(Radiographics. 2001;21:1275-1281.)
© RSNA, 2001
Nerves of the Thorax: Atlas of Normal and Pathologic Findings1
Suzanne L. Aquino, MD,
Gregory R. Duncan, MS and
L. Anne Hayman, MD
1 From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (S.L.A.); the Departments of Molecular and Cellular Biology (G.R.D.), Radiology (L.A.H.), and Psychiatry and Behavioral Sciences (L.A.H.) and the Frensley Center for Imaging Research (L.A.H.), Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030-3498. Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received March 15, 2001; revision requested April 11 and received May 15; accepted May 15. Address correspondence to L.A.H. (e-mail: lhayman@bcm.tmc.edu).
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Abstract
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An anatomic and imaging atlas was created to provide detailed information about the six pairs of thoracic nerves (phrenic nerves, vagus nerves, recurrent laryngeal nerves, sympathetic trunks, costal nerves, long thoracic nerves). Serial axial computed tomographic (CT) scans of the normal thorax were obtained and included in the atlas, along with drawings showing the proper location of each nerve relative to adjacent anatomic structures. CT scans obtained in both symptomatic and asymptomatic patients with various thoracic diseases were paired with appropriate drawings and normal CT scans in the atlas. This format was designed to help determine the presence and severity of related disease, including injury from surgery, trauma, or penetrating injury, metastatic disease involvement, and, rarely, primary tumor. Although the nerves of the thorax are rarely identified at cross-sectional imaging, their location can be inferred by localizing easily identified anatomic landmarks. Familiarity with the functional anatomy and clinical significance of the nerves of the thorax is important for the correct interpretation of thoracic images.
Index Terms: Nerves, 60.92 • Nerves, CT, 60.1211 • Nerves, diseases • Thorax, anatomy, 60.92 • Thorax, CT, 60.1211
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Introduction
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Anatomic and imaging atlases provide only limited information on the anatomy and function of the intrathoracic nerves, which are often omitted. To help remedy this situation, we obtained serial axial computed tomographic (CT) scans of the normal thorax from the first through the ninth thoracic vertebrae and constructed an anatomic atlas of the thorax. The location of the phrenic nerves, vagus nerves, recurrent laryngeal nerves, sympathetic trunks, costal nerves, and long thoracic nerves was confirmed by one author (G.R.D.) after dissecting 40 cadavers. We color-coded each nerve and placed it in its proper location (relative to adjacent anatomic structures identified at CT) on drawings based on CT scans. To demonstrate the usefulness of these data, we paired CT scans of various thoracic diseases in both symptomatic and asymptomatic patients with appropriate drawings and normal CT scans from the atlas.
In this article, we discuss and illustrate the functional and clinical relevance of each of the six sets of thoracic nerves (1–5). The anatomic and imaging atlas that was created from this information can be used as a reference tool to help determine the presence and severity of related disease.
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Phrenic Nerves
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The phrenic nerves lie along the lateral mediastinum and run from the thoracic inlet to the diaphragm (Figs 1a, 1b, 2–4). They course through the upper chest, medial to the mediastinal pleura and the apex of the right or left lung. The right phrenic nerve lies lateral to the right brachiocephalic vein and the superior vena cava. The left phrenic nerve courses along the lateral aspect of the transverse arch of the aorta. The two nerves subsequently pass anterior to their respective pulmonary hila and then inferiorly in a broad vertical plane along the margin of the heart between the fibrous pericardium and the mediastinal pleura (5). The phrenic nerves can occasionally be visualized at cross-sectional imaging (6,7).
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Figure 1a. (a, b) Drawings (axial view) illustrate the normal thoracic CT anatomy at the level of the T2 (a) and T3 (b) vertebral bodies. (c, d) Pancoast tumor in a 62-year-old man with Horner syndrome. (c) Axial CT scan demonstrates a Pancoast tumor in the left upper lobe (t). The mass is contiguous with the first rib in the area of the inferior cervical ganglion (purple arrowhead). The T1 intercostal nerve lies immediately below the first rib. Involvement can cause severe pain in the T1 dermatome of the anteromedial aspect of the arm. (d) Axial CT scan obtained at the level of T3 shows the tumor (t) abutting the sympathetic chain. The second intercostal nerve lies above the third rib (gold arrowhead). Damage can cause loss of sensation to the skin of the armpit and the area overlying the second intercostal space.
