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1. Describe the anatomy of the larynx.

2. What is the innervation of the larynx
3. From where does the larynx derive its blood supply.
4. With damage to the nerves of the larynx what is the position of the cords with a unilateral complete palsy.
!. Describe the procedure for insertion of a percutaneous tracheostomy
Functions 1. "rotects respiratory tree
2. allows speech
3. allows swallowing
4. allows coughing# straining
$xtends % root of tongue to cricoid ring.
&artilages ' paired ( arytenoids
3 unpaired $piglottis
*igaments of larynx
4 extrinsic ( thyrohyoid
+ hyoepiglottic
+ cricothyroid
+ cricotracheal
,uscles of the larynx
$xtrinsic ( -.) outside
-+ternothyroid /depresses larynx0 arises sternum to thyroid
.+nferior constrictor /arises posterior border0
)+ thyrohyoid /elevates larynx0
.ntrinsic ( & "*1))
&+ cricothyroid )ilts cricoid increases 2ocal cord tension
"+osterior cricoarytenoid 1bducts cords
*+ateral cricoarytenoid 1dducts cords
1+ryepiglottic &onstricts cords
)+ransverse arytenoids From arytenoids to arytenoids constricts
)+hyroarytenoid "ulls arytenoids forward 34*5 34$ )3 6$*17 &36D-
8lood supply
1832$ glottis ( superior laryngeal artery from external carotid
8$*3W glottis ( inferior laryngeal branch of inferior thyroid from subclavian
6$&966$4) *1654:$1* ( sensation 8$*3W glottis
( 1** intrinsic muscles $7&$") cricothyroid
( close to inferior pole of thyroid and left side has intra+thoracic path therefore at ris;
from lung tumours# aneurysm# oesophageal tumours. Damage causes
paralysed midline cord if unilateral if bilateral causes severe stridor and
-uperior laryngeal ( sensation 1832$ glottis close to superior thyroid vessels can be damaged at surgery
resulting hoarseness if unilateral % opposite often ta;es over in time.
( cricothyroid
*ymphatics mainly to deep cervical chain.
2iew of the laryngx at laryngoscopy
1ppropriate anatomy for percutaneous tracheostomy insertion
1. Describe the landmar;s of the respiratory tree with respect to the relevant vertebral body.
2. <ighlight the anatomical differences between the left and right bronchial trees.
3. Describe the circulation of blood through the lungs.
4. What are the essential chec;s for a patient after the insertion of a double lumen tube.
!. Describe the diaphragm with reference to its points of insertion and its foramina.
)rachea &' %)4 at bifurcation 1=+1!cm long 1>mm diameter 1!+2= incomplete cartilage rings. )hyroid isthmus over 2+4
cartilage ring
8lood supply inferior thyroid artery and veins
4erves recurrent laryngeal and -4- from cervical chain
*ymphatic deep cervical pre ? para tracheal nodes
8ronchial tree 23 bifurcations 1' onward are transitional and respiratory
*$F) bronchus passes 94D$6 aortic arch in F634) of oesophagus@thoracic duct and descending aorta then below and
behind left pulmonary artery.
6ight main bronchus is shorter wider and more vertical passes 94D$6 the aAygous and is above and behind the right
pulmonary artery.
*ayers ,ucosal % ciliated and goblets cells /reduced numbers in smaller bronchioles0
8asement menmrane %
-ubmucous % elastic fibres
,uscular % unstriped withstand respiratory pressures relative thic;ness increases as bronchi get smaller
1ct as sphinters at terminal bronchioles /entry point into alveolar sacs0
&artilage % rings replaced by plates in intrapulmonary area become less complete
"leura 8oundaries % upper 4cm above clavical
+ behind sternum at level 2
+ >
rib midclavicular line 1=
rid mid+axillary line and 12
rib posteriorly
2isceral + no sensory innervation
*ung <ilum 83)< sides % phrenic@anterior nerve plexus and minor vessels 14)$6.36 vagus 8$<.4D
6ight % -2& 61 anterior to aAygous arches over hilum
*eft % thoracic aorta posterior and arch superior
6ight two fissures transverse /upper and middle lobes0 and obliBue /middle and lower lobes0
8lood supply "ulmonary artery provides capillary networ; for oxygen exchange
bronchial arteries from descending aorta 1 right 2 left
2eins ( 2 on each side ( 6ight aAygous and left hemi+aAygous
/43)$ these and the cardiac thebesian veins constitute the physiological shunt0
"-4- 2agus
-4- thoracic sympathetic chain
*ymph deep bronchial plexus C bronchopulmonary nodes C mediastinal nodes
Diaphragm -eparates thoracic from abdominal cavities. ,ain muscle of respiration
&entral tendinuos portion and muscular periphery slightly higher on right.
