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2011-11-01 20:16:53
Anatomy Mediastinum

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  1. Unpaired (Visceral) Arteries
    • Aorta-Ductus arteriosus/ligamentum arteriosum
    • Bronchial a.
    • Esophageal a.
    • Pericardial a.
    • Mediastinal a.
    • *come off front of aorta
  2. Paired (Parietal) Arteries
    • Superior Intercostal-1 & 2 space via costocervical trunk
    • Posterior Intercostal-3-11 via Aorta
    • Subcostal-12 via Aorta
    • Anterior Intercostal-1-6 via Internal thoracic
    • at bottom of rib cage split into
    • -superior epigastric-6th space to rectus sheath
    • -musculophrenic-costal margin
    • *back of aorta and run around posterior wall into intercostal spaces
  3. System of 3 long vessels
    • Azygos (Rt.)-posterior intercostal drain into-only on right side
    • Hemiazygos (Lower Lt.)
    • Accessory Hemiazygos (Upper Lt.)
    • Continuation of ascending lumbar v.
    • connect SVC with IVC-important anastomotic channel
  4. Azygos v. origin
    Origin: 1) Rt. ascending lumbar and subcostal v., 2) Rt. renal v.
  5. Route of Azygos v.
    • Origin: 1) Rt. ascending lumbar and subcostal v., 2) Rt. renal v.
    • Enter thorax on rt. side of TD and aorta
    • Ascends on vertebral bodies to root of lung
    • Emerges under esophagus and arches forward above bronchus to SVC
  6. Azygos v. valves
    Imperfect valves: tributaries have numberous ones
  7. Azygos v. recieves?
    • 2 hemiazygos
    • lower 8 post. intercostal & subcostal v.
    • Rt. superior intercostal (1 & 2)
    • Esophageal, pericardial, broncial, mediastinal
  8. Hemiazygos v. origin and route
    • Origin: left ascending lumbar and lt. renal v.
    • Enters thorax-lt crus of diaphragm on lt. side of vertebrae
    • 8-9th vertebrae cross columb behind aorta, esophagus and TD
  9. Hemiazygos v. recieves?
    lower 4-5 posterior intercostals and occasionally accessory hemiazygos
  10. Accessory hemiazygos v. origin and route
    • Origin: variable-often continuous with lt. sup. intercostal
    • inversely proportional to sup. intercostal
    • decends on lt. side of column to hemiazygos
  11. Accessory hemiazygos v. receives?
    3-4 post. intercostals between lt. sup. and hemiazygos
  12. Superior Intercostals drain and empty into?
    • Drain 1-5 intercostals (variable)
    • Empty into lt. brachiocephalic v.
  13. Vertebral Plexus of Veins
    • Runs length of vertebral canal
    • Interconnections with SVC & IVC
    • No valves
    • can move up or down
  14. Thoracic duct route
    • Begins with cisterna chyli (T12)
    • 2 lumbar trunks and interstinal trunk
    • Ascends behind aorta through hiatus
    • Azygos v. (rt. ) and aorta (lt.)
    • T5-deviates to left behind esophagus
    • Ascends into neck behind carotid sheath and ant. to vertebral artery
    • Empties into union of internal Jugualar and Subclavian
    • *Main collecting duct-lower limbs, pelvis, GI tract, left upper limb and left head
    • *transparent-returns protein back into venous system-if cut during surgery can be fatal within days
  15. Preganglionic Fibers
    • Origin: T1-L2
    • Leave spinal n. as White Rami Communicantes (myelinated)-lateral part
    • Join thoracic chain at ganglia
    • Number of preganglionic fibers < Number of ganglion cells
  16. What occurs once preganglionic fibers enter chain
    • synapse
    • ascend and then synapse
    • descend and then synapse
    • leave chain without synapse
  17. Where do the areas of preganglionic fibers go to in the body?
    • T1-T5-head, neck, upper limb, thorax-ascend
    • T6-L2-Descend
  18. Where is the Sympathetic Chain at?
    Outside posterior mediastinum-behind costal pleura
  19. Postganglionic Fibers
    • Some rejoin spinal nerves as Gray Rami communicantes (unmyelinated)-medial aspect
    • Others leave trunk to thoracic viscera-synapse at point of exit
  20. Ganglia
    • Superior, middle, inferior cervical (neck)
    • 1st Thoracic-may be independent but often fused with inf. cervical
    • 2-10 usually single, slightly below nerve
    • usually only 11 ganglia (11th and 12th often fused)
  21. Thoracic Branches
    • Gray Rami-to spinal nerves
    • Br. to Cardiac & pulmonary plexuses
    • Splanchnic (preganglionic)
    • Greater-T5-T9 (10)-Exit crura of diaphragm (aortic)
    • Lesser-T10-11-exit crura of diaphragm
    • least-T12
  22. Referred pain
    • angina-pain referral to left limb
    • pain fibers traveling with sympathetic system
    • synapse with sympathetic fibers-go out to blood vessels-vasocontricution to area of skin
    • area irritated-afferent pain fibers activated and back into spinal cord-somatic sources-into thalamus
    • perceive pain in arm rather than heart
    • sensory fibers-travel on gray then white back to spinal cord
  23. Relations
    • Hemiazygos v.-behind everything-compress=no blood crossing over
    • vein (most superior) then artery, then nerve-connects to sympathetic chain with white and gray rami
    • azygos v. and thoracic duct parallel with each other-azygos v. more lateral-sympathetic trunk more lateral to azygos v.
  24. Esophagus origin and termination
    • origin: cricoid cartilage (C6)
    • Termination-Cardiac opening of stomach
  25. Esophagus Constrictions (3)
    • Cricoid cartilage (C6)-larynx can flatten out if constricted
    • Bifurcation of trachea (T4-broncho-aortic constriction-flatten out against vertebral column)
    • Esophageal hiatus of diaphragm (T 11)-spicter for esophagus-costal agents or foreign objects stuck here
  26. Blood supply to esophagus
    • Inferior thyroid
    • Aorta
    • Intercostal artery
    • Lt. gastric
    • Inferior phrenic
    • *small sized vessels*
    • *esophagus-thick and muscular*
  27. Nerve supply to esophagus
    • Vagus-rotates 90 degrees to the right: lf-ant.; rt.-posterior to esophagus
    • Sympathetic chain-greater splanchnic n.
  28. Origin of Diaphragm
    • bony elements around circumference
    • Sternal-2 slips
    • Costal
    • Crura-2 bundles (lt.-3, rt.-2)
    • Arcuate lig.-med. and lat. ligament
  29. Insertion points of Diaphragm
    • central tendon
    • Crura-medial fibers arch around aorta
    • right also loop around esophagus
    • Arcuate lig.-med. over psoas mus. and lat. over quad. lumborum mus.
  30. Nerve supply to Diaphragm
    Phrenic-C3, 4, 5
  31. Arteries supply of Diaphragm
    Intercostals, musculophrenic, inf. phrenic, pericardiophrenic
  32. Openings of Diaphragm
    • a, e, i-12, 10, 8
    • T 12-aorta between crura and TD, azygos v.
    • T 10-esophagus and rt and lt vagus n.
    • T8-IVC-central tendon and rt phrenic