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Figure 1b. (a, b) Drawings (axial view) illustrate the normal thoracic CT anatomy at the level of the T2 (a) and T3 (b) vertebral bodies. (c, d) Pancoast tumor in a 62-year-old man with Horner syndrome. (c) Axial CT scan demonstrates a Pancoast tumor in the left upper lobe (t). The mass is contiguous with the first rib in the area of the inferior cervical ganglion (purple arrowhead). The T1 intercostal nerve lies immediately below the first rib. Involvement can cause severe pain in the T1 dermatome of the anteromedial aspect of the arm. (d) Axial CT scan obtained at the level of T3 shows the tumor (t) abutting the sympathetic chain. The second intercostal nerve lies above the third rib (gold arrowhead). Damage can cause loss of sensation to the skin of the armpit and the area overlying the second intercostal space.
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Figure 1c. (a, b) Drawings (axial view) illustrate the normal thoracic CT anatomy at the level of the T2 (a) and T3 (b) vertebral bodies. (c, d) Pancoast tumor in a 62-year-old man with Horner syndrome. (c) Axial CT scan demonstrates a Pancoast tumor in the left upper lobe (t). The mass is contiguous with the first rib in the area of the inferior cervical ganglion (purple arrowhead). The T1 intercostal nerve lies immediately below the first rib. Involvement can cause severe pain in the T1 dermatome of the anteromedial aspect of the arm. (d) Axial CT scan obtained at the level of T3 shows the tumor (t) abutting the sympathetic chain. The second intercostal nerve lies above the third rib (gold arrowhead). Damage can cause loss of sensation to the skin of the armpit and the area overlying the second intercostal space.
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Figure 1d. (a, b) Drawings (axial view) illustrate the normal thoracic CT anatomy at the level of the T2 (a) and T3 (b) vertebral bodies. (c, d) Pancoast tumor in a 62-year-old man with Horner syndrome. (c) Axial CT scan demonstrates a Pancoast tumor in the left upper lobe (t). The mass is contiguous with the first rib in the area of the inferior cervical ganglion (purple arrowhead). The T1 intercostal nerve lies immediately below the first rib. Involvement can cause severe pain in the T1 dermatome of the anteromedial aspect of the arm. (d) Axial CT scan obtained at the level of T3 shows the tumor (t) abutting the sympathetic chain. The second intercostal nerve lies above the third rib (gold arrowhead). Damage can cause loss of sensation to the skin of the armpit and the area overlying the second intercostal space.
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Figure 2a. (a) Drawing (axial view) illustrates the normal thoracic CT anatomy at the level of T3. (b) Neurofibromatosis in an asymptomatic 28-year-old man. Axial CT scan obtained at the level of T3 shows tumor masses in the region of the phrenic and vagus nerves. Neurofibroma is also present in the region of the ascending left recurrent laryngeal nerve.
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Figure 2b. (a) Drawing (axial view) illustrates the normal thoracic CT anatomy at the level of T3. (b) Neurofibromatosis in an asymptomatic 28-year-old man. Axial CT scan obtained at the level of T3 shows tumor masses in the region of the phrenic and vagus nerves. Neurofibroma is also present in the region of the ascending left recurrent laryngeal nerve.
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Figure 3a. (a) Drawing (axial view) illustrates the normal thoracic CT anatomy at the level of T5. (b) Enlarged lymph nodes in a 72-year-old man who presented with hoarseness and a left upper lobe mass. Axial CT scan obtained at the level of T5 shows enlarged lymph nodes in the left mediastinum at the aortopulmonary window and left paratracheal regions, which lie along the course of the ascending and descending left recurrent laryngeal nerve. Lesions in this region explain the patient’s hoarseness. The adjacent vagus and phrenic nerves were not clinically affected in this case.
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Figure 3b. (a) Drawing (axial view) illustrates the normal thoracic CT anatomy at the level of T5. (b) Enlarged lymph nodes in a 72-year-old man who presented with hoarseness and a left upper lobe mass. Axial CT scan obtained at the level of T5 shows enlarged lymph nodes in the left mediastinum at the aortopulmonary window and left paratracheal regions, which lie along the course of the ascending and descending left recurrent laryngeal nerve. Lesions in this region explain the patient’s hoarseness. The adjacent vagus and phrenic nerves were not clinically affected in this case.