6elations + &entral ( trefoil tendon contiguous with fibrous pericardium
,uscle ( tips last ' costal margins xiphoid posterior surface.
3 arcuate ligaments % ,edia* % psoas *ateral Buadratum lumborum median % arch between crura
&rura ( *eft from 1
and 2
lumber vertebral bodies
6ight from 1
to 3
lumber vertebral bodies
Foramina % 3 maDor openings in the diaphragm
1 )> ( inferior vena cava /sometimes right phrenic nerve0
2 )1= ( oesophagus 2agi *$F) gastric artery and vein
3 )12 ( aorta thoracic duct and aygous vein.
,otor supply ( phrenic /&3+!0
-ensory % phrenic to central tendinous portion
*ower thoracic to muscular areas.
1. Describe the coronary circulation
2. <ow is blood returned to the circulation from the coronary vessels.
3. Describe the innervation of the heart
4. What are the structures that may be damaged during the insertion of an internal Dugular line.
<eart 8orders 6ight ( right atroum
*eft ( left atrial appendage and left ventricle
1nterior ( mainle right ventricle
.nferior ( right and left ventricles onto diaphragm
"osterior ( left atrium
4 chambers 6ight atrium ( receives de+oxygenated blood from vena cava flows through tri+cuspid into right ventricle.
-1 node is situated in upper part 12 lies near base of tricuspid valve
6ight ventricle % pumps blood into pulmonary artery through the pulmonary valve /tricuspid in structure0
4ormally relatively thin walled as pulmonary circulation is low pressure system
*eft atrium % oxygenated blood from lungs via 4 pulmonary veins blood passes through mitral/2 leaflet0 valve into
*eft ventricle.
*eft ventricle % thic; walled pumps blood through three leafleted aortic valve /left#right and posterior leaflet0
-mall sinuses above leaflets give rise to coronary vessels.
&onducting system -1 node ( near opening -2& in 6 atrium initiates impulse in direct contact with atrial tissue and wave of conduction passes
across both atria.
12 node % receives impulse from -1 node. 4o direct contact with -1 or contractile tissue allows delay in conduction so atria
and ventricles do not contract simultaneously.
8undle of <is % nerve fibre tissue that carries 12 impulse through intra+ventricular septum dividing at its base to form left and
right branches these terminate within the ventricular tissue as the per;inDe fibres.
"ericardium Fibrous envelopes heart cone shaped attached to surrounding tissues internal -$639- pericardium composed two layers
visceral and parietal. "otential space between lubrication.
2ascular supply + 6ight coronary ( right aortic sinus travels in atrioventricular groove combines with left coronary inferiorly
-upplies ( 6 atrium and part * atrium# 6 vent# "osterior intervent septum and -1 /'=E of cases0 and 12 />=E0
*eft coronary ( arises left posterior aortic sinus divides into two main branches
&ircumflex % runs in left atrioventricular groove
1nterior interventricular /formally ;nown as left anterior descending0 rund in interventricular groove.
-upplys % * atrium * vent# anterior interventricular septum -1 and 12 node in smaller numbers of people.
2enous drainage two thirds follows arteries and enters directly into right atrium via anterior cardiac vein or coronary sinus.
3ne third directly into cardiac cavity ( venea cordis minimae
4erves 1utonomic ( "arasympathetic 21:9- /inhibitory #slows heart rate0
( -ympathetic &1+)1 and upper thoracic )2+)!.
( phrenic supplys pericardium /&3+!0
1orta From aortic valve to bifurcation at common iliacs /*40
1scending % gives off the two coronarys
1rch gives off % brachiocephalic that becomes right common carotid and right subclavian
+ left common carotid
+ left subclavian
+ thyroidea ima /sometimes0
Descending + )4 to diaphragmatic opening at )12
+ visceral branches to pericardium# bronchial# oesophageal# mediastinal and phrenic
+ somatic branches to posterior intercostals# lateral cutaneous and mammary
1bdominal + paired lumbar
+ paired visceral ( inferior phrenic# suprarenal# renal# gonadal
+ 9npaired midline arteries ( celiac to foregut
( superior mesenteric to midgut
( inferior mesenteric to hindgut
,aDor vessels of the nec;
6ight common carotid + branch of brachiocephalic ascends in carotid sheath and divides at level &4 into internal and external
*eft common carotid % direct branch from aortic arch
.nternal carotid % main blood supply to intracranial structures enters s;ull through carotid canal 1= branches within the s;ull
.ncluding anterior#middle cerebral# ophthalmic# posterior communicating Forms part of circle of willis.
