Anatomical variations of the upper thoracic sympathetic chain: a review

Abstract

OBJECTIVES The objective of this study is to provide a thorough overview of the anatomical variations of the upper thoracic sympathetic trunk to improve clinical results of upper thoracic sympathectomy. In addition, this study strives for standardization of future studies regarding the anatomy of the upper thoracic sympathetic chain. METHODS The Web of Science, PubMed and Google Scholar databases were searched using keywords, alone or combined, regarding the anatomy of the thoracic sympathetic chain. The search was limited to studies performed in humans. RESULTS Fifteen studies were finally included. Cervicothoracic ganglion and nerve of Kuntz were present in 77% and 53%, respectively. The upper thoracic ganglia were predominantly located in their corresponding intercostal space with a relatively downwards shift at the lower thoracic levels. The right sympathetic trunk is prone to have more communicating rami then the left. The lower levels of ganglia tend to have more normal rami. No clear pattern was found concerning the presence of the ascending rami and there was a decrease in the number of descending rami as the chain runs caudally. The intercostal rami remain a rare anatomical variation. CONCLUSIONS This study presents an overview of the anatomy of the upper thoracic sympathetic chain. Its results may guide upper thoracic sympathectomy to improve clinical results. This review also provides a baseline for future studies on anatomical variations of the thoracic sympathetic trunk. More uniform reporting is necessary to compare different anatomical studies.

Novel ultrasound‐guided supraclavicular stellate ganglion block

“…Also, we consider there are additional benefits that could improve outcomes due to the following: Target localization of the inferior cervical ganglion, which is located lower than where the C6–C7 technique is performed. Blockade of the sympathetic nervous system due to this distal approach does not bypass Kuntz's nerves. These nerve fibers, not constantly present in all populations, 11,12 which connect the second intercostal nerve with the first thoracic spinal nerve, can be blocked. Patients suffering from sympathetic diseases in the upper extremity may therefore benefit from this technique. The procedure can be performed in a sitting, lateral decubitus, or supine position without the need for neck rotation or extension. Patient neck anatomy is irrelevant as the probe position is supraclavicular.…”

“…• Blockade of the sympathetic nervous system due to this distal approach does not bypass Kuntz's nerves. These nerve fibers, not constantly present in all populations, 11,12 which connect the second intercostal nerve with the first thoracic spinal nerve, can be blocked. Patients suffering from sympathetic diseases in the upper extremity may therefore benefit from this technique.…”

Impact of endoscopic thoracic R4 sympathicotomy combined with R3 ramicotomy for primary palmar hyperhidrosis

“…RC is primarily accountable for connecting the thoracic sympathetic ganglion and the intercostal nerve. There are four types of variations (19,20), namely, normal branch (NR), ascending branch (AR), descending branch (DR), and intercostal branch (IR). These variant branches constantly lie during the clipping of the lower sympathetic chain to cause persistent palm-sweating after surgery.…”

Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis

“…Endoscopic thoracic sympathicotomy has been proven to be a safe and most effective treatment for PPH, with R3 or R4 sympathicotomy being established as the standard approach for palmar hyperhidrosis. However, the results and side effects of this procedure can vary due to anatomical variations of sympathetic ganglions [ 6 – 9 ].The sympathetic ganglions are usually obscured by fat and the pleura under normal thoracoscopy. Therefore, ribs are frequently (only) used as anatomical landmarks to indirectly determine the location of ganglia.…”