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Figure 4a. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4b. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4c. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4d. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4e. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4f. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4g. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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Figure 4h. (a-d) Drawings (axial view) illustrate the normal thoracic CT anatomy between the levels of T6 and T9. (e-h) Neurofibromatosis in an asymptomatic 28-year-old man. Serial axial CT scans obtained at the same four levels demonstrate neurofibromas involving the phrenic and vagus nerves bilaterally, the sympathetic chain, and a right intercostal nerve.
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The phrenic nerves provide motor innervation to the diaphragm and sensory innervation to the central intrathoracic and peritoneal surfaces of the diaphragm. They also innervate the pericardium and mediastinal pleura and mediate pain from these areas to the neck and shoulder. Manifestations of phrenic nerve disease include diaphragmatic paralysis with elevation or persistent hiccups (8).
Primary tumors of the phrenic nerves are rare but are seen in neurofibromatosis (9). Metastatic disease involvement from primary lung cancer is more common (10). Injury to the phrenic nerves can occur from penetrating injury, surgery, and trauma from suboptimal placement of right-sided subclavian catheters or cardiac leads (11–13). Temporary palsy and diaphragmatic elevation that resolves over time can occur after open-heart surgery (14). The phrenic nerves can be compromised by enlarged lymph nodes, bronchial obstruction, pericardial disease, cardiomegaly, myocardial infarction, and subphrenic disease (8).
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Vagus Nerves, Esophageal Plexus, and Vagal Trunks
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The complex anatomy of the vagal fibers is further complicated by the fact that their names change as they descend through the thorax. In brief, the right and left vagus nerves enter the thorax between their respective brachiocephalic veins and the subclavian artery, medial to the mediastinal pleura. They descend posterior to their respective pulmonary hila, ramify to form the esophageal plexus, and then pass through the esophageal hiatus of the diaphragm as the anterior and posterior vagal trunks.
There are, however, small but significant differences between the pathways of the right and left vagal fibers. The right vagus nerve descends in the mediastinum between the lung and the trachea before dividing into several branches to the esophagus, which form part of the esophageal plexus. Most of these plexal fibers reunite behind the esophagus to form the posterior vagal trunk, which continues through the diaphragm to the posterior aspect of the stomach. The left vagus nerve descends in the mediastinum between the left common carotid artery and left subclavian artery. It continues immediately lateral to the transverse arch of the aorta. Inferiorly, it runs lateral to the trachea and esophagus. It ramifies to join the esophageal plexus, which reunites in front of the esophagus to form the anterior vagal trunk, and continues through the diaphragm to the anterior aspect of the stomach (5).
The vagus nerves and their plexuses mediate esophageal swallowing, gastric emptying, and meal satiety. Stimulation leads to increased peristalsis and increased activity of the secretory glands of the gastrointestinal tract from the esophagus to the middle of the transverse colon (15). Stimulation of the cardiac branches of the vagus nerves will lead to a decrease in heart rate (16). Manifestations of vagus nerve impairment include gastroesophageal reflux, achalasia, and dysmotility disorders (17).
As with all the thoracic nerves, primary tumors are rare. The most commonly reported neoplasms are paragangliomas and neurofibromas (18–22). Metastatic involvement may occur rarely. Injury to the vagus nerves can occur from penetrating injury, thyroid or parathyroid surgery, and trauma (23).
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Recurrent Laryngeal Nerves
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The recurrent laryngeal nerves follow an asymmetric pathway through the upper chest (Figs 1a, 1b, 2, 3). The right recurrent laryngeal nerve originates from the right vagus nerve at the level of the right subclavian artery and loops under this artery to ascend out of the thorax (Fig 1a). The left recurrent laryngeal nerve originates from the left vagus nerve at the level of the transverse aortic arch and loops under it immediately posterior to the ligamentum arteriosum to ascend along the posterolateral tracheal margin and exit the thorax (Figs 1a, 1b, 2, 3) (5). The recurrent laryngeal nerves provide ipsilateral motor innervation to the intrinsic laryngeal muscles for vocalization and sensory innervation to the upper esophagus. They also mediate airway sensation from the level of the true vocal cords to the carina (24). Damage or tumoral involvement is nearly always unilateral and manifests as hoarseness, brassy cough, or vocal cord weakness (8).