$xternal carotid % main blood supply to head and nec; ' branches superior thyroid# ascending pharyngeal# facial# occipital# posterior
auricular before bifurcating within the parotid as the superficial temporal and maxillary.
,aDor veins of head and nec;
$xternal Dugular drains scalp# face drains into subclavian
.nternal Dugular runs from Dugular foramen runs in carotid sheath to Doin subclavian drains cranial vault
1. Describe with the aid of a diagram the blood supply to the brain.
2. Draw a cross section of the spinal cord.
3. What is peculiar about the blood supply of the spinal cord and at which area is it particularly at ris;.
4. *ist the structures through which your needle will pass whilst performing a neuroaxial bloc;.
!. Where is &-F form and describe its circulation throughout the &4-.
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1rterial supply paired ( carotids and vertebral / which forms the basilar0
2enous drainage dural sinuses to the internal Dugular
&ircle of willis
-pinal cord
4!cm long cylindrical with flattening in lumbar region. extends as extension of medulla oblongata to lumbar region where it becomes
the conus medullaris. )hin thread extends to attach to coccyx as the filum terminale.
31 paired spinal nerve roots / > cervical 12 thoracic ! lumbar ! sacral and 1 coccygeal0
&auda eBuina % elongation of lumbar and sacral nerve roots prior to them leaving the intervertebral foramina.
$4D- % usually between *1 ? *2 /neonate lower border of *3 vertebral body0
6oughly circular in cross section. Flattened 1" aspect.
)wo indentations 1 anterior median fissure
2 posterior median sulcus / forms a septum further down0
&entral canal from 4
ventricle continues throughout % enlarges at conus medularis
:rey matter <+li;e structure posterior narrower section has substancia gelatinosa at its tip
White matter *ongitudinal nerve fibres
descending corticospinal /motor0
descending 1nterior corticospinal /minor motor0
1scending posterior column /touch and proprioception0
1scending spinothalamic % lateral ( pain ? temp
+ anterior ( touch and deep pain
1scending spinocerebellar % proprioception
2ascular supply
1rterial 1nterior /single0 from vertebral arteries 2#3rds of supply
"osterior % paired from cerebellar arteries branches from nearby arteries.
6adicular arteries % branch to both anterior and posterior arteries Fartery of adam;iewicAG
2enous series of venous plexuses which drain into aAygous# vertebral# lumbar and lumbrosacral veins.
,eninges 3 contiguous layers protect and support
1rranged epidural space % dura % subdural space % arachnoid mater % subarachnoid space % pia mater applied to neural tissue.

$xtradural space /epidural0 separate dura from periosteuim triangular in cross section.
$xtends foramen magnum to sacral hiatus. sideways within spinal foramina.
Depth 3+!cm from s;in surface extends 1mm cervical to 'mm lumbar
&ontents fat lymphatics arteries veins/valveless batsons plexus % communication of pelvic to cerebral veins0
Dura dense fibrous double layer % outer attaches to foramen magnum ? &2+3 extends to *!+-3.
&overs filum terminale to attach at coccygeal periosteum
1ttached anteriorly to posterior longitudinal ligament latteraly to foramina posterior surface is not attached.
-ubdural space potential space
1rachnoid mater thin delicate
-ubarachnoid space contains &-F
"ia ,ater 2ascular connective tissue that closely envelopes neural tissue
1nterior )hic;end as Flinea splendensG
*ateral strands that attach to dura ( ligamentum denticulatum
"osterior incomplete attachment to dura by posterior subarachnoid septum
.nferior to coccyx
&-F 1!=ml in total 2!ml in subarachnoid space
"roduced choroids plexus of lateral# 3
and 4
ventricles passes lateral C foramina of monro C 3
vent C 4
vent C spinal cord via
Foramina of lush;a /lateral0 and magendie /medial0
1bsorbed arachnoid villi in cerebral venous sinuses some in lymphatics.
