posteriorly concave curvature of cervical & lumbar regions (LPLC) c. Cervical (7): Atlas (C1): no vertebral body - space for dens of Axis (C2) d. Thoracic (12): have 4 costal facets for rib articulation i. Articulate with same number (T6 superior facet articulates with head of rib 6) ii. Thoracic aorta depression on anterior left surface of each vertebrae e. Lumbar (5): thicker bodies & laminae; two extra sets of processes (mammillary & accessory) f. Sacral (5, fused): transmits body weight from spine to pelvic girdle i. Sacral hiatus (S5): lacks laminae; exit of sacral canal; bounded by cornua ii. Sacral groove: between median & lateral crests; contains posterior sacral foramina iii. Female sacrum is shorter, wider, and less curved than in males g. Coccygeal (4, fused): only vertebral bodies, no processes; gluteus max attachment 7. Spina bifida: (split spine) incomplete embryonic neural tube closing; some vertebrae not fully formed,
unfused & open allowing spinal cord protrude (occulta), with meninge-filled cyst (mningocele)

8. Vertebral body: anterior weight-bearing; separated from other bodies by disks 9. Vertebral arch: posterior, encircles & protects spinal cord/meninges a. 2 Pedicles (lateral): each has superior & inferior vertebral notch b. 2 Laminae (postero-lateral): flat surface c. 7 bony processes (spinous, transverse, articular): deep back muscle attachment 16

10. Spinal process: Base of the neck (C7); Scapular spine (T4); Inferior angle of the scapular spine (T7); Level of the iliac crests (L4); Sacral triangle apex (S3) 11. Intervertebral notch: adjacent notches form intervertebral foramen for spinal nerves & vertebral arteries a. Spinal Canal: enclosed within intervertebral foramen; protected by ligamentum flavum posteriorly & posterior longitudinal ligament anteriorly 12. Spinal Cord: extends from foramen magnum to second lumbar vertebra a. Gray matter: (cell bodies, dendrites, axons) posterior (dorsal), anterior (ventral), lateral horns i. Dorsal roots: receives sensory info (afferent: to spinal cord); bipolar; 1. Dorsal root ganglia: cell bodies outside cord ii. Ventral roots: sends motor signals (efferent: away from spinal cord) 1. Cell bodies lie in clusters (ganglia) within ventral gray horn 2. Unipolar: singular axon leaving cord as part of a ventral rootlet b. White matter: myelinated; 3 columns (funiculli) divided into sensory or motor tracts c. Spinal nerve: (31 pairs) mix of motor & sensory between rootlets & d/v branches i. Exits each level through intervertebral foramen (cervical above respective vertebrae; rest of spine below), splitting into: ii. Dorsal primary rami: motor to back, sensation to posterior trunk 1. Also send sensory branches to IV joints iii. Ventral primary rami: motor & sensation to abd & limb muscles d. Cauda medullaris: spinal cord distal to L2 tapers to a fibrous strand i. Filum terminale: fibrous extension anchors cord limiting movement in canal ii. L3-Co1 nerve rootlets travel down parallel to filum terminale e. Cauda equina: bundle of nerve rootlets below conus medularis f. Lumbar cistern: subarachnoid space between L2 & S2 (dural sac termination) 13. Meninges: a. Epidural space: contains venous plexuses, fat, and loose connective tissue i. Caudal Epidural nerve block: anesthesia injected into epidural space diffuses though arachnoid granulations into CSF b. Dura: outermost membranous CT layer; helps anchor spinal cord c. Subdural space: separates dura from arachnoid d. Arachnoid: intermediate membranous layer of CT; covers cauda equina
i. Arachnoid granulaitons pump CSF out of subarachnoid space, to venous

ii. Denticulate ligaments: arachnoid extensions that connect to dura (stability) e. Subarachnoid space: filled with arachnoid trabeculae (CT strands) & CSF i. Lumbar puncture site: between L3/L4; contains CSF, cauda equina, & filum terminale; located at upper edge of iliac crest f. Pia: innermost membranous CT layer, adheres to cord; coats each nerve; anchors the cord, preventing lateral deflection; continues as filum terminale 14. Anterior (1) & Posterior (2) spinal arteries: (branches of vertebral a.) run longitudinally on pia matter (pierce arachnoid & dura), and supply spinal cord
a. Anterior & posterior radicular a.: collateral circulation between spinal a. & intercostal a.

15. Internal (epidural) venous plexus: extends from pelvis to brain; potential route for prostate cancer metastasis to spine & skull/brain 17

16. Joints of the back: a. Intervertebral disk: largest in lumbar region, thickest in cervical & lumbar i. Annulus fibrosus: outer, washer-like, fibrous CT & fibro-cartilage ii. Nucleus pulposus: fills AF hole; highly cartilaginous & elastic, high water content; avascular, receives nourishment via diffusion from AF 1. Progressively dehydrates with age reduction in stature iii. Stenotic lumbar vertebrae: with age, ligaments (flavum) & bones thicken
narrowing spinal canal squeezes nerves pain, numbness in back & legs

b. Anterior longitudinal ligament: flat vertically oriented fibers; prevents hyperextension c. Posterior longitudinal ligament: narrow; against anterior surface of vertebral canal covering posterior of all vertebral bodies (except C1) & disks; prevents hyperflexion & disk herniation into canal
d. Ligamentum flava: between adjacent laminae in posterior canal
(anterior surface of superior lamina to posterior surface of inferior lamina)

i. Preserves natural shape & curvatures, assists in maintaining upright posture after flexion ii. Hypertrophy of ligamentum flava: causes spinal canal stenosis (narrowing) severe back & lower limb pain e. Interspinous ligament: between adjacent spinous processes,
from ligamentum flavum anteriorly to supraspinous ligament posteriorly

f. Supraspinous ligament: tough, vertical cord running along spinous processes tips; prevents hyperflexion g. Sacroiliac ligaments: (anterior & posterior) stability between spine & ilium

17. Muscles of the back: a. Superficial layer: move upper extremity; not true muscles of the back i. Trapezius: moves scapula; innervated by CNXI (spinal accessory n.) ii. Latissimus dorsi: extends & adducts upper limb; Thoracodorsal n. (brachial plexus) b. Intermediate layer: respiratory muscles (insert onto ribs) i. Innervated by dorsal scapular nerve (brachial plexus) 1. Levator scapulae: elevate & adduct scapula 2. Rhomboid major/minor: move scapula medially ii. Innervated by intercostal nerves (T1, T2, T10/11) 1. Serratus posterior superior: raises ribs in inspiration 2. Serratus posterior inferior: lowers ribs in expiration 18

c. Deep layer: all act to extend trunk (straighten back) when acting bilaterally; true back muscles: innervated by dorsal primary rami i. Splenius: thin, flat, bandage-like muscle ii. Erector spinae: fibers parallel to vertebrae column covered by thoracolumbar fascia; when acting unilaterally laterally flexes column
1. Form two longitudinal bulges on column sides & extend into neck

2. Iliocostalis lumborum: most lateral 3. Longissimus thoracis: intermediate 4. Spinalis thoracis: most medial (closest to spinous processes) iii. Transversospinalis: deep to erector spinae; fibers angled up and toward spines; parts differ in how many vertebrae they cross: 1. Semispinalis: 5 or 6 2. Multifidius: 3 or 4; laterally flexes & rotates column (unilaterally); stabilize column as other muscles contract iv. Rotatores: (long & short): stabilize & assist with local extension & rotation v. Levator Costarum: elevate ribs; vertebral column lateral flexion

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