Primary tumors are rare, but the left recurrent laryngeal nerve is often involved when metastatic lung cancer involves the left side of the mediastinum, either by direct invasion or lymph node spread (25). Other mediastinal tumors that can involve the recurrent laryngeal nerve include esophageal, tracheal, and thyroid tumors (26–28). Lymphadenopathy from inflammatory and infectious causes may also affect this nerve (29). Mass effect from enlarged mediastinal structures (eg, vascular aneurysms), an enlarged left atrium, right nerve palsy of the cervical aortic arch, tracheal diverticulum, and lung collapse have also been reported (8,30–34).
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Sympathetic Chains and Splanchnic Branches
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The sympathetic chains are paired, symmetric structures that extend from the thoracic inlet to the diaphragm (Figs 1b–d, 2a, 3a, 4). These fibers and ganglia run in a vertical line that crosses the necks of the ribs. They are covered by the parietal pleura, except for the most inferior segment of the right chain. Three splanchnic branches emerge from each chain and pass medially to the abdominal sympathetic ganglia (5).
The upper part of this system mediates dilation of the pupil, the levator muscles of the upper eyelids, the sweat glands, vasoconstriction of superficial vessels of the skin, and vasodilation of the deep arteries to striated muscles (8). In the gastrointestinal tract, the sympathetic system causes a decrease in bowel peristalsis and inhibits secretory gland activity from the esophagus to the middle of the transverse colon. Stimulation of the branches to the heart and lungs leads to increases in heart and respiratory rates.
One of the most common diseases to involve the thoracic sympathetic system is Pancoast tumor (Fig 1c, 1d) (35). This form of lung cancer is typically a squamous cell carcinoma or adenocarcinoma involving the upper thoracic wall. Tumor extension to the paraspinal region and thoracic apex can involve the superior cervical ganglion of the sympathetic system and cause Horner syndrome (ptosis of the eyelid, pupil miosis, facial anhidrosis) (8). As with other nerves in the thorax, primary tumors of the nerves and nerve sheaths may also involve the sympathetic system (36–38). CT localization of the sympathetic nerves and ganglia is important in helping alleviate sympathetic symptoms in the upper limb such as hyperhidrosis or Raynaud disease (39).
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Costal Nerves
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An intercostal nerve courses along the inferior edge of each of the first through 11th ribs. A subcostal nerve is located beneath each of the 12 ribs. These nerves innervate the muscles that join the ribs and provide sensory input from the overlying skin of the chest. (The first three intercostal nerves also mediate sensation from the upper extremities and axilla.) The costal nerves also refer sensation from the adjacent lower parietal pericardium, the parietal pleura, and the peripheral segment of the intrathoracic diaphragm (8). The subcostal nerves located under the 12th ribs along with the intercostal nerves from T6 to T12 innervate the muscles of the upper abdominal region and the overlying skin (5).
Trauma to an intercostal nerve caused by thoracotomy can lead to a loss of sensation in the skin overlying the injured nerve. When costal nerve damage is caused by tumor invasion, direct trauma, or rib fractures, patients may complain of chest wall pain or numbness. These symptoms can be alleviated with a costal nerve block (40–42). Herpes zoster can affect a single costal nerve, leading to pain and herpetic vesicles in the distribution of the nerve (8).
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Long Thoracic Nerves
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The paired long thoracic nerves are symmetric and are present in every section of the thorax (Figs 1a, 1b, 2a, 3a, 4a–d). They do not have a sensory component but provide motor innervation to the anterior serratus muscle. Because they course along the midaxillary line of the lateral chest wall, trauma or surgery that damages this area results in an ipsilateral winged scapula (5). Repetitive trauma due to archery can also cause a palsy of the long thoracic nerve (43).
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Conclusions
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Although the nerves of the thorax are rarely identified at cross-sectional imaging, their location can be inferred by localizing easily identified anatomic landmarks. Familiarity with the functional anatomy and clinical significance of these nerves is important for the correct interpretation of thoracic images.
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Acknowledgments
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The authors are grateful to Carolyn Adams for her expert assistance in the preparation of the manuscript and the figures used in this article.
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Abstract
Introduction