"ressure gravity dependent '+1=ch when lying and 2=+4=cm in lumbar region when sitting.
&omposition osmo 2>= sp 1==! p< H.4 gluc 1+4 4a 14=+1!= bicarb 2!+3=
<igher than plasma ( cl 12=+14=
-pinal nerves
31 pairs /> cervical 12 thoracic ! lumbar ! sacral and 1 coccygeal0
,ixed motor and sensory formed from fusion of anterior /ventral0 motor and posterior /dorsal0 nerve roots/ has ganglion0.
$xit via intervertebral foramina sheathed in meninges.
8ranches -mall meningeal branch to supply vertebral body
Dorsal and ventral rami
6ami communicantes ( branch to sympathetic chain
Dorsal posterior rami generally smaller divides medial and lateral branches. :$4$61**5 dermatomal
$xcept 1
cervical ( dorsal ramus is totally ,3)36 supplies suboccipital region
cervical ( lerge medial branch /occipital nerve0 and smaller lateral branch
&occygeal % very small doesnIt divide and supplys s;in over coccyx.
2entral anterior primary rami generally larger supply limbs and anterior# lateral torso
-ome combine to form plexuses % cervical brachial lumbosacral
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&ervical ventral rami &1+4
Divide $xcept &1 into ascending and descending branches these further divide into deep and superficial.
.nnervation -;in % head and nec;
,otor % nec; and diaphragm.
4 ,aDor groups 1. &ommunicating % pass to hypoglossal# vagus and sympathetic chain.
2. "hrenic + motor to diaphragm also proprioception to diaphragm# pleural and pericardial fibres.
"ath % descends over scalenus anterior
+ over subclavian artery
+ under subclavian vein
+ through thoracic inlet
6ight + follows great vessels to pierce central diaphragmatic tendon lateral to .2&
*$F) + crosses 32$6 arch aorta in front of vagus 32$6 lung root and pericardium to pierce the
diaphragm lateral to pericardial attachment..
3. -uperficial branches + sensory to nec;
1scending + lesser occipital &2
+ greater auricular &2?3
Descending + supraclavicular nerves &3+4
)ransverse + anterior cutaneous nerve of nec; &2+3
4. Deep branches + motor to nec; ( anterior vertebral and contribution to scalenus medius
levator scalpulae sternomastoid and trapeAius
8rachial plexus
Formed ventral rami of &! %) 1 / can be contribution from &4 and )20
6oots ! pass between scalenus medius and anterior
)run;s 9pper &! ? ' J
,iddle &H J pass over first rib at lateral border divides
*ower &> ? )1 J
Divisions anterior and posterior occurs behind the clavicle
&ords dependent upon position around axillary artery
*ateral anterior divisions of upper and middle trun;s
,edial anterior division of lower trun;
"osterior posterior divisions of all three trun;s
-urrounded by fibrous sheath from origin at scalene up to the axilla.
,aDor nerves
1. median nerve superficial flexors abductor#flexor pollicis brevis opponens pollicis flexor pollicis longus and pronator.
2. 6adial nerve axillary deltoid and s;in over posteromedial upper arm
9pper arm triceps brachioradialis extensor carpi radialis
Forearm elbow Doint wrist intercarpel Doints 1** extensor muscle of forearm /except carpi longus0
Dorsum of lateral 2+3 fingers
3. 9lnar nerve sensory ulnar half of palm and hand elbow Doint flexi carpi ulnaris
<and % hypothenar eminence interossei 3
and 4
lumbricles adductor pollicis.
*umbar plexus 2entral rami *1+4 contribution from )12 in !=E or from *!
Forms within psoas
*1 divides upper ( iliohypogastric and ilioinguinal
*ower ( Doins with *2 to form genitofemoral
*2+*4 divides Dorsal % *2?3 ( lateral cutaneous nerve of thigh
*2+4 ( femoral nerve
2entral 3bturator nerve
*4 ? ! Doins lumbosacral plexus
Femoral nerve *2+4 formed within the psoas descends between psoas and iliacus entering the thigh lateral to the femoral artery.
-plits within the femoral triangle to anterior and posterior branches.
,uscles ( anterior branch to sartorius
( posterior branch to Buadriceps femoris
-ensory ( anterior % cutaneous and medial cutaneous nerve of thigh
( posterior % terminal saphenous
-aphenous nerve *16:$-) 8614&< 3F F$,361* 4$62$
Descends between sartorius and gracilis passing down medial border of tibia to end within the foot.
-acrococcygeal plexus wide variation exists
-acral plexus *4+! ? -1+4
&occygeal -4?! and the coccygeal nerve
*4 ? ! forms lumbrosacral trun; at medial border of psoas
)ravels over pelvic brim to Doin -1
2entral rami -1+4 and -! and coccygeal Doin the trun; within the pelvis.
8ranches 1. -uperior gluteal *4+! and -1
2. inferior gluteal *! -1?2
3. posterior cutaneous femoral nerve -1+3
4. "erforating cutaneoud -2?3
!. "udendal -2+4
'. -ciatic -2+4
&occygeal portion is small and forms anococcygeal nerve /-4?! and coccygeal/
-;in over coccyx.
-ciatic nerve
*4+! and -1+3 passes through greater sciatic foramen % deep to gluteus maximus running posterior to acetabulum.
6oute "oint midway between greater trochanter and ishial tuberosity it runs directly on the Buadriceps femoris passing
between two heads of biceps femoris.
)erminates as common peroneal and tibial nerves.
-upplys ,uscle semitendinous#membranous bicep femoris and part of adductor magnus ? Buads
-ensory hip and ;nee Doint and s;in anterior thigh medial lower leg and foot.
)ibial nerve arises lower third thigh
"asses through popliteal fossa leaving between heads gastrocnemius to run on posterior tibial border
$nters foot deep to flexor retinaculum
8ranches ,uscles popliteus gastrocnemius soleus plantaris plantars of foot
&ommon peroneal 6uns lateral part popliteal fossa wraps around head of fibula then divides
Deep anterior to tibia at an;le ,ucles ( extensors
-ensory ( 1
? 2
web spaces
-uperficial % lateral surface of tibia and becomes anterior over an;le
-ensory % lower outer aspect of leg and dosrsum of foot.
Other nerves of note
1. .ntercostal nerves derived ventral rami of )1+11
$merge intervertebral foramina and for a short distance lie between pleura and inner muscle layer.
)hen "ass posterior and below the intercostals arteries to run between the innermost and inner intercostals muscles.
Follows subcostal groove
8ranches &ollateral arises angle of rib and supplies underlying muscle
*at cutaneous arises mid axillary line and supplys overlying s;in sensation
1nt cutaneous arises anterior chest to supply s;in overlying.
1typical forms )1 no cutaneous branches forms part of brachial plexus
)2 *at cutaneous branch forms intercostobrachial and supplys s;in of upper arm.
)H+11 4o abdominal branches
Autonomic nervous system
)ypically myelinated which emerge from &4- synapse and then secondary 94,5$*.41)$D fibres pass on to end organs.
-4- ganglia close to central nervous system cell bodies in lateral horn of spinal cord.
$xtends )1 % *2
&ervical ganglia usually 3
)horacic usually 12
*umbar usually 4
-acral usually 4
48 1. -tellate ganglia &H+)1 close relationship with sympathetic chain
"osition % between transverse process of &H and 1
rib about 3cm above sternoclavicular Doint
8loc; head full extension needle right angles to s;in hit transverse process about 3cm inDect
Why painful arms &6"- post herpetic.
"roduces <orners indicates successful bloc; .
2. &ardiac plexus Deep ( anterior to bifurcation of trachea % cervical and )1+4 and vagal braches
-uperficial ( anterior to pulmonary artery# under arch upper right cervical braches and *$F) vagus
3. &oeliac plexus largest sympathetic plexus anterior to aorta around celiac artery. 8ehind pancreas and stomach.
Parasympathetic nervous system
&ranial nerves ... 2.. .7 and 7
Function pupilaary constriction salivation lacrimation cardiac inhibitory bronchoconstriction and stimulates intestinal motor activity.
-acral formed ventral rami of -2+4
Function rectal and bladder motor function genital vasodilatation.
$dinger westphal nucleus
Where opiates cause miosis
1cts via occulomotor nerve.
Vertebral column
)ypical vertebra anterior body and posterior nural arch lumbar are largest bodies separated by fibous disc
1rch connected to body by two strong pedicles.
"edicles have inferior and superior articulation facets which articulate via synovial Doints.
4ural arch completed posteriorly by two bony lamina Doining at spinous process.
)ransverse process provides additional attachment area for muscles.
&ostal processes well developed in the thoracic region.
1tlas no true body ring of bone supports weight of s;ull and articulates with occipital condyles and inferior facets with axis.
1lso % has rounded facet on anterior arch to articulate with odontoid peg.
-;ull roc;s bac; and forward on atlas.
1xis allows head to rotate odontoid attached to occipital bone by apical ligaments
*aminae strong and transverse processes are short.
&H vertebrae prominens
*argest cervical occasional cervical rib is seen.
)horacic vertebrae has articulations for the ribs
-pinous processes generally slender long and downward pointing.
*umbar vertebrae largest lac; costal facets bodies large and ;idney shaped pedicles short and strong superior and inferior articulating facets
are vertical
*! % body is wedge shaped.
-acrum fusion of ! sacral vertebrae central axis of pelvis
1rticulates above ( *!
-ides ( innominates at sacroiliac Doints
8elow ( coccyx
.s concave anteriorly and wedge shaped.
Foramina 4 pairs
&anal contains cauda eBuine
Filum treminale
-pinal meninges
&occygeal#sacral nerves
$pidural fat and veins
-acral hiatus failure of fusion of 4
sacral laminae
&overed by sacrococcygeal ligament
&audal anaesthetic given by finding eBualteral triangle from posterior superior iliac spines and sacral hiatus
2ertebral ligaments 1. .ntervertebral iscs % 2!E of vertebral height outer annulus fibrosus inner annulus pulposus surfaces of vertebral bodies
lined with hyaline cartlage ti allow adhesion to discs.
2. 1nterior longitudinal ligament % runs anterior surface of vertebral bodies and discs &2 % sacrum
3. "osterior ligament % attached disc and vertebral bodies.
4. *igamentum flava % thic; elastic vertical ligaments connecting adDacent laminae.
!. .nterspinous ligaments shafts of spinous processes.
'. -upraspinous % tough fibrous connects tips of spinous processes.
H. ligamentum nuchae superior extension of supraspinous ligament % from &H to occiput.
)he s;ull
Fossa 1. "osterior % largest and deepest anterior borders are sphenoid temporal "osterior laterally by occipital bones..
)ransverse sinuses create the deep grooves running laterally the occipital prominence lies centrally extending to
the attachment of the falx cerebelli.
&ontains % medulla pons cerebellum 8$*3W tentorium cerebelli and occipital lobes above
Foramina 1. internal acoustic ( facial# vestibulococchlear nerves and labarynthine vessels
2. Dugular ( glossopharyngeal vagus and accessory nerves Dugular vein
3. <ypoglossal canal ( hypoglossal and ascending pharyngeal artery.
4. Foraman magnum ( largest medulla meninges vertebral arteries and spinal accessory nerve.
2. ,iddle % temporal lobes of brain
8ound 1nteriorly by wings of sphenoid
*aterally % temporal bone
"osteriorly % petrous temporal crests
-penoid % houses the pituitary
&onnects with orbit via optic canal and supra+orbital fissure.
Foramina 1. 3ptic canal ( optiv nerve and artery
2. -uperior orbital fissure ( occulomotor trochlear branches trigeminal abducens
3phthalmic veins orbital branch middle meningeal artery# lacrimal artery and -4- fibres
3. 6otundum ( maxillary division of trigeminal
4. 3vale ( mandibular trigeminal and lesser petrosal nerves
!. -pinosum ( middle meningeal vessels and branch mandibular nerve
'. *acernum ( branch ascending pharyngeal and emissary veins
H. &arotid canal ( internal carotid and sympathetic chain
>. -tylomastoid ( facial and posterior auricular
3. 1nterior + &ontains % frontal lobes
8ound % anterior ( frontal bone
"osterior ( wings of sphenoid
Floor ( ethmoid
&entral % prominence for attachment falx cerebri
Foramina + 1. cribiform plate ( olfactory
2. anterior ethmoid canal ( anterior ethmoid nerves and vessels
3. "osterior ethmoid canal ( posterior vessels and nerves
Thoracic inlet
.s roughly ;idney shaped
8ound 1nterior superior manubrium
"osterior anterior surface of first vertebral body
*aterally first rib and cartilages
*ung apex proDects 3cm above clavical
grooved anteriorly by subclavian artery
posteriorly by stelleate ganglion superior intercostal artery and first thoracic ventral rami
1. scalenus muscles 3 of them ( anterior# medius and posterior
1ntreior + originates from &3+' passes to scalene tubercule of first rib
+ lies 8$<.4D sternomastoid
+ related stuctures + 14)$6.36 ( phrenic nerve
)horacic duct /on left0
&arotid sheath superiorly inferiorly only internal Dugular is anterior
-ubclavian vein
+ "3-)$6.36*5 subclavian artery
8rachial plexus roots
+ ,$D.1**5 subclavian and branches
&ommon carotid
-ympathetic trun;
2. First rib shortest flattest most curved.
1natomy head with facet for body of )1
4ec; and tubercle for transverse process )1
)he intercostal space
1. ,uscles 1. $xternal intercostals ( 11 pairs outer most layer.
"asses % lower border upper t upper border of lower rib
8ecomes more tendenous towards chondral margins
2. .nternal ( 11 pairs fibres run at right angles to external intercostals
$xtends % fron sternum to angle of rib becoming more tendinous.
3. .nnermost ( largely incomplete. 4umerous slips of muscle continuous fascial sheet.
-eparated from pleura by endothoracic fascia
2.4eurovascular bundle ( 214 /top to bottom0
1. 2eins % anterior veins drain into musculophrenic or internal thoracic and posterior drains into hemi+aAygous.
2. 1rteries % 1nterior % )1+K ( from branches subclavain
+ "osterior % from thoracic aorta )3+11 and from superior intercostal artery for )1 nd )2.
43)$ )1= and )11 only supplied by posterior intercostal artery.
3. 4erves 2entral rami )1+11
)H % )11 within internal and innermost layers+ continuing to supply abdominal wall as well.
6ami communicantes ( -4- chain
&ollateral ( to intercostal muscle and pleura
*ateral cutaneous ( lateral s;in wall and muscels
1nterior cutaneous ( anterior wall and muscles
)he abdominal wall
$xtends xiphy sternum at )K to iliac crest# inguinal ligament and pubis symphysis inferiorly.
9mbilicus % dermatome )1= and *3 vertebral body.
1. ,uscles a0 abdominal rectus
6ectus sheath % contains muscle superior and inferior epigastric vessels terminal nerves of )H+)11.
b0 $xternal obliBue is outer most wall.
$xtends linea alba to pubis#iliac crest and rib insertions
Fibres run down and medial
c0 .nternal obliBue is inner to external obliBue
continuation of internal intercostals above.
Fibres run upwards and lateral
d0 )ransverse abdominis is innermost muscle with horiAontal fibres
8lood supply
,aDority ( inferior epigastric from external iliac
-uperior epigastric from internal thoracic artery.
4erve supply
2entral rami )H to *1
Inuinal canal
$xtends deep inguinal ring /opening trabsversalis fascia0
Down medially to superficial ring /external obliBue fascia opening0
.nguinal ligament % extends from pubic tubercle to anterior superior iliac spine.
8oundaries 1nterior aponeurosis external obliBue
"osterior common tendon of internal obliBue
Floor inguinal ligament
6oof fibres of transverses abdominis and internal obliBue.
&ontents ,1*$ ilioinguinal nerve spermatic cord /vas deferens# testiculat artey# pampiniform plexus# genital branch of
F$,1*$ ilioinguinal nerve and round ligament
Paravertebral space
8oundaries anterior ( parietal pleura
,edial ( vertebral body disc and vertebral foramen
1bove and below ( head and nec; ofribs
-uperiorly ( transverse vertebral ligament
&ontents fat vessels and spinal nerve roots
8loc; indications ( rib fractures thoracic surgery breast surgery cholecystectomy
&an use catheter for prolonged analgesia
,ethod 1. "t sitting or lying on side operative side upper most.
2. full asepsis
3. spinous process of appropriate vertebra
4. 2.! cm lateral needle inserted perpendicular to s;in.
!. 1dvance until hit transverse process 2+!cm
'. 1ngle needle cephalad and wal; off of upper surface. 1dvancing 1+2cm.
H. *oss of resistance or parasthesia along intercostals nerve.
>. .nDect !+1!ml of local anaesthetic high volumes may bloc; 3+! dermatomes.
&omplications 1. Failure
2. .ntra+pleural inDection
3. "neumothorax
4. <aematoma
!. .nfection
'. $pidural or spinal spread
H. *ocal anaesthetic toxicity /area of high upta;e0
>. .ntravascular inDection
K. 4erve inDury.
Antecubital